Eosinophilic Esophagitis

Aka: Eosinophilic Esophagitis, Chronic Eosinophilic Esophagitis

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II. Pathophysiology

  1. Chronic inflammatory disease of the Esophagus ("Asthma of the Esophagus")
  2. IgE Immune-mediated Esophagitis

III. Symptoms: Teens and Adults

  1. Solid Dysphagia
  2. Food impaction (associated with Esophageal Strictures in up to 31%)
  3. Central Chest Pain refractory to Antacids
  4. Refractory GERD
  5. Upper abdominal (Epigastric Pain)

IV. Symptoms: Younger Children

  1. Feeding dysfunction
  2. Vomiting
  3. Abdominal Pain

V. Associated Conditions: Allergic Disorders

  1. Asthma
  2. Atopic Dermatitis
  3. Food Allergies
  4. Gluten Sensitive Enteropathy
  5. Environmental Allergies

VI. Diagnosis

  1. Upper Endoscopy with biopsy
    1. Esophageal Trachealization
      1. Concentric rings within Esophagus
    2. Esophageal biopsy
      1. Superficial mucosa with Eosinophil infiltration
  2. Factors more suggestive of Eosinophilc Esophagitis (in contrast to GERD)
    1. Younger age
    2. Male gender
    3. Dysphagia
    4. Food allergies
    5. Esophageal Rings, furrows or Plaques on endoscopy
    6. Hiatal Hernia absent

VII. Differential Diagnosis

  1. See Vomiting
  2. Gastroesophageal Reflux Disease
  3. Esophageal Dysmotility
  4. Inflammatory Bowel Disease
  5. Esophageal Cancer
  6. Parasitic Infection
  7. Other Esophagitis (e.g. candidal Esophagitis)

VIII. Management

  1. Manage as Gastroesophageal Reflux disease initially (prior to diagnosis by endoscopy and biopsy)
    1. Proton Pump Inhibitor (high dose, e.g. Omeprazole 40 mg orally twice daily)
    2. GERD precautions (avoiding Alcohol, Tobacco, Caffeine, food within 2 hours of lying supine)
  2. Avoid possible food triggers
    1. Identify and avoid triggering food (e.g. milk, wheat, eggs, soy, nuts and seafood)
      1. See Elimination Diet
      2. Risk of Vitamin Deficiency if restrictive diet
    2. Triggering food elimination results in up to 40% remission
    3. Formal Food Allergy testing is not recommended
  3. Inhaled Corticosteroids (e.g. Flovent HFA, budesonide) swallowed instead of inhaled
    1. Use Metered Dose Inhalers (not Dry Powder Inhalers)
    2. Puff the Inhaler within the mouth without inspiring, and then swallow the medication
      1. Alternatively, may mix budesonide nebules with Splenda and swallow
    3. Rinse mouth of steroid, but do not swallow water, other liquid or solid for at least 30 minutes
      1. Risk of Oral Candidiasis
    4. Alternative agents
      1. Budesonide Oral Suspension (Eohilia) is $2000/month in 2025
      2. Budesonide inhalation suspension 2 mg/dose
        1. Compound as home in honey or maple syrup (10 ml total) swallowed
  4. Biologic Agents
    1. Interleukin-4 Alpha Receptor Antagonist: Dupilumab (Dupixent)
      1. FDA approved down to 1 year in refractory Eosinophilic Esophagitis
  5. Maintenance
    1. Continue maintenance therapy indefinitely (if not resolved with food trigger avoidance)
      1. Expect flares to recur at 3 months after stopping maintenance therapy
    2. Endoscopy
      1. Endoscopy performed at routine intervals
      2. Espohageal Biopsy is typically obtained at 8 to 12 weeks after starting treatment to assess response

IX. Complications

  1. Esophageal Stricture

X. References

  1. Bonis and Furuta (2017) ...Eosinophilic Esophagitis, UpToDate, Wolters Kluwer, accessed 11/4/2017
  2. (2017) Presc Lett 24(11): 65
  3. (2025) Presc Lett 32(4): 23

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