GI NOTES
Eosinophilic Esophagitis
Key points
- EoE is a chronic, immune (type 2) mediated disease: esophageal dysfunction plus at least 15 eosinophils per high-power field, with other causes excluded.
- A failed PPI trial is no longer required for the diagnosis (ACG 2025).
- Take at least 6 biopsies from 2 levels of the esophagus, even if the mucosa looks normal.
- First-line options: high-dose PPI, swallowed topical steroids, or an elimination diet. Dupilumab is for non-responders or patients with significant atopic disease.
- Judge response with repeat endoscopy and biopsy 8 to 12 weeks after each change, because symptoms alone are unreliable.
1. Presentation
| Group | Typical symptoms |
|---|---|
| Adults and adolescents | Solid-food dysphagia, food impaction, chest pain, slow eating and compensatory habits (chewing a lot, drinking water with each bite) |
| Children | Feeding problems, vomiting, abdominal pain, failure to thrive |
More common in males and people with atopy (asthma, eczema, allergic rhinitis, food allergy). EoE is the most common cause of food impaction in young adults.
2. Diagnosis
- Endoscopy: grade findings with EREFS: Edema, Rings, Exudates, Furrows, Stricture. Up to 1 in 10 patients have normal-looking mucosa.
- Biopsies: at least 6, from the proximal or mid and distal esophagus. Target exudates and furrows.
- Histology: peak count of 15 or more eosinophils per high-power field.
- Exclude other causes of esophageal eosinophilia: GERD, achalasia, drug reactions, infection, Crohn disease, hypereosinophilic syndrome, eosinophilic GI disease beyond the esophagus.
FIGURE: TREATMENT CYCLE IN EOE
Diagnosis confirmed
High-dose PPI
Swallowed topical steroid
Elimination diet (1 or 2 food)
Repeat EGD and biopsy at 8 to 12 weeks
Fewer than 15 eos/hpf: continue as maintenance
No response: switch option or add dupilumab
Dilation for strictures, together with anti-inflammatory therapy
Original diagram based on the ACG 2025 EoE guideline.
3. Treatment options
| Option | Typical regimen | Notes |
|---|---|---|
| PPI | High dose, for example omeprazole 20 to 40 mg twice daily (or equivalent) for 8 to 12 weeks | About 4 in 10 respond histologically. Inexpensive and simple. |
| Swallowed topical steroid | Budesonide oral suspension 2 mg twice daily (FDA approved), or budesonide slurry or orodispersible tablet, or swallowed fluticasone 880 to 1760 mcg per day in divided doses | Take after meals or at bedtime, then nothing by mouth for 30 to 60 minutes. Main side effect is esophageal candidiasis. |
| Elimination diet | Start with 1-food (milk) or 2-food (milk and wheat) elimination, step up if needed | Best with a dietitian. Re-introduce foods one at a time with endoscopic checks. |
| Dupilumab (anti-IL-4 receptor alpha) | 300 mg subcutaneously weekly in adults and adolescents; weight-based in children 1 year and older | For failure of or intolerance to PPI and steroids; consider earlier with significant asthma or eczema. |
| Esophageal dilation | Balloon or bougie, gradual | Treats strictures and dysphagia but not inflammation. Serious complications are rare. |
EoE is chronic: symptoms and inflammation come back after stopping effective treatment, so plan long-term maintenance at the lowest effective dose.
4. Food impaction
- Complete obstruction (cannot handle secretions) needs emergency endoscopy, ideally within 6 hours; partial obstruction within 24 hours.
- Use the push technique or retrieval devices; protect the airway when needed.
- Take esophageal biopsies at the index endoscopy if safe, or arrange early follow-up endoscopy, because many patients with impaction have EoE and are lost to follow-up.
- Glucagon has low success and is not recommended to delay endoscopy.
5. High-yield pearls
- A young man with food impaction and asthma has EoE until proven otherwise.
- Normal-looking mucosa does not exclude EoE: always biopsy when it is suspected.
- Dilation without anti-inflammatory therapy just treats the symptom, not the disease.
- Swallowed steroids from an inhaler must be swallowed, not inhaled; no spacer.
Self-check questions
- Is a PPI trial required before diagnosing EoE?
- How many biopsies, and from where?
- How do you know a treatment is working?
- A patient is unable to swallow saliva after a steak dinner. Timing of endoscopy?
Answers: (1) No. Since the 2025 ACG guideline, PPI is one of the first-line treatments, not a diagnostic step. (2) At least 6, from at least 2 levels of the esophagus. (3) Repeat EGD with biopsies 8 to 12 weeks later; under 15 eos/hpf is a histologic response. (4) Emergency, ideally within 6 hours.
References
- 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.
- Hirano I, Chan ES, Rank MA, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastroenterology. 2020;158(6):1776-1786.
- Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis (AGREE). Gastroenterology. 2018;155(4):1022-1033.
- Dellon ES, Rothenberg ME, Collins MH, et al. Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis. N Engl J Med. 2022;387(25):2317-2330.
For educational purposes only. This note does not replace clinical judgment or local protocols. Check doses against current labeling and institutional guidance.
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