EREFS Endoscopic Reference Score (Eosinophilic Esophagitis)
The EREFS ENDOSCOPIC REFERENCE SCORE (Hirano and colleagues 2013) grades five endoscopic features of eosinophilic esophagitis.
Open the calculator → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Proximal esophagus - Edema
- 1
- Proximal esophagus - Rings
- 1
- Proximal esophagus - Exudates
- 0
- Proximal esophagus - Furrows
- 1
- Proximal esophagus - Stricture
- 0
- Distal esophagus - Edema
- 1
- Distal esophagus - Rings
- 2
- Distal esophagus - Exudates
- 1
- Distal esophagus - Furrows
- 1
- Distal esophagus - Stricture
- 0
Result: 8
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What the result means
- Regions
- PROXIMAL AND DISTAL ARE SCORED SEPARATELY: 0 to 9 each, 0 to 18 overall. Reporting one regional score as "the EREFS" halves the scale.
- Edema
- 0 absent; 1 present - loss of normal vascular markings, pallor or decreased transparency.
- Rings
- 0 absent; 1 mild; 2 moderate; 3 severe. The descriptors for mild, moderate and severe differ between renderings and are not asserted here.
- Exudates
- 0 absent; 1 mild, under 10% of the mucosal surface; 2 severe, 10% or more.
- Furrows
- 0 absent; 1 mild; 2 severe. One rendering gives only absent/present; two give three grades.
- Stricture
- 0 absent; 1 present. PRESENT-OR-ABSENT ONLY - the least granular item, worth the same single point as edema while rings get four grades.
- Weighting
- The five features have DIFFERENT maxima and are not equally weighted: 1, 3, 2, 2, 1 - nine points per region.
- Which score
- AMBIGUOUS: three composites are published from the same features - full (0-18), inflammatory excluding rings and stricture (0-10), and modified presence-or-absence (0-10). All three are returned.
- Bands
- NONE are validated and none is returned. The instrument is used as a trial endpoint by CHANGE from a patient own baseline.
- Scope
- Describes appearance. Does NOT diagnose - that needs a biopsy eosinophil count, and a normal-looking esophagus can still be histologically active.
- Limits
- Does not measure symptoms or dysphagia, and decides no dilation, diet elimination, topical steroid or biologic therapy.
What you enter
- Proximal esophagus - Edema.
- Proximal esophagus - Rings.
- Proximal esophagus - Exudates.
- Proximal esophagus - Furrows.
- Proximal esophagus - Stricture.
- Distal esophagus - Edema.
- Distal esophagus - Rings.
- Distal esophagus - Exudates.
- Distal esophagus - Furrows.
- Distal esophagus - Stricture.
Full field descriptions
- Proximal esophagus - Edema [0 = Absent; 1 = Present - loss of normal vascular markings, pallor or decreased transparency]. Contributes up to 1 point in this region.
- Proximal esophagus - Rings [0 = Absent; 1 = Mild; 2 = Moderate; 3 = Severe]. Contributes up to 3 points in this region.
- Proximal esophagus - Exudates [0 = Absent; 1 = Mild - under 10% of the mucosal surface; 2 = Severe - 10% or more of the mucosal surface]. Contributes up to 2 points in this region.
- Proximal esophagus - Furrows [0 = Absent; 1 = Mild; 2 = Severe]. Contributes up to 2 points in this region.
- Proximal esophagus - Stricture [0 = Absent; 1 = Present]. Contributes up to 1 point in this region.
- Distal esophagus - Edema [0 = Absent; 1 = Present - loss of normal vascular markings, pallor or decreased transparency]. Contributes up to 1 point in this region.
- Distal esophagus - Rings [0 = Absent; 1 = Mild; 2 = Moderate; 3 = Severe]. Contributes up to 3 points in this region.
- Distal esophagus - Exudates [0 = Absent; 1 = Mild - under 10% of the mucosal surface; 2 = Severe - 10% or more of the mucosal surface]. Contributes up to 2 points in this region.
- Distal esophagus - Furrows [0 = Absent; 1 = Mild; 2 = Severe]. Contributes up to 2 points in this region.
- Distal esophagus - Stricture [0 = Absent; 1 = Present]. Contributes up to 1 point in this region.
How this is calculated
Hirano I, Moy N, Heckman MG, Thomas CS, Gonsalves N, Achem SR. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2013;62(4):489-495. Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.