Esophageal biopsy remains an important procedure for the diagnosis of RE, as well as for the identification of other causes of esophagitis. Although grasp biopsy specimens obtained by fiberoptic endoscopy are routinely performed for patients suspected of having reflux disease, they are infrequently oriented prior to their submission to the surgical pathology laboratory. Basal zone thickness and height of papillae, parameters considered by most pathologists to be useful for the diagnosis of RE, cannot be evaluated in unoriented sections. Hence, the search for intraepithelial neutrophils, and especially intraepithelial eosinophils, is critically important in grasp biopsy specimens. The finding of only a few intraesophageal eosinophils is sufficient for the diagnosis of reflux esophagitis (in the proper clinical setting) in both children and adults. In any biopsy specimen, the identification of eosinophils is easier and more reliable than the determination of basal zone thickness and height of papillae. The significance of finding only balloon cells in esophageal biopsy specimens from patients with suspected RE needs to be clarified by further study.