Quantitative Analysis of Tug Sign: An Endoscopic Finding of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterized by esophageal inflammation and dysfunction, with a rising incidence affecting approximately 1:1000 individuals worldwide. Chronic inflammation can lead to tissue remodeling in the esophagus with fibrosis in the lamina propria that is partially responsible for symptoms and complications of EoE. At times, a firmness to the esophagus can be appreciated with a noticeable force required to obtain biopsies from EoE. This sensation has been described as the "tug" or "pull" sign. Recently, with the advent of endoscopic functional luminal impedance, the fibroelastic properties of the esophagus, including diminished compliance and distensibility, have been described in patients with EoE. Quantification of these fibroelastic properties of the esophagus may aid in diagnosis and prognosis of EoE. To this date, a method to quantitatively measure the "tug sign" has not been developed. The primary objective of this study was to measure if a quantifiable difference in force is required to obtain endoscopic esophageal biopsies in patients with EoE compared with those without.