EREFS, EoE endoscopic reference score

Grades the five endoscopic features of eosinophilic esophagitis, Edema, Rings, Exudates, Furrows, Strictures, into a single score used to describe disease activity and to track change across endoscopies.

Evidence tier: Validated instrument.

Formula / logic

EREFS = Edema (0-1) + Rings (0-3) + Exudates (0-2) + Furrows (0-1) + Stricture (0-1). Maximum 8 in the validated modified system, in which the severity grading for oedema and furrows was collapsed to binary after the interobserver study. Score the WORST-affected oesophageal segment; proximal and distal scores may also be recorded separately.

Interpretation

EREFS describes what the endoscopist sees; it does not diagnose EoE and it does not replace histology. Diagnosis still requires >=15 eosinophils per high-power field on biopsy, and a normal-looking oesophagus does not exclude the disease. The score is most useful WITHIN a patient over time, a falling EREFS alongside falling peak eosinophil counts is the endoscopic half of a treatment response. Separate the two kinds of feature when you read it: exudates, furrows and oedema are INFLAMMATORY and generally reversible with therapy, whereas rings and stricture are FIBROSTENOTIC, reflect remodelling, and may persist or need dilation even when inflammation is controlled.

Evidence & citations

  1. Hirano I, Moy N, Heckman MG, et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2013;62(4):489-495. PMID 22619364
  2. Dellon ES, Muir AB, Katzka DA, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2025;120(1):31-59. PMID 39745304

Clinician decision support. Verify against the cited source. Not a substitute for clinical judgment. 100% on-device; no patient data is stored or transmitted.