Eosinophilic Esophagitis.Care & specialists in Spain

Eosinophilic esophagitis (EoE) is a chronic immune-mediated disease in which eosinophils, a type of white blood cell, infiltrate the lining of the esophagus in response to food and aeroallergens. It causes dysphagia, food impaction, and heartburn that does not fully respond to acid-suppressing drugs. Diagnosis requires endoscopy with biopsy showing at least 15 eosinophils per high-power field.

Acid reflux (GERD) causes heartburn and regurgitation that typically respond fully to standard PPI therapy. EoE causes solid-food dysphagia and food impaction more than heartburn, shows characteristic rings, furrows, and exudates at endoscopy, and requires a biopsy to confirm eosinophilic inflammation. The two can coexist, and PPI-responsive eosinophilia is now considered part of the EoE spectrum rather than a separate condition.

Adults usually present with slowly progressive solid-food dysphagia, recurrent food impaction, heartburn that does not fully resolve on PPI, and adaptive eating behaviors like drinking water with every bite or avoiding dry meats and bread. Many patients have years of subtle symptoms before diagnosis.

Children present with feeding refusal, vomiting, abdominal pain, prolonged meal times, food selectivity (eating only soft textures), and failure to thrive. Older children and teenagers begin to develop the adult pattern of solid-food dysphagia and food impaction.

Diagnosis requires upper endoscopy with biopsies showing at least 15 eosinophils per high-power field in a patient with symptoms of esophageal dysfunction, after excluding other causes. The 2018 AGREE international consensus removed the prior requirement for a PPI trial before diagnosis — PPI is now considered a treatment rather than a diagnostic test.

EoE is an immune-mediated reaction to food and aeroallergens, but it is not a classical IgE-mediated food allergy. Reactions are delayed (days to weeks rather than minutes), confined to the esophagus, and standard allergy tests do not reliably predict triggers. Empiric elimination diets identify triggers more reliably than allergy testing.

Milk is the most common trigger in both adults and children, followed by wheat, egg, and soy. Nuts and fish or shellfish are less common but possible triggers. The empiric 6-food elimination diet removes all six classes; the step-up approach starts with milk alone and adds foods sequentially.

EoE is not curable in the sense of permanent disease eradication, but it is highly controllable. With appropriate drug, dietary, or biologic therapy maintained long-term, histologic remission and freedom from food impaction are achievable in most patients. Withdrawal of therapy almost always leads to relapse within 6-12 months.

The six-food elimination diet removes milk, wheat, egg, soy, nuts, and fish/shellfish for 6-8 weeks. Endoscopy confirms remission, then foods are reintroduced one at a time over months with repeat biopsies to identify the specific triggers. About 60-75% of strictly adherent patients achieve remission with this approach.

The step-up diet starts with milk elimination alone for 6 weeks. If remission is not achieved, wheat is added (2-food); if still active, the diet expands to 4-food (milk, wheat, egg, soy). The STEP-UP trial (Kliewer 2023) showed comparable remission rates to the empiric 6-food approach with far less burden.

Dupilumab is a monoclonal antibody that blocks the IL-4 receptor alpha subunit, inhibiting both IL-4 and IL-13 — the key cytokines driving the type-2 inflammation in EoE. It is given as a weekly subcutaneous injection and achieved histologic remission in approximately 60% of patients at 24 weeks in the LIBERTY EoE TREET phase 3 trials (Dellon NEJM 2022).

Eohilia is a pre-mixed budesonide oral suspension, the first FDA-approved drug specifically for EoE (approved 2024). Patients swallow 2 mg twice daily and avoid eating or drinking for 30 minutes after each dose, allowing the steroid to coat and treat the esophageal mucosa. Histologic remission was achieved in roughly 53% at 12 weeks in pivotal trials.

PPI-responsive EoE is the subgroup of patients whose esophageal eosinophilia and symptoms remit on twice-daily proton pump inhibitor therapy. It was previously called a separate diagnosis (PPI-REE) but is now considered part of the EoE spectrum (Molina-Infante 2018). Roughly 30-50% of newly diagnosed adults respond to PPI alone.

Yes. EoE is the cause of roughly 50% of adult food impactions presenting to emergency departments and is the most common cause of food impaction in adults under 50. Any adult presenting with food impaction should have biopsies taken at the endoscopy used to remove the bolus.

EoE does not increase the risk of esophageal cancer based on current evidence. The main complications are stricture formation and food impaction, not malignancy. Surveillance endoscopy is performed to monitor inflammation and stricture, not for cancer screening.

After diagnosis, endoscopy is repeated at 8-12 weeks of any new therapy to confirm histologic remission. Once stable, intervals stretch to every 6-12 months and then every 1-2 years for surveillance. Symptom improvement alone does not prove that eosinophilic inflammation has cleared, so periodic biopsy is essential.

EoE has a strong genetic component. First-degree relatives have a roughly 10-fold higher risk, and twin studies estimate monozygotic concordance around 14-15%. Risk genes include CAPN14, TSLP, LRRC32, and STAT6, all in type-2 immune pathways. Atopic background in the family also raises individual EoE risk.

Most children do not outgrow EoE; without sustained therapy, inflammation persists into adulthood and can progress to stricture. Some pediatric patients can transition off restrictive diets onto medications during adolescence with continued surveillance, but spontaneous remission is uncommon.

Persistent heartburn or dysphagia despite 8 weeks of standard PPI therapy is one of the most common reasons EoE is diagnosed. EoE responds partially or fully to PPI in 30-50% of adults, but the rest need swallowed topical steroids, dietary elimination, or dupilumab. Endoscopy with biopsy clarifies whether eosinophilic inflammation is the underlying driver.

Untreated EoE is chronic and progressive. Each year of diagnostic delay raises the risk of a fixed esophageal stricture by approximately 9%. Food impactions become more frequent, the esophagus narrows diffusely, and dilation is eventually required. EoE does not shorten life expectancy or cause cancer, but it can severely impair quality of life.

Modern stepwise dilation (rule of 3 mm increments) is safe; serious complications such as perforation occur in under 0.5% of procedures. Post-procedural chest pain is common (roughly 75%) and usually settles within a few days. Dilation does not treat the underlying inflammation, so it is combined with drug or diet therapy.

Most patients need lifelong maintenance therapy because withdrawal causes histologic and symptomatic relapse in over 80% of adults within 12 months. Long-term dosing of swallowed steroids, dupilumab, PPI, or sustained dietary elimination is similar in principle to managing asthma or atopic dermatitis.