Diagnosis and Management of Eosinophilic Esophagitis

Diagnostic Criteria

The American Gastroenterological Association recommends that eosinophilic esophagitis (EoE) is diagnosed when a patient has symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or ~60 eosinophils/mm²) on esophageal biopsy, after a comprehensive assessment has ruled out other disorders that could cause or contribute to esophageal eosinophilia 1, 2
Symptoms of esophageal dysfunction are required for diagnosis, including dysphagia, food impaction, chest pain, or feeding difficulties, as stated by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition 3, 1
Concomitant atopic conditions (asthma, allergic rhinitis, eczema) increase suspicion for EoE, according to the American Academy of Allergy, Asthma, and Immunology 2, 4
At least 15 eosinophils per high-power field (or ~60 eosinophils/mm²) in at least one esophageal biopsy specimen is required for diagnosis, as recommended by the British Society of Gastroenterology 3, 1
Multiple biopsies (at least six) should be taken from different anatomical sites within the esophagus to increase diagnostic yield, as suggested by the American Society for Gastrointestinal Endoscopy 3, 1

Additional histological features supporting the diagnosis include basal cell hyperplasia, eosinophil microabscesses, eosinophil layering, eosinophil degranulation, subepithelial sclerosis, and spongiosis (epithelial edema), as described by the World Gastroenterology Organisation 3

Assessment for non-EoE disorders that cause or potentially contribute to esophageal eosinophilia is required, including gastroesophageal reflux disease (GERD), hypereosinophilic syndrome, achalasia, Crohn's disease, infections, and connective tissue disorders, as recommended by the American College of Gastroenterology 1, 2, 5, 6

Proton pump inhibitors (PPIs) are effective in inducing histological and clinical remission, and should be given twice daily for 8-12 weeks before assessing response, as recommended by the National Institute for Health and Care Excellence 7
Topical steroids (fluticasone, budesonide) are effective for inducing histological and clinical remission, but clinical and histological relapse is high after withdrawal of topical steroid treatment, as stated by the European Society of Gastrointestinal Endoscopy 7
Elimination diets are effective in achieving clinico-histological remission, and options include six-food elimination diet, two or four food elimination diets, and elemental diets, as recommended by the Academy of Nutrition and Dietetics 3, 7
Endoscopic dilation is safe and effective for patients with fibrostenotic disease, and can be performed using either balloon or bougie dilators, as suggested by the American Society for Gastrointestinal Endoscopy 7

PPI-responsive esophageal eosinophilia is now considered part of the EoE spectrum, not a separate entity, as stated by the American Gastroenterological Association 1, 2
A PPI trial is no longer required for diagnosis of EoE, as recommended by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition 1, 5
EoE and GERD are not mutually exclusive and can coexist in the same patient, as described by the World Gastroenterology Organisation 3, 1
At least six biopsies should be taken from different anatomical sites within the esophagus, as suggested by the British Society of Gastroenterology 3
Gastric and duodenal biopsies should be obtained if clinically indicated by symptoms or endoscopic findings, as recommended by the American College of Gastroenterology 1
Histological remission is defined as <15 eosinophils per 0.3 mm², as stated by the European Society of Gastrointestinal Endoscopy 3, 4
Symptoms may not always correlate with histological activity, as described by the World Gastroenterology Organisation 3, 6