Eosinophilic
Esophagitis
Is
Anything
But
Obvious
Diagnosing eoe Managing eoe Diagnosing eoe Managing eoe
Reveal the unseen
and unspoken signs
of Eosinophilic
Eosinophilic Esophagitis
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Uncover the signs of chronic, relapsing esophageal inflammation across the 3 domains of EoE:  symptoms, endoscopy, and histopathology.1-4 symptoms, endoscopy, and histopathology.1-4

SEE EoE BEYOND

Symptoms

Caution Dysphagia

~50% of dysphagia cases may not be reported to a clinician, and it is the most common symptom of EoE, according to a 2018 online survey.*1,3-5 Patients may develop adaptive behaviors that mask symptoms, making EoE difficult to diagnose by symptoms alone.3,4,6,7

*In an April 2018 Takeda-sponsored cross-sectional, self-administered online health survey of 31,129 people, 4998 people reported dysphagia. Among these patients, 2553 sought healthcare, and 399 confirmed an EoE diagnosis.5

Reveal symptoms

SEE EoE BEYOND

Endoscopy

Strictures ahead sign

EoE should not be ruled out based on endoscopic findings alone. In a 2007 retrospective study of 117 patients with EoE, 1 in 4 had normal endoscopic findings.†8

†Of 117 patients with EoE, the esophageal mucosa was regarded as normal in 24.8% of the patients.8

Reveal endoscopy

SEE EoE BEYOND

Histopathology

Eosinophil counts alone do not establish an Eosinophilic Esophagitis (EoE) diagnosis.

Without investigating symptoms and endoscopic findings, the histological presence of esophageal eosinophilia alone does not establish an EoE diagnosis.3

Reveal histopathology

EoE is an inflammatory disease marked by the elevated presence of eosinophils localized in the esophagus2,9

EoE is a chronic, immune-mediated disorder in which eosinophils accumulate in the esophagus, causing inflammation and edema to the surrounding tissue.9,10 Eosinophils are not typically found in the esophagus under normal circumstances.9 In EoE, however, an immune response to food allergens or aeroallergens increases the number of eosinophils in the esophagus along with other inflammatory immune cells.11

EoE impacts patients in many different ways9,12,13

In addition to symptoms like dysphagia, untreated chronic inflammation can manifest in endoscopic complications like strictures, horizontal rings, and furrows.10,14,15 Some patients with EoE may also present with psychiatric comorbidities.13 One 2020 retrospective study of 883 patients found that up to 28% of patients with EoE experienced psychiatric comorbidities such as anxiety (23%) and depression (17%).‡13

EoE involves the complex interplay of genetics, environmental factors, immune system dysfunction, and atopy16

Some patients with EoE have a history of IgE-mediated allergic comorbidities, with sensitivity to food or other allergens in the esophagus.3,17-20 Esophageal inflammation and remodeling in EoE may be a result of repeated exposure to food and environmental allergens that can eventually lead to impaction of solid or coarse foods, which may not necessarily contain those inflammation-triggering allergens.17,18 Educating your patients about the consequences of this ongoing inflammatory process is important.

‡In a study using the University of North Carolina EoE Clinicopathologic Database from 2002 to 2018. Of 883 patients diagnosed with EoE (per consensus guidelines), 241 (28%) had a psychiatric comorbidity. Study limitations include that this is a single-center retrospective study where a comparison to the national representative figures was done through nonstatistical analyses.13

The mechanism of disease in EoE

The prevalence
of EoE is rising21-23

orange underline
1 in 2000

Approximately 1 in 2000 people in the U.S. live with EoE14,17,22-24

Icon of a parent holding a child's hand.

The majority of EoE cases are in children, adolescents, and adults ages 50 or younger, but it can affect all ages.1,3,14,25,26

Twice as common

EoE is approximately twice as common in men vs women and more common among Caucasians, but can affect all sexes and races14,25,26

Food impaction icon

EoE is a leading cause of dysphagia and food impaction for children and young adults3

Rise icon

Emerging evidence suggests environmental factors such as microbes, early life events affecting the microbiome, and other factors may be contributing to the rise in prevalence of EoE11,17,21,27-29

Brain

One 2020 retrospective study of 883 patients reported that one-third of adults and 1 in 7 children with EoE have received a diagnosis of a psychiatric condition§13

