The Evolving Role of Esophageal Biopsy in Clinical Practice—Lessons from Gastroesophageal Reflux Disease and Eosinophilic Esophagitis

Upper endoscopy (esophagogastroduodenoscopy [EGD]) is the definitive modality for the evaluation of a wide variety of upper gastrointestinal (GI) tract symptoms and diseases including, but not limited to, heartburn, gastroesophageal reflux disease (GERD), erosive esophagitis, Barrett’s esophagus (BE), dysphagia, esophageal strictures, non-cardiac chest pain, dyspepsia, abdominal pain, diarrhea, anemia, GI bleeding, and malignancy.

When EGD is performed to evaluate a specific symptom and an etiological structural lesion is observed, the decision to biopsy is straightforward. For example, tongues of salmon-colored mucosa and an orally displaced squamocolumnar junction (‘Z’ line) suggest a diagnosis of BE.

Esophageal biopsies showing goblet cells and specialized columnar epithelium (intestinal metaplasia) confirm the diagnosis and influence future clinical care.¹ Similarly, when an esophageal mass is encountered in a patient with dysphagia, esophageal biopsies are required as the first step to establish a tissue diagnosis prior to further staging.² The situation is less clear when there are no structural abnormalities, such as in the patient with heartburn and non-erosive reflux disease (NERD) or the patient with dysphagia and a normal-appearing esophagus.

This article will start by describing the proper technique for esophageal biopsy, and then focus on the evolving role of esophageal biopsies for adult patients in GERD and NERD in the increasingly recognized entity eosinophilic esophagitis (EoE).

Esophageal Biopsy Technique
Compared with the stomach, intestine, or colon, where the lumen caliber is large and motility is slow, the esophagus is narrower with more prominent motility. These factors can conspire with the frequently tangential biopsy angle to make obtaining optimal esophageal biopsies challenging.

The initial step is to select the appropriate biopsy forceps. A detailed review of all types of forceps available from all makers is beyond the scope of this article. There are several general features to keep in mind. The first consideration is the biopsy cup size. This dictates the amount of tissue obtained: the larger the cup, the larger the tissue sample. Some experts recommend using so-called ‘jumbo forceps’ to obtain tissue during surveillance of BE to increase the sensitivity for dysplasia,¹ but these are not typically necessary for other conditions. The downside to jumbo forceps is that they may require an operating channel size ≥3.2mm, which is larger than that of the standard upper endoscope. The next matter is whether to use forceps with a ‘spike.’ This feature allows two biopsies to be performed in one pass, with the first sample secured on the spike and the second contained in the cup. Although this can increase efficiency, the first sample can be lost and there may be a tradeoff, with the first specimen suffering from crush artifact.³

While there are many techniques for successfully obtaining esophageal biopsies,² these have not been rigorously studied, so we will describe one in our experience that is felt to be both safe and effective. With the scope in the body of the stomach, advance the biopsy forceps into the gastric lumen. This allows safe deployment and may decrease the risk for inadvertent esophageal perforation. Next, the scope can be withdrawn into the esophagus and the area targeted for biopsy visualized. Keeping the scope in close proximity to this area, the biopsy forceps are opened, then pulled back until the cups are in contact with the end of the scope.