A Condition That Used to Be Missed
Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease in which eosinophils — a type of white blood cell associated with allergic reactions — accumulate in the esophagus. The result is inflammation, scarring, and narrowing that causes swallowing problems, food impaction, and symptoms that often look like reflux but don't respond to acid suppression.
EoE was barely recognized 25 years ago. It is now diagnosed in roughly 1 in 2,000 adults and is increasingly common in children. At Zimmer Medical Group, we consider EoE in patients with persistent swallowing symptoms, food impaction, or refractory reflux.
How Symptoms Differ Between Adults and Children
Adults
- Difficulty swallowing solid foods (dysphagia) — particularly meat, bread, raw vegetables
- Food impaction — food getting stuck and requiring intervention
- Heartburn that doesn't fully respond to PPI therapy
- Chest pain
- Coping behaviors: chewing very thoroughly, eating slowly, drinking with every bite, avoiding certain foods
Many adults have learned to compensate for swallowing difficulty over years and don't recognize it as abnormal until they have a food impaction.
Children
- Feeding difficulties
- Vomiting
- Abdominal pain
- Failure to thrive
- Heartburn that doesn't respond to standard treatment
Who Develops EoE
EoE is more common in:
- Men (roughly 3:1 male predominance)
- White individuals
- Patients with other allergic conditions: asthma, allergic rhinitis, eczema, food allergies
- Family history of EoE or allergic disease
- Adolescents and young adults (peak diagnosis age 30–40)
Many patients with EoE have a personal or family history of allergic conditions.
Why It Often Looks Like GERD
EoE and GERD can be very difficult to distinguish on symptoms alone. Both can cause heartburn, chest pain, and even some swallowing difficulty. The difference often becomes apparent when:
- Symptoms don't respond to adequate PPI trials
- Food impaction occurs
- Endoscopy shows characteristic findings
This is one reason endoscopy is important when reflux symptoms persist despite treatment, particularly in younger adults — see our companion guide on long-term PPI use.
Diagnosis Requires Endoscopy and Biopsy
Diagnosis of EoE requires:
- Symptoms of esophageal dysfunction
- ≥ 15 eosinophils per high-power field on esophageal biopsy
- Other causes of esophageal eosinophilia excluded
Because the condition can affect the esophagus in patches, multiple biopsies (typically 2–4 each from proximal and distal esophagus) are recommended even when the esophagus looks normal.
Endoscopic findings can include:
- Linear furrows
- Concentric rings ("trachealization")
- White exudates or plaques
- Strictures or narrowing
- Sometimes a normal-appearing esophagus despite significant disease
Distinguishing EoE from PPI-Responsive Esophageal Eosinophilia
Some patients have esophageal eosinophilia that responds to PPI therapy alone — historically considered separate from EoE but now grouped under the same diagnosis if biopsy criteria are met. The practical implication: a trial of PPI therapy is usually still appropriate before further EoE-specific treatment.
Treatment Options
EoE is a chronic disease requiring ongoing management. Three main treatment approaches:
1. Proton Pump Inhibitors
A trial of high-dose PPI therapy (often 20–40 mg twice daily) for 8–12 weeks remains a reasonable first step. About 30–50 percent of patients respond. Those who do may continue PPIs as their primary treatment.
2. Topical Corticosteroids
Swallowed topical corticosteroids — budesonide oral suspension (Eohilia) or off-label use of fluticasone (from an asthma inhaler) — are highly effective. The medication coats the esophagus and reduces inflammation locally with minimal systemic absorption.
Eohilia received FDA approval in 2024 specifically for EoE in patients ≥ 11 years old, providing a standardized formulation for esophageal delivery.
3. Dietary Therapy
Several dietary approaches can be effective:
- Six-food elimination diet (SFED): removes the most common food triggers — milk, wheat, eggs, soy, nuts, and fish/shellfish
- Four-food elimination diet (FFED): removes milk, wheat, eggs, and soy
- Targeted elimination based on testing: less reliable than empiric approaches for adults
- Elemental diet: amino acid-based formula; highly effective but difficult to maintain
After dietary improvement is documented, foods are typically reintroduced one at a time to identify specific triggers.
4. Biologic Therapy
Dupilumab (Dupixent) received FDA approval for EoE in 2022 in patients ≥ 1 year old weighing ≥ 15 kg. This injected biologic blocks IL-4 and IL-13 signaling, key drivers of EoE inflammation. Dupilumab is particularly useful for patients with EoE plus other atopic conditions (asthma, eczema, chronic rhinosinusitis with nasal polyps).
5. Esophageal Dilation
For patients with strictures causing significant symptoms, endoscopic dilation can mechanically widen the esophagus. This addresses symptoms but doesn't treat the underlying inflammation; medical or dietary therapy is still needed.
What to Do During Food Impaction
Food impaction in the esophagus is a medical emergency requiring prompt evaluation. While waiting for help:
- Don't try to wash food down with more food or large amounts of liquid
- Don't induce vomiting
- Spit out saliva you can't swallow
- Get to an emergency department for endoscopic removal
After the impaction is resolved, biopsies should be obtained to evaluate for EoE — many cases of EoE are first diagnosed after a food impaction.
Long-Term Management
EoE is a chronic disease that recurs without ongoing treatment. Long-term management includes:
- Continued treatment to maintain remission
- Periodic endoscopy with biopsies to confirm continued response
- Adjustment of therapy based on symptoms and biopsy findings
- Addressing other allergic conditions
When to See Your Doctor
- Difficulty swallowing solid foods that has progressed over months
- Food getting stuck in the throat or chest
- Reflux symptoms not responding adequately to PPI therapy
- A history of food impaction
- Personal or family history of allergic conditions plus persistent esophageal symptoms
The American Gastroenterological Association and the American Partnership for Eosinophilic Disorders provide additional patient resources on EoE.
Persistent swallowing problems or treatment-resistant reflux? Contact Zimmer Medical Group for an evaluation that considers EoE and the right next steps for diagnosis and treatment.