§In a study using the University of North Carolina EoE Clinicopathologic Database from 2002 to 2018. Of 883 patients diagnosed with EoE (per consensus guidelines), 241 (28%) had a psychiatric comorbidity. Study limitations include that this is a single-center retrospective study where a comparison to the national representative figures was done through nonstatistical analyses.13

Adaptive behaviors can contribute to disconnects in what patients say and what their endoscopies show1,3,11,28

For patients with EoE, inflammation can lead to symptoms such as dysphagia and food impaction, which may produce a certain amount of fear and interfere with everyday life.9 Without realizing, some patients develop adaptive behaviors to cope with these symptoms.6,28 But adaptive behaviors can minimize awareness and symptom reporting, so symptoms of EoE should always be assessed in conjunction with endoscopies and biopsies.3,4,6,28

Identify adaptive behaviors to help reveal EoE||

Chewing food excessively

Chewing food excessively3,28,30

watch a patient story

Eating slowly

Eating slowly7,28,30

watch a patient story

Cutting food into small pieces

Cutting food into small pieces1,11

watch a patient story

Other common adaptive behaviors

  • Avoidance of large meals31
  • Avoidance of foods that have hard or lumpy textures6,28,31
  • Poor acceptance of new foods30,31
  • Lubricating food bites with condiments28,30
  • Drinking with most bites of food6,28,30
  • Substituting solids with blended or pureed foods30,31
  • Avoiding social settings involving food30,32

watch a patient story

||Illustrative only. Adaptive behaviors will vary by patient.

Asking the right questions can identify adaptive behaviors
and potentially reveal masked symptoms of EoE1

LEARN MORE

SEE EoE THROUGH 3 DIAGNOSTIC DOMAINS:

orange underline

Symptoms, Endoscopy, Histopathology

According to guidelines, diagnosis and monitoring of EoE require the holistic approach of assessing the 3 domains together¶2-4,28

There are several limitations associated with each of the 3 domains so no single domain alone should be relied on to draw conclusions about diagnosis, or how to manage ongoing disease activity.2-4,28 EoE is heterogeneous and can have overlapping signs and symptoms with other eosinophilic conditions, reinforcing the need for a differential diagnosis through the 3 domains.2

As per the 2018 updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis from the A Working Group on proton pump inhibitor–responsive esophageal eosinophilia (AGREE) Conference.

Diagram: The three Eosinophilic Esophagitis (EoE) diagnostic domains of symptoms, endoscopy and histopathology.
3 domains

SEE EoE THROUGH 3 DIAGNOSTIC DOMAINS:

Symptoms, Endoscopy, Histopathology Symptoms, Endoscopy, Histopathology

According to guidelines, diagnosis and monitoring of EoE require the holistic approach of assessing the 3 domains together¶2-4,28

There are several limitations associated with each of the 3 domains so no single domain alone should be relied on to draw conclusions about diagnosis, or how to manage ongoing disease activity.2-4,28 EoE is heterogeneous and can have overlapping signs and symptoms with other eosinophilic conditions, reinforcing the need for a differential diagnosis through the 3 domains.2

As per the 2018 updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis from the A Working Group on proton pump inhibitor–responsive esophageal eosinophilia (AGREE) Conference.

icon symptoms

SEEING EoE BEYOND

Symptoms

In a 2018 cross-sectional U.S. online survey of 31,129 people, 1 in 6 adults reported experiencing dysphagia (difficulty swallowing).#5 In adults with EoE, dysphagia is the most frequently reported symptom.1,7 Symptoms like dysphagia can generate fear, embarrassment, and distress for patients, which brings additional complexity to their struggle with the disease.9

Beyond dysphagia, EoE presents with a variety of symptoms across all ages.1,25 Understanding how symptoms may vary between age groups can be helpful when assessing clinical manifestations of EoE.1,14 Family history of EoE or dysphagia should increase the clinical index of suspicion.2

#In an April 2018 Takeda-sponsored cross-sectional, self-administered online health survey of 31,129 people, 4998 people reported dysphagia. Of these people, 399 confirmed an EoE diagnosis.5

Common symptoms of EoE**28

Adults

  • Difficulty or pain when swallowing
  • Food getting stuck in esophagus
  • Heartburn that does not respond to medicine
  • Swallowed food coming back up
  • Abdominal, chest, or throat pain
  • Avoiding certain foods that trigger symptoms

Children

  • Difficulty or pain when swallowing
  • Choking sensation
  • Food getting stuck in esophagus
  • Abdominal, chest, or throat pain
  • Nausea and vomiting
  • Disrupted sleep
  • Loss of appetite

