Evaluation of the diagnostic accuracy of two esophageal biopsy sites compared to three in histological follow-up of eosinophilic esophagitis – A multicentric study

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INTRODUCTION AND AIM: Guidelines recommend sampling 2-3 esophageal locations (4-6 biopsies) during EoE follow-up, but the optimal scheme is uncertain. We assessed whether two biopsies (distal, proximal) reliably classify activity versus three sites (distal, middle, proximal). METHODS: Retrospective analysis of EoE follow-up endoscopies (2020-2024, tertiary centers) with three-site histology. Active disease was defined as ≥15 eos/0.3 mm² in ≥1 site; sub-analyses used ≥6 and ≥1 eos/0.3 mm². We compared active/inactive classification for two-site (distal+proximal) versus three-site sampling. RESULTS: Among 634 histologic evaluations, 306 three-site sets and 293 two-site sets were positive at ≥15 eos/0.3 mm²; all 328 three-site negatives remained negative with two sites. Thus, omitting the middle site would miss 2.0 % of active disease. Two-site performance: accuracy 98.0 %, sensitivity 96 %, specificity 100 %, PPV 100 %, NPV 96 %, AUC 0.98 (95 % CI, 0.97-0.99), Cohen's κ 0.98. At ≥6 eos/0.3 mm², sensitivity 97 %, accuracy 98.6 %, AUC 0.98 (95 % CI, 0.98-0.99). At ≥1 eos/0.3 mm², sensitivity 99 %, AUC 0.99 (95 % CI, 0.98-0.99). CONCLUSIONS: In EoE follow-up, two-site (distal+proximal) biopsies provide classification nearly equivalent to three-site sampling, with only a 2 % miss rate for active disease when the middle site is omitted. This approach may reduce procedure time, patient discomfort, and costs while maintaining excellent diagnostic performance.

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