Eosinophilic esophagitis: Causes, symptoms, diagnosis and treatment


Eosinophilic esophagitis (EoE) is a chronic immune system disease that affects the esophagus, the tube that carries food from the mouth to the stomach. Characterized by a high concentration of eosinophils—a type of white blood cell—within the esophagus, EoE can lead to various gastrointestinal symptoms. This guide aims to provide patients with a comprehensive understanding of EoE, its symptoms, causes, diagnosis, and treatment options.

What is eosinophilic esophagitis?

Eosinophilic esophagitis (EoE) is driven by an allergic reaction to food or environmental triggers, leading to inflammation of the esophagus. This inflammation can cause scarring, narrowing, and stiffening of the esophagus, making it difficult to swallow and increasing the risk of food getting stuck (impaction).

Eosinophilic esophagitis: Causes and risk factors

The exact cause of EoE is not fully understood, but it is believed to be related to an allergic response to certain foods or environmental allergens. Risk factors may include:

  • A history of atopic diseases such as asthma, eczema, or allergic rhinitis
  • Family history of EoE or other allergic conditions
  • Being male, as males are more commonly affected than females
  • Seasonal allergies, which can worsen the condition

Eosinophilic esophagitis: Diagnosis criteria

The diagnosis of eosinophilic esophagitis (EoE) is comprehensive, involving clinical evaluation, endoscopic findings, histologic confirmation, and the exclusion of other conditions that could mimic EoE. Here’s a detailed look at the criteria for diagnosing EoE:

1. Clinical Symptoms

EoE presents with a variety of symptoms related to esophageal dysfunction, which can include:

  • Dysphagia (difficulty swallowing)
  • Food impaction (food getting stuck in the esophagus)
  • Chest pain not related to the heart
  • Heartburn that doesn’t respond well to proton pump inhibitors (PPIs)
  • In children, symptoms may also include feeding difficulties, failure to thrive, nausea, and abdominal pain.

2. Endoscopic Findings

While not all patients with EoE will have visible esophageal changes, common endoscopic findings can include:

  • Rings forming in the esophagus, often described as a “trachealization” appearance
  • Linear furrows or vertical lines along the esophageal lining
  • White plaques or specks that may be eosinophilic abscesses
  • Esophageal narrowing or strictures
  • A crepe-paper-like appearance due to fragility of the esophageal mucosa

3. Histologic Confirmation

Histology involves examining tissue samples (biopsies) taken from the esophagus under a microscope. The hallmark of EoE is:

  • A high density of eosinophils in the esophageal tissue, typically defined as 15 or more eosinophils per high-power field (hpf) in at least one biopsy specimen.

4. Response to Therapy

A significant improvement in symptoms and histologic findings following dietary management or the use of topical steroids can support the diagnosis of EoE.

5. Differential Diagnosis

Other conditions that can cause eosinophilic infiltration of the esophagus should be excluded, such as:

GERD is a particularly important condition to rule out because it can also cause eosinophil infiltration of the esophagus, but typically to a lesser degree than EoE. A trial of proton pump inhibitors (PPIs) is often used to help distinguish between GERD and EoE. If symptoms and histologic features persist despite adequate acid suppression therapy, it supports a diagnosis of EoE rather than GERD.

Eosinophilic esophagitis: Treatment and management

Treatment for EoE aims to reduce eosinophil levels in the esophagus, alleviate symptoms, and prevent complications. Treatment strategies include:

  • Dietary Management: Identifying and eliminating foods that trigger symptoms. This may involve an elimination diet, in which common allergens are removed and then slowly reintroduced to identify triggers.
  • Medications: Topical steroids (swallowed, not inhaled) can reduce inflammation in the esophagus. Proton pump inhibitors (PPIs) are also used to treat acid reflux symptoms that can co-occur with EoE.
  • Dilation: For those with significant narrowing of the esophagus, endoscopic dilation may be performed to widen the esophagus and alleviate swallowing difficulties.

Living with eosinophilic esophagitis

Living with EoE can be challenging, but with the right management plan, most patients can lead normal, healthy lives. It’s important for patients to work closely with their healthcare team, including gastroenterologists and dietitians, to develop a personalized treatment plan.


The diagnosis of eosinophilic esophagitis (EoE) is multifactorial and requires a careful integration of clinical presentation, endoscopic examination, histologic analysis, and response to therapy, while also excluding other causes of eosinophilic infiltration in the esophagus. Given the complexity of the condition and its overlap with other gastrointestinal diseases, patients suspected of having EoE should be evaluated by a gastroenterologist experienced in the management of this disease.

Last update: 12 April 2024, 00:52


Gastroenterologist - Hepatologist, Thessaloniki

PhD at Medical School, Aristotle University of Thessaloniki, Greece

PGDip at Universitair Medisch Centrum Utrecht, The Netherlands

Ex President, Hellenic H. pylori & Microbiota Study Group