Infants and Toddlers

  • Food aversion
  • Vomiting
  • Choking while eating
  • Disruptive sleep

**Individual symptoms will vary by patient.

Patients

Limitations of symptoms alone Limitations of symptoms alone

If your patient is suffering from symptoms of EoE, consider an endoscopy with biopsies to help assess esophageal inflammation and confirm suspicions of EoE.1 Some patients may present with symptoms that do not correlate with endoscopic and histologic findings because they can be masked by adaptive behaviors or overlap with other conditions.3,28,33 Learn more about adaptive behaviors, or scroll to see EoE beyond endoscopy.

Adaptive behaviors
icon endoscopy

SEEING EoE BEYOND

Endoscopy

Esophageal remodeling driven by inflammation can manifest as endoscopic features that can vary
by age3,34

Data in adults suggest that there's potential for inflammation to progress into strictures in some EoE patients with untreated disease.18,35

EoE endoscopy progression

Illustration adapted from Dellon ES, Hirano I. Gastroenterology. 2018;154(2):319-332.e3.

In adults, esophageal remodeling can manifest as fibrostenotic complications, such as strictures, which can lead to food impactions.12,34,36 For infants and toddlers, remodeling can lead to food avoidance.1,3 In children, endoscopic features like edema and exudates are more commonly seen.12,34,36 Diagnostic delays may increase the risk of fibrostenotic complications.10,12

Assessing endoscopic severity of EoE through 5 key features

There are 5 key endoscopic features–edema, rings, exudates, furrows, and strictures–that have been well studied and validated to help assess the endoscopic severity of inflammation and fibrostenotic remodeling in EoE across all ages.3,12,28,37,38 Though endoscopic findings are well documented in EoE, they cannot reliably establish a diagnosis on their own.3,37

Edema

Edema
  • Swelling of the esophageal mucosa3,28,39
  • Thick and whitish appearance28,39
  • Decreased vascularity3,39
  • May be more common in children34,36

Horizontal Rings

Horizontal Rings
  • Formation of multiple rings28
  • Can appear fine, web-like, or thickened28
  • Also termed trachealization or the "corrugated/ringed" esophagus28
  • May be more common in adults34,36

Exudates

Exudates
  • Patches of whitish papules28
  • Often 1-2 mm in diameter28
  • Resembles esophageal candidiasis28
  • May be more common in children34,36

Furrows

Linear Furrows
  • Vertical esophageal lines or ridges in the esophageal wall28
  • May be more common in children34,36

Strictures

Strictures
  • Narrowed esophagus, usually <13 mm diameter3,33
    • Featureless, unchanging column28
    • Poor expansion on air insufflation28
    • Proximal and/or distal stenosis28
  • Can cause food impactions and block endoscope40
  • May be more common in adults34,36
  • Edema
  • Horizontal Rings
  • Exudates
  • Furrows
  • Strictures

Edema

  • Swelling of the esophageal mucosa3,28,39
  • Thick and whitish appearance28,39
  • Decreased vascularity3,39
  • May be more common in children34,36
Edema

Horizontal Rings

  • Formation of multiple rings28
  • Can appear fine, web-like, or thickened28
  • Also termed trachealization or the "corrugated/ringed" esophagus28
  • May be more common in adults34,36
Horizontal Rings

Exudates

  • Patches of whitish papules28
  • Often 1-2 mm in diameter28
  • Resembles esophageal candidiasis28
  • May be more common in children34,36
Exudates

Furrows

  • Vertical esophageal lines or ridges in the esophageal wall28
  • May be more common in children34,36
Linear Furrows

Strictures

  • Narrowed esophagus, usually <13 mm diameter3,28
    • Featureless, unchanging column28
    • Poor expansion on air insufflation28
    • Proximal and/or distal stenosis28
  • Can cause food impactions and block endoscope40
  • May be more common in adults34,36
Strictures

Internal images of the body are artistic representations. Endoscopic features will vary by patient.

