What Is the Current Approach to Diagnosing and Treating Eosinophilic Esophagitis?

Diagnosis requires biopsy even when the esophagus looks normal

Typical endoscopic findings include rings, furrows, exudates, edema and strictures, summarized by the EoE Endoscopic Reference Score (EREFS). Yet endoscopy can appear deceptively normal. The 2025 ACG guideline emphasizes adequate tissue sampling: six biopsies from at least two levels rather than a single distal specimen.

PPI response no longer defines a separate disease

Earlier frameworks separated 'PPI-responsive esophageal eosinophilia' from EoE. That distinction has been abandoned. PPIs are now understood as a therapeutic option for EoE, not a diagnostic exclusion test.

First-line treatment should be individualized

Patients can reasonably start with high-dose PPI therapy, swallowed topical steroids such as budesonide or fluticasone, or an empiric food-elimination diet. If diet is chosen, current practice favors starting with less restrictive strategies such as one- or two-food elimination rather than automatically imposing six-food elimination. Response should be confirmed with repeat endoscopy and biopsy because symptom improvement alone does not reliably establish histologic control.

Fibrostenosis needs mechanical and anti-inflammatory treatment

Dilation can improve dysphagia and treat a clinically important stricture, but it does not treat the underlying inflammation. Dilation should therefore complement, not replace, anti-inflammatory therapy. Patients with a narrow-caliber esophagus may require staged dilation.

Maintenance matters

EoE recurs when effective therapy is stopped in many patients. Once a treatment achieves clinical and histologic control, maintenance dietary or pharmacologic therapy is generally appropriate. Dupilumab is particularly relevant in treatment-resistant disease or in patients with substantial coexisting atopic disease.

A practical clinical approach

1. Elicit dysphagia, food impactions and compensatory eating behaviors, plus atopic history.
2. Perform diagnostic endoscopy under conditions that minimize false-negative histology when clinically feasible.
3. Document EREFS and obtain six biopsies from two esophageal levels.
4. Choose PPI, topical steroid or empiric dietary therapy through shared decision-making.
5. Reassess with endoscopy and biopsy rather than symptoms alone.
6. Dilate clinically significant narrowing while continuing anti-inflammatory treatment.
7. Maintain effective therapy; consider dupilumab for appropriate step-up patients.

Common errors to avoid

• Diagnosing EoE from symptoms alone.
• Taking too few biopsies.
• Using symptom improvement as proof of histologic remission.
• Treating a stricture with dilation but leaving inflammation untreated.
• Assuming a PPI response excludes EoE.

What should trainees remember?

The key conceptual change is that EoE is a chronic inflammatory and fibrostenotic disease. Diagnosis is histologic; treatment targets inflammation and, when present, narrowing.

Free further reading from Dr. Alan B. R. Thomson

For a broad framework, see Dr. Thomson's Guideline-Based Management in Gastroenterology and Practice Review in Gastroenterology.

Frequently asked questions

Is a PPI trial required before diagnosing EoE?

No. PPI failure is no longer a diagnostic requirement.

How many biopsies should be obtained?

Current ACG guidance recommends six targeted biopsies from two esophageal levels.

Can dilation be used alone?

It can relieve narrowing, but anti-inflammatory treatment should also be used because dilation does not treat the disease process.

References

1. Thomson ABR. Guideline-Based Management in Gastroenterology. CAPstone Academic Publishers; 2015. ISBN 978-1515078623.

2. Thomson ABR. Practice Review in Gastroenterology. CAPstone Academic Publishers; 2014. ISBN 978-1500855321.

3. Dellon ES, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Updated January 2025. American College of Gastroenterology.

4. Eluri S. A Look at the Updated ACG Eosinophilic Esophagitis Clinical Guidelines. Evidence-Based GI. 2025.