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The “caterpillar sign”: a novel endoscopic indicator of eosinophilic esophagitis

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Abstract

Background

Although several endoscopic findings of eosinophilic esophagitis (EoE), such as the EoE endoscopic reference score (EREFS), have been reported thus far, these endoscopic findings exhibit low specificity. Furthermore, most of these endoscopic findings were evaluated solely in patients from Western nations. We have recently noted a fragile, protruded mucosal lesion sandwiched between longitudinal furrows (similar to caterpillar tracks) on the esophagus in patients with EoE. We have termed this novel finding the “caterpillar sign”. This study evaluated the clinical significance of the caterpillar sign and the EREFS for diagnosis of EoE in Japanese patients.

Methods

We retrospectively analyzed endoscopic images from 165 consecutive patients who underwent tissue collection on suspicion of EoE. We compared the clinical significance between the EREFS and the caterpillar sign. We defined EoE as the presence of ≥ 15 eosinophils on esophageal mucosa per high-power field; control images had < 15 eosinophils per high-power field. For evaluation of endoscopic diagnosis capacity using the total EREFS, 2 points was set as the cutoff value. The presence or absence of the caterpillar sign was evaluated.

Results

The sensitivity, specificity, positive predictive value, and negative predictive value of total EREFS ≥ 2 for the diagnosis of EoE were 100%, 56.2%, 56.6%, and 100%; for the caterpillar sign, those values were 83.3%, 98.1%, 96.2%, and 91.2%, respectively. Interobserver agreement for identification of the caterpillar sign was substantial (κ = 0.80)

Conclusions

The caterpillar sign could be a novel reliable indicator for endoscopic diagnosis of EoE.

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Acknowledgements

We thank Ryan Chastain-Gross, Ph.D., from Edanz Group (https://en-author-services.edanzgroup.com/ac) for editing a draft of this manuscript. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by MA, NM, JN, MF, TK, KI, KI, and KH. The first draft of the manuscript was written by MA and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Noriaki Manabe.

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Ethical Statement

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions.

Conflict of interest

Maki Ayaki, Noriaki Manabe, Jun Nakamura, Minoru Fujita, Tomoari Kamada Kazumi Imamura, Kazuhiko Inoue, and Ken Haruma declare that they have no conflict of interest.

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Informed consent or substitute for it was obtained from all patients for being included in the study.

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Ayaki, M., Manabe, N., Nakamura, J. et al. The “caterpillar sign”: a novel endoscopic indicator of eosinophilic esophagitis. Esophagus 18, 156–162 (2021). https://doi.org/10.1007/s10388-020-00791-0

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  • DOI: https://doi.org/10.1007/s10388-020-00791-0

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