Limitations of endoscopy alone Limitations of endoscopy alone

Due to the patchy nature of the disease, some patients with EoE can present with normal endoscopic findings.1-4 Endoscopies can miss complications, such as strictures, caused by chronic inflammation in EoE.41 Endoscopic findings should be assessed in conjunction with symptoms and histopathology.1-4 Scroll on to see EoE beyond histopathology.

icon histopathology

SEEING EoE BEYOND

Histopathology

Chronic inflammation in EoE can be found inside the esophageal tissue, where eosinophils and other cells can cause recruitment of additional inflammatory immune cells, which contribute to tissue damage of the esophagus.10,11,18

The guidelines from the 2017 AGREE conference indicate that an eosinophil count of ≥15/HPF (high-power field) in at least one of multiple esophageal biopsy samples taken from different locations is clinically indicative of EoE.2,3 The presence of esophageal eosinophilia alone, however, cannot establish an EoE diagnosis without further investigation of symptoms and endoscopy.2-4

See inflammation beyond eosinophils2,3,42 See inflammation beyond eosinophils2,3,42

Other histologic features can help assess the severity and extent of esophageal inflammation. The interactive tissue below can help reveal other markers of inflammation.

Basal zone hyperplasia (BZH): Basal zone hyperplasia (BZH):
>15% of the epithelial thickness3,11,42
Papillary elongation:
Papillae extend above the mid portion of the squamous mucosa.3,11,43 Also observed in GERD.43
Dilated intercellular spaces (DIS): Dilated intercellular spaces (DIS):
Spaces around squamous epithelial cells that exhibit intercellular bridges3,12,47
Eosinophil inflammation (EI): Eosinophil inflammation (EI):
Eosinophil count within the most densely populated HPF (high-power field)3,11,42
Lamina propria fibers (LPF): Lamina propria fibers (LPF):
Thickened connective tissue fibers in the lamina propria3,42
Tissue Section

Basal zone hyperplasia (BZH):

>15% of the epithelial thickness3,11,42

Papillary elongation:

Papillae extend above the mid portion of the squamous mucosa.3,11,43 Also observed in GERD.43

Lamina propria fibers (LPF):

Thickened connective tissue fibers in the lamina propria3,42

Dilated intercellular spaces (DIS):

Spaces around squamous epithelial cells that exhibit intercellular bridges3,11,42

Eosinophil inflammation (EI):

Eosinophil count within the most densely populated HPF (high-power field)3,11,42

Internal images of the body are artistic representations. Histologic features will vary by patient.

Internal images of the body are artistic representations. Histologic features will vary by patient.

Limitations of histopathology alone Limitations of histopathology alone

Histopathology may help confirm a suspected diagnosis, but esophageal eosinophilia can be a sign of various esophageal-related diseases besides EoE, like eosinophilic gastritis and GERD.2 Moreover, due to patchy infiltration of eosinophils along the esophagus in EoE, multiple biopsies should be taken from distal, mid, and proximal locations.2,3,44

Investigate all 3 domains of EoE to reduce delays
in diagnosis and help manage EoE over time2,3

Diagnosing Eosinophilic Esophagitis flow chart

According to the 2018 updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis from the AGREE Conference, PPIs are no longer a tool to diagnose EoE.2

Rationale for changing the EoE diagnostic criteria changing the EoE diagnostic criteria and removing the PPI trial2:

  • Similarities between EoE and proton pump inhibitor–responsive esophageal eosinophilia (PPI-REE)
  • EoE and GERD are not necessarily mutually exclusive
  • Lack of a criterion standard for GERD diagnosis
  • Novel mechanisms of action of PPIs to explain response of eosinophilia
  • Observation that PPI-REE could also respond to classic EoE treatments
  • Concern about using a treatment response to define a disease

A better standardization
for diagnosis

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According to a 2018 cross-sectional online survey comprised of 240 adult and pediatric gastroenterologists, only 12% of physicians said they use all 3 EoE diagnostic criteria listed in evidence-based guidelines from 2018.49 This study highlights the need for better standardization in practice.

 

Diagnostic Delays

There is a multidisciplinary path to EoE diagnosis3,41,45

Diagnosing, managing, and monitoring EoE can require collaboration across disciplines like gastroenterologists, allergists, pathologists, primary care clinicians, and dietitians.3,41,45 Many patients with EoE may see a variety of these clinicians before receiving a confirmed diagnosis for their condition.3,41,45 But a gastroenterologist will likely be involved when making a diagnosis, because endoscopies and biopsies are required to reveal EoE.1,3,45

Help reduce the risk of complications by uncovering inflammation in EoE early10,12 uncovering inflammation in EoE early10,12

