Editor’s Choice: The esophageal biopsy “pull” sign

Senior Associate Editor, Lauren B. Gerson MD, MSc, FASGE, recommends this article from the January issue: “The esophageal biopsy “pull” sign: a highly specific and treatment-responsive endoscopic finding in eosinophilic esophagitis (with video)” by Evan S. Dellon, MD, MPH, Jessica H. Gebhart, MSHS, Leana L. Higgins, MS, et al.

The diagnosis of eosinophilic esophagitis (EoE) is increasing in the United States. Patients with EoE typically present with refractory heartburn, dysphagia, chest pain, and food impaction. Endoscopic findings associated with EoE have included esophageal rings, furrows, plaques, and esophageal strictures. The “pull sign” has been defined as resistance felt when obtaining an esophageal biopsy specimen in EoE patients. This study demonstrated that a positive pull sign was present in 76% of EoE patients compared to controls and was associated with a high sensitivity (76%) and specificity (98%) for the presence of EoE.

This article describes the utility of a relatively new tool that can be used by endoscopists for patients with suspected EoE in addition to the previously described endoscopic findings. The article does a nice job of describing the pull sign with an accompanying video, and comparing the sensitivity of this sign to traditional endoscopic findings. Figure 2 is a nice example of an “area under the curve” for the pull sign which plots pre-test and post-test probability. The AUC was high at 0.87. The authors also demonstrated that the pull sign resolved in patients who were successfully treated for EoE and demonstrated histologic response.

Figure 2. Diagnostic utility of the “pull” test, as illustrated by using likelihood ratios. The pretest probability (before assessing the “pull” sign) of having eosinophilic esophagitis is on the x-axis. The posttest probability (after assessing the “pull” sign) is on the y-axis and is affected by whether the “pull” sign is positive or negative. Posttest probabilities were calculated by using the Bayes theorem.

When multivariate analysis was performed, the pull sign was the greatest predictor of EoE with an odds ratio (OR) of 46 compared to the presence of esophageal rings (OR=6) and furrows (OR=13). Overall agreement between three different endoscopists was high at 90% (kappa=0.81). Resolution of the pull sign post-therapy suggested esophageal remodeling. Endoscopists should report the presence or absence of this endoscopic finding in addition to the traditional signs of EoE during endoscopic examinations in patients with suspected EoE.

Read the abstract for this article here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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