Eosinophilic oesophagitis (EoE)

By Dr. Bahir Hadi — Consultant Surgeon, PhD

Eosinophilic oesophagitis (EoE): the allergic oesophageal disease

Eosinophilic oesophagitis (EoE) is a chronic, immune-mediated inflammatory disease of the oesophagus in which allergic inflammatory cells (eosinophils) accumulate in the mucosa. EoE is the second most common cause of chronic dysphagia after GERD, and prevalence has risen sharply over the past 20 years - now estimated at 1 in 2,000 in Western countries [1]. It most commonly affects men in their 20s-40s with concurrent asthma, eczema or hay fever.

Symptoms

EoE is a chronic progressive disease - symptoms often develop over years:

Dysphagia - especially for solid food
Food bolus impaction - food stuck in the oesophagus (classic acute presentation in young men)
Chest pain - may mimic cardiac pain
Heartburn - often PPI-refractory
Vomiting, regurgitation
Adaptive eating behaviour - patients eat slowly, chew thoroughly, drink much water with meals

In children: failure to thrive, vomiting, food aversion.

Why does EoE occur?

EoE is a type 2 immune reaction against food antigens (milk, wheat, egg, soy, nuts, fish) or aeroallergens. Genetic factors (TSLP, CAPN14, CCL26) predispose. Eosinophilic inflammation leads to:

Acute phase: oedema, mucosal furrows, white exudates
Chronic phase: tracheal rings ("feline oesophagus"), strictures, fibrosis

Diagnosis

EoE is diagnosed by three concurrent criteria [2]:

Symptoms of oesophageal dysfunction
≥15 eosinophils per high-power field on oesophageal biopsy
Exclusion of other causes (especially GERD)

Gastroscopy with multiple biopsies is mandatory - at least 6 biopsies from proximal AND distal oesophagus, because inflammation is patchy.

Typical endoscopic findings:

Concentric rings
Longitudinal furrows
White exudates (eosinophil microabscesses)
Strictures
"Crepe paper" mucosa

Differential diagnoses

Condition	Distinction
GERD	Responds to PPI; eosinophilia usually distal
PPI-responsive oesophageal eosinophilia	EoE responding to PPI (now considered a subgroup of EoE)
Achalasia	Abnormal manometry; dysphagia to both liquids and solids
Candida oesophagitis	White plaques, usually immunosuppressed
Crohn's with oesophageal involvement	Rare; biopsy shows granulomas

Treatment - the 3 Ds

1. Drugs:

Proton pump inhibitors (PPIs) - 40-60 % achieve histological remission [3]. First-line.
Topical steroids - swallowed fluticasone or orodispersible budesonide (Jorveza). 60-80 % effective.
Dupilumab (IL-4/IL-13 blocker) - approved 2022 for PPI-refractory EoE.

2. Diet:

Empirical 6-food elimination diet (milk, wheat, egg, soy, nuts, fish) - 70 % remission, restrictive.
4-food elimination diet (milk, wheat, egg, soy) - 50 % efficacy, easier to follow.
Reintroduction of one food at a time + check gastroscopy.

3. Dilatation:

Endoscopic dilatation for symptomatic strictures - safe (perforation rate <1 %).
Treats symptoms but not underlying inflammation.

Follow-up

Repeat gastroscopy with biopsies 8-12 weeks after starting therapy to assess histological response.
Long-term treatment is required - symptoms and inflammation recur on stopping treatment.

Treatment at Kirurgen.dk

We investigate chronic dysphagia, heartburn and food impaction with oral or nasal gastroscopy and routine biopsies from proximal and distal oesophagus when EoE is suspected. See also: Dysphagia, GERD, Peptic ulcer, Nasal vs. oral gastroscopy.

References

Dellon ES, Hirano I. Epidemiology and natural history of eosinophilic esophagitis. Gastroenterology 2018;154(2):319-32.
Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis. United European Gastroenterol J 2017;5(3):335-58.
Laserna-Mendieta EJ, Casabona S, Savarino E, et al. Efficacy of therapy for eosinophilic esophagitis in real-world practice. Clin Gastroenterol Hepatol 2020;18(13):2903-11.

Eosinophilic oesophagitis (EoE)