Diagnostic delays may increase the risk of complications10,12

  • Mean diagnostic delay is up to 3.5 years in children and 8 years in adults25
  • According to a 2013 restrospective analysis of 200 patients in the Swiss EoE Database:
    • For every decade of living with untreated EoE, the likelihood of esophageal fibrosis doubles10
    • Mean diagnostic delays of up to 8 years in symptomatic adults may translate to a 40% increase in risk of fibrosis10
    • Fibrosis was seen in 46% of symptomatic adult patients with a 2-year diagnostic delay, and in 87% of symptomatic patients with a delay of 20 years or more10
  • According to one single-center retrospective study based on data from 2002-2018 of 883 patients:‡‡13
    • A psychiatric diagnosis in patients with EoE was more likely in adult patients with a longer duration of symptoms preceding diagnosis
    • U.S. adult patients with EoE had a higher prevalence of a psychiatric diagnosis when compared to the general adult population in the U.S. (36% compared to 18.9%, respectively)

‡‡In a study using the University of North Carolina EoE Clinicopathologic Database from 2002-2018. Of 883 patients diagnosed with EoE (per consensus guidelines), 241 (28%) had a psychiatric comorbidity. Study limitations include that this is a single-center retrospective study where a comparison to the national representative figures was done through nonstatistical analyses.13

Based on a retrospective study of 200 patients from 1989-2007 using the Swiss EoE Database10

Strictures may be more likely when diagnosis is delayed10

Graph prevalence of strictures

Other factors can contribute to diagnostic delays in EoE

PPI-REE

Up until 2018, experts believed that evaluating the response to a proton pump inhibitor (PPI) was the best way to rule out inflammation related to gastroesophageal reflux disease (GERD) in patients with EoE.2 This led to the term PPI-responsive EoE (PPI-REE), which was initially considered a separate disease.2 Current guidelines no longer support using PPIs as a diagnostic tool.2 Therefore, rather than being considered a separate disease, PPI-REE is now considered a type of EoE.2 In all cases, EoE should be diagnosed through a holistic assessment of symptoms, endoscopy, and histopathology.2-4

Differential diagnosis

Patients with EoE can exhibit signs and symptoms that can also present in other eosinophilic gastrointestinal diseases.‡‡1-3 These other diseases should be ruled out to confirm an EoE diagnosis.1-3 However, EoE can coexist with other eosinophilic conditions as well, which can make diagnosing EoE a challenge.1-3 To differentially diagnose EoE from other eosinophilic conditions, there should be holistic consideration of symptoms, endoscopy, and histopathology.2

‡‡Such as gastroesophageal reflux disease (GERD), other eosinophilic gastrointestinal diseases such as eosinophilic gastroenteritis, hypereosinophilic syndrome, Crohn’s disease, infection (Candida or parasites), achalasia, drug hypersensitivity, connective tissue diseases, and others.

Comorbidities

Patients frequently present with atopic comorbidities that can lead to delayed diagnosis of EoE. In one retrospective study of 449 patients from 2005-2015, ~78% of patients had ≥1 atopic disease.§§20 A family or personal history of pre-existing allergic diseases should increase the suspicion for EoE and should be considered.2,20 Consider investigating EoE further with endoscopies and biopsies when patients present with symptoms of esophageal dysfunction along with any of the following:

  • Allergic rhinitis1,20
  • Asthma1,20
  • Atopic dermatitis1,20
  • Food allergy1,20
  • GERD3,33

§§In a retrospective study of 449 patients who presented with clinical and pathological features of EoE and received an esophageal biopsy between January 1, 2005, and June 30, 2015, at the Cleveland Clinic. The prevalence of patients with ≥1 atopic disease was 77.5%.20

Management
Approaches

A standardized approach to EoE management could prove beneficial30

Finding the appropriate way to manage EoE starts with a patient-centric approach and shared decision-making that suits the patient's lifestyle.3 A range of management options are available for EoE based on the severity and quality of response.46 Management of EOE may include dietary modifications, proton pump inhibitors and localized steroid therapy, as well as newer medications as they become available.47

Inflammation in EoE can be managed by medical and/or dietary therapy35

2020 AGA + JTF
TREATMENT ALGORITHM

There is significant variation in EoE treatment patterns, with physicians using diet (7%), topical steroids (32%), twice-a-day PPIs (33%), and daily PPIs (28%), according to a 2018 online survey of 240 adult and pediatric gastroenterologists.||||49

The 2020 guidelines for management of EoE published by the American Gastroenterological Association and Joint Task Force on Allergy-Immunology Practice Parameters (AGA-JTF) did not evaluate dupilumab, which has since been approved by the FDA for EoE.47

||||A cross-sectional study before the dissemination of the 2018 guidelines.

