eosinophilic oesophagitis
Contents
Chronic immune-mediated oesophageal disease defined by symptoms of oesophageal dysfunction + ≥15 eosinophils/hpf on biopsy. Most common cause of food impaction and dysphagia in young adults. Three treatment pillars: PPI (first-line), topical swallowed corticosteroids, and elimination diet. Dupilumab (Dupixent) for PPI-refractory disease. Untreated EoE progresses from inflammatory to fibrostenotic phenotype — early treatment prevents stricture formation.
diagnosis
Both required:
- Symptoms of oesophageal dysfunction (dysphagia, food impaction, chest pain, heartburn unresponsive to PPI in adults; feeding difficulty, vomiting, abdominal pain in children)
- ≥15 eosinophils/hpf on oesophageal biopsy
biopsy protocol
- ≥6 biopsies from at least 2 oesophageal levels (proximal and distal) — eosinophilic infiltration is patchy
- Biopsy any visible abnormalities (rings, furrows, exudates) AND normal-appearing mucosa
- PPI no longer needs to be trialled before biopsy — PPI-responsive oesophageal eosinophilia is now considered part of the EoE spectrum
EREFS endoscopic scoring
| feature | appearance |
|---|---|
| Edema | loss of vascular pattern, mucosal pallor |
| Rings | concentric mucosal rings (“trachealization”) |
| Exudates | white punctate plaques |
| Furrows | longitudinal linear grooves |
| Strictures | fixed luminal narrowing |
Up to 10% of EoE patients have grossly normal endoscopy. Always biopsy if clinical suspicion — especially young males with dysphagia, food impaction, or atopic history.
treatment
Goal: histological remission (<15 eos/hpf, ideally <6) + symptom improvement. Symptom resolution alone is insufficient — subclinical inflammation drives fibrostenotic remodelling.
first-line: PPI
- Standard or high-dose PPI × 8 weeks → repeat EGD with biopsies
- Achieves histological remission in ~50%
- If remission: continue maintenance PPI at the lowest effective dose
second-line: topical swallowed corticosteroids
For PPI non-responders or as initial therapy in centres that prefer this approach.
| agent | dose | formulation |
|---|---|---|
| budesonide oral suspension (Jorveza-type) | 1 mg twice daily | purpose-made orodispersible tablet (where available) |
| budesonide nebuliser solution (swallowed) | 1 mg twice daily | mix with sucralose, swallow — do not inhale |
| fluticasone MDI (swallowed) | 880–1760 µg/day in divided doses | actuate into mouth without spacer, swallow; do not rinse |
- No eating or drinking for 30 minutes after dosing
- Repeat EGD at 8–12 weeks to confirm histological remission
- Maintenance: reduce to lowest effective dose; relapse is nearly universal off therapy
- Oesophageal candidiasis risk (~5–10%) — counsel on symptoms
dietary therapy: step-up elimination
Effective alternative, particularly if patient prefers non-pharmacological approach.
| step | foods eliminated | histological response |
|---|---|---|
| 2-food | dairy, wheat | ~40–50% |
| 4-food | + egg, legumes/soy | ~55–65% |
| 6-food | + seafood, nuts | ~70–75% |
- Start with 2-food elimination × 6 weeks → EGD with biopsies
- If no remission, step up to 4-food, then 6-food
- Once remission achieved, reintroduce one food group every 6 weeks with EGD to identify the trigger
- Requires motivated patient and dietician support
biologic therapy: dupilumab
- Indication: PPI-refractory EoE in adults and adolescents ≥12 years weighing ≥40 kg
- LIBERTY EoE TREET (2022) — 60% histological remission vs 5% placebo at 24 weeks
- Dose: 300 mg SC weekly
- Also addresses concurrent atopic comorbidities (asthma, atopic dermatitis)
dilation
- For established fibrostenotic strictures causing mechanical dysphagia despite anti-inflammatory therapy
- Through-the-scope balloon or Savary bougie — gradual dilation, not aggressive single-session
- Does not treat underlying inflammation — always combine with medical or dietary therapy
- Perforation risk is low (~0.3%) with modern graded technique — the historical fear of “fragile EoE oesophagus” is overstated
monitoring
- Repeat EGD with biopsies is the only reliable way to assess remission — symptoms correlate poorly with histology
- After achieving remission: EGD at 1 year, then as clinically indicated
- Assess for fibrostenotic progression at each endoscopy (EREFS scoring)
common traps
- Relying on symptoms alone to assess treatment response — subclinical eosinophilic inflammation persists in up to 40% of asymptomatic patients; repeat biopsies are mandatory
- Forgetting to biopsy after food impaction — EoE is the underlying cause in the majority of young adults with food bolus impaction
- Insufficient biopsies — <6 biopsies miss patchy disease; biopsy proximal and distal oesophagus
- Stopping topical steroids after remission without a maintenance plan — relapse rate approaches 90% within 1 year off therapy
- Dilating without treating inflammation — strictures recur rapidly without concurrent anti-inflammatory therapy
related: gastro-oesophageal reflux disease · dysphagia · Barrett’s oesophagus