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Eosinophilic esophagitis — Clinical Guidelines

Overview

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the esophageal mucosa 2 3 5.

Diagnosis

Clinical Symptoms: Dysphagia, food impaction, chest pain, and abdominal pain 2 3 5.

Endoscopic Findings: Characteristic endoscopic features include rings, furrows, strictures, and white plaques 2 3 5.

Histopathology: Biopsy showing ≥15 eosinophils per high-power field (HPF) on at least one site 1 2 3 5.

Exclusion of GERD: Initial trial of proton pump inhibitors (PPIs) followed by endoscopic and histologic reassessment if symptoms persist 2 9 29.

Diagnostic Criteria: Updated criteria recommend against routine use of PPIs for diagnosis 29.

Management

First-Line Treatments:

- Dietary Therapy: Elimination diets, including elemental diets in pediatric patients 15 18. - Topical Corticosteroids: Fluticasone propionate or budesonide for topical application 2 18.

Adjunctive Treatments:

- Systemic Corticosteroids: For refractory cases, though not routinely recommended 40. - Biologics: Dupilumab for severe refractory cases 9.

Esophageal Dilation: For esophageal strictures 1.

Special Populations

Pediatrics: Elemental diets and early dietary elimination strategies are effective 3 15.

Comorbidities: Consider vitamin D levels as potential modifiers of disease severity 14.

Key Recommendations

Diagnosis Requires Biopsy Evidence: Confirm diagnosis with esophageal biopsy showing ≥15 eosinophils per HPF 2 3 5 (Evidence: Strong).

Avoid Routine PPI Trial for Diagnosis: Exclude GERD through other means before diagnosing EoE 29 (Evidence: Moderate).

Topical Corticosteroids as First-Line Therapy: Use fluticasone propionate or budesonide for symptom control 2 18 (Evidence: Strong).

Consider Dietary Interventions: Implement elimination diets, particularly in pediatric patients 15 18 (Evidence: Moderate).

Monitor and Reassess Regularly: Regular endoscopic and histologic monitoring to assess response to therapy 1 2 3 5 (Evidence: Expert opinion).

References

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Helicobacter 2025. link 5 Domingues G, Moraes-Filho JPP, Chinzon D, Delgado Á. BRAZILIAN GASTROENTEROLOGY FEDERATION (FBG) CLINICAL GUIDELINE: DIAGNOSIS AND TREATMENT OF EOSINOPHILIC ESOPHAGITIS IN ADULTS AND ADOLESCENTS. Arquivos de gastroenterologia 2025. link 6 Levartovsky A, Dar L, Fay S, Ukashi O, Shachar E, Engel T et al.. Performance of gastroenterologists and multimodal LLMs in endoscopic EREFS scoring of Eosinophilic Esophagitis. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2025. link 7 Webber KF, Slaughter JC, Patel DA, Hiremath G. Impact of transfer from pediatric gastroenterology to adult gastroenterology care in eosinophilic esophagitis. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus 2025. link 8 McGowan EC, Wright BL, Ruffner MA, Pesek RD, Rothenberg ME, Spergel JM et al.. Eosinophilic esophagitis: An allergy and immunology perspective on the updated guidelines. The Journal of allergy and clinical immunology 2025. link 9 Bowyer K, Swisher AR, Jiang N, Liang J. Dupilumab adverse reactions in eosinophilic esophagitis treatment: a Food and Drug Administration Adverse Event Reporting System database analysis. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus 2025. link 10 Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N et al.. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Journal of pediatric gastroenterology and nutrition 2024. link 11 de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G et al.. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2024. link 12 de Bortoli N, Visaggi P, Penagini R, Annibale B, Baiano Svizzero F, Barbara G et al.. The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis - Definition, Clinical Presentation and Diagnosis. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2024. link 13 Schlager H, Baumann-Durchschein F, Steidl K, Häfner M, Dinkhauser P, Weitersberger M et al.. Diagnosis and management of eosinophilic esophagitis and esophageal food impaction in adults : A position paper issued by the Austrian Society of Gastroenterology and Hepatology (ÖGGH). Wiener klinische Wochenschrift 2024. link 14 Cameron BA, Anderson CW, Jensen ET, Dellon ES. Vitamin D Levels as a Potential Modifier of Eosinophilic Esophagitis Severity in Adults. Digestive diseases and sciences 2024. link 15 Mayerhofer C, Kavallar AM, Aldrian D, Lindner AK, Müller T, Vogel GF. Efficacy of Elimination Diets in Eosinophilic Esophagitis: A Systematic Review and Meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2023. link 16 Kim D, Kim J, Gil NS, Yoo SY, Kim YR, Ko JS et al.. The utility of the perfusion index as an indicator of anesthetic depth for repeated propofol sedation in children: An observational study. Pediatrics international : official journal of the Japan Pediatric Society 2023. link 17 Dhar A, Haboubi HN, Attwood SE, Auth MKH, Dunn JM, Sweis R et al.. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut 2022. link 18 Hirano I, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis. Gastroenterology 2020. link 19 Tourlamain G, Garcia-Puig R, Gutiérrez-Junquera C, Papadopoulou A, Roma E, Kalach N et al.. Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice. Journal of pediatric gastroenterology and nutrition 2020. link 20 Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM et al.. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology 2020. link 21 Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM et al.. Technical review on the management of eosinophilic esophagitis: a report from the AGA institute and the joint task force on allergy-immunology practice parameters. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology 2020. link 22 Alcaide Suárez N, Santos Fernández J, Fernández Salazar L. Eosinophilic esophagitis after an episode of herpetic esophagitis. Revista espanola de enfermedades digestivas 2019. link 23 Miehlke S, von Arnim U, Schlag C, Frieling T, Madisch A, Loibl R et al.. Clinical management of eosinophilic esophagitis - a nationwide survey among gastroenterologists in Germany. Zeitschrift fur Gastroenterologie 2019. link 24 Chang JW, Saini SD, Mellinger JL, Chen JW, Zikmund-Fisher BJ, Rubenstein JH. Management of eosinophilic esophagitis is often discordant with guidelines and not patient-centered: results of a survey of gastroenterologists. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus 2019. link 25 Pierre R, Vieira M, Vázquez R, Ninomiya I, Messere G, Daza W et al.. Prevalence of eosinophilic esophagitis: A multicenter study on a pediatric population evaluated at thirty-six Latin American gastroenterology centers. Revista de gastroenterologia de Mexico (English) 2019. link 26 Kumar S, Choi S, Gupta SK. Eosinophilic Esophagitis-A Primer for Otolaryngologists. JAMA otolaryngology-- head & neck surgery 2019. link 27 Mousavinasab F, Babaie D, Nilipour Y, Mansouri M, Imanzadeh F, Dara N et al.. Increased number of regulatory T cells in esophageal tissue of patients with eosinophilic esophagitis in comparison to gastro esophageal reflux disease and control groups. 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Eosinophilic esophagitis