Grading of Recommendations Assessment (GRADE)

published in the 2020 AGA-JTF Clinical Guidelines for the Management of EoE##35

Therapeutic Approach

Strength of Recommendation

Quality of Evidence

Proton Pump Inhibitors
(vs no treatment)

Strength of Recommendation Conditional

Quality of Evidence Very Low

Topical Glucocorticosteroids
(vs no treatment)

Strength of Recommendation Strong

Quality of Evidence Moderate

Topical Glucocorticoids
(vs Systemic [Oral] Glucocorticosteroids)

Strength of Recommendation Conditional

Quality of Evidence Moderate

Esophageal Dilation
(vs no dilation)

Strength of Recommendation Conditional

  • Recommended for adult patients with dysphagia from a stricture associated with EoE

Esophageal dilation does not address the esophageal inflammation associated with eosinophilic esophagitis.

Quality of Evidence Very Low

Anti-Interleukin-13, Anti-Interleukin-5, and Anti-Interleukin-4 receptor α
(only in clinical trials)

Strength of Recommendation No Recommendations

Quality of Evidence Knowledge Gap

Anti-IgE Therapy

Strength of Recommendation Conditional recommendation against the use of anti-IgE therapy for EoE

Quality of Evidence Very Low

Montelukast, Cromolyn Sodium, Immunomodulators, or Anti-TNF Therapy
(only in clinical trials)

Strength of Recommendation No Recommendations

Quality of Evidence Knowledge Gap

Dietary Approach

Strength of Recommendation

Quality of Evidence

Elemental Diet
(vs no treatment)

Strength of Recommendation Conditional

  • Patients who put a higher value on avoiding the challenges of adherence to an elemental diet and the prolonged process of dietary reintroduction may reasonably decline this treatment option

Quality of Evidence Moderate

Empiric 6-Food Elimination Diet
(vs no treatment)

Strength of Recommendation Conditional

  • Patients who put a higher value on avoiding the challenges of adherence to diet involving elimination of multiple common food staples and the prolonged process of dietary reintroduction may reasonably decline this treatment option

Quality of Evidence Low

Allergy Testing-Based Elimination Diet
(vs no treatment)

Strength of Recommendation Conditional

  • Due to the potential limited accuracy of currently available, allergy-based testing for the identification of specific food triggers for EoE, patients may prefer alternative medical or dietary therapies to an exclusively testing-based elimination diet

Quality of Evidence Very Low

Current guidelines strongly recommend swallowed topical glucocorticosteroids in the management of EoE. Management approaches like PPI, diet therapy, and esophageal dilation were supported by evidence for conditional recommendations.##35

##An assessment/analysis was made of current treatment approaches and published by the AGA and the JTF. Using the GRADE methodology, the AGA and JTF categorize the strength of their recommendations as either "strong" or "conditional." These recommendations are based on evidence that is categorized as "high," "moderate," "low," or "very low."35

GRADE LEVELS

Guidelines have been developed to help standardize EoE management in practice30,35

Ongoing
Monitoring

Ongoing monitoring of EoE requires clearly defined management goals clearly definedmanagement goals across the 3 domains, according to a review of approaches to EoE management30

In chronic inflammatory diseases, a treat-to-target approach involves monitoring specific and objective measures of inflammation.50 A treat-to-target approach in EoE can assess inflammation across the 3 domains and help identify discrepancies among them, like symptom persistence despite normalized histological findings.30 Management goals should be defined to help monitor each domain and achieve clinical, endoscopic, and histological response.30

Ongoing management and monitoring goals to consider in EoE:

  • Resolution of dysphagia without modifying diet or avoiding specific food textures30
  • Normalization of esophageal histopathology measured by eosinophils and other markers of esophageal inflammation and tissue injury30
  • Reductions in endoscopic features of EoE combined with a maintained esophageal diameter of ≥16 mm30

A complete response in EoE management has been described as improvements in all 3 domains by minimizing symptoms, endoscopic findings, and histopathologic features of EoE.30

There are several challenges to treating patients with EoE. Despite the challenges, shared decision-making through a patient-centric approach may help keep patients engaged with long-term management plans.3,23

These challenges may include:

  • Adherence challenges3,30,51
  • Long-term impact on day-to-day life for patients3,51,52

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