Eosinophilic Esophagitis (EoE): Symptoms and Treatment

What is eosinophilic esophagitis?

EoE is a chronic inflammatory disease of the esophagus — the tube that connects the throat to the stomach. In EoE, a type of white blood cell called an eosinophil accumulates in the esophageal lining in response to food or environmental allergens 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring. Over time this inflammation causes the esophagus to swell, stiffen, and sometimes develop rings or narrowed areas (strictures) that make swallowing difficult.

EoE was relatively rare two or three decades ago but has been recognized with increasing frequency, particularly in people who have other allergic conditions like asthma, eczema, or food allergies. It affects both children and adults, though the way it presents can differ with age 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring.

What are the symptoms of EoE in adults?

The defining symptom in adults is dysphagia — difficulty swallowing, especially solid foods. This can feel like food moving slowly, scraping, or becoming stuck in the mid-chest or throat area 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring. The most alarming event is food impaction: food (often a piece of meat or a pill) becomes completely lodged in the esophagus and cannot pass down or come back up without medical help.

Other symptoms adults commonly report:

• Needing to drink a lot of liquid to wash food down
• Cutting food into very small pieces or avoiding certain textures
• Chest pain unrelated to the heart, particularly when eating
• Heartburn or regurgitation that does not fully respond to antacids or proton pump inhibitors 3Ref 3Yadlapati R, Gyawali CP, Pandolfino JE; CGIT GERD Consensus Conference Participants (2022).AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review.Context for distinguishing EoE from GERD; PPI-responsive esophageal eosinophilia and its relationship to EoE spectrum
• Avoiding social eating because of embarrassment or fear

Many people with EoE adapt their eating habits for years before the condition is diagnosed. The average delay from first symptoms to diagnosis has historically been several years 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring.

How is EoE diagnosed?

EoE can only be definitively diagnosed with an upper endoscopy and biopsies 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring. A gastroenterologist passes a flexible camera into the esophagus, and small tissue samples are taken from different levels. The pathologist looks for elevated numbers of eosinophils in the tissue — a threshold of 15 or more eosinophils per high-power field in the setting of esophageal symptoms is the standard diagnostic criterion.

During endoscopy the gastroenterologist may also see characteristic visual findings: horizontal rings across the esophagus (sometimes called feline or corrugated esophagus), white specks on the lining, vertical furrows, or areas of narrowing.

A proton pump inhibitor (PPI) trial is sometimes used as part of the evaluation, but it is now understood that some people have PPI-responsive eosinophilic esophagitis, which is considered part of the same spectrum. Both groups are typically treated similarly 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring3Ref 3Yadlapati R, Gyawali CP, Pandolfino JE; CGIT GERD Consensus Conference Participants (2022).AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review.Context for distinguishing EoE from GERD; PPI-responsive esophageal eosinophilia and its relationship to EoE spectrum.

What are the treatment options for EoE?

Treatment has three main pillars: diet modification, swallowed topical steroids, and managing strictures 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring.

Dietary approaches

Because EoE is driven by food allergens, removing trigger foods can reduce inflammation significantly. Two main strategies are used:

• Elimination diets — the six-food elimination diet removes the most common triggers: milk, wheat, eggs, soy, nuts, and seafood. Foods are reintroduced one at a time under a gastroenterologist's guidance to identify which specific allergen is responsible
• Elemental diet — an amino acid-based formula with no intact proteins; highly effective but difficult to sustain long-term

Milk and wheat are the most common single triggers in adults 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring.

Swallowed topical corticosteroids

Budesonide (as an oral viscous suspension) and fluticasone propionate (swallowed from an inhaler rather than inhaled into the lungs) coat the esophageal lining directly and reduce eosinophil inflammation. Unlike systemic steroids, the doses needed are low enough that whole-body side effects are uncommon, though oral candidiasis (thrush) can occur 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring.

Biologic therapy: dupilumab

Dupilumab (Dupixent) received FDA approval for EoE in adults and adolescents aged 12 and older in May 2022 — the first approved drug for this condition. In the pivotal phase 3 trial, weekly dupilumab achieved histologic remission (≤6 eosinophils per high-power field) in 60% of patients versus 5% with placebo, and significantly improved swallowing symptoms 2Ref 2Dellon ES, Rothenberg ME, Collins MH, et al. (2022).Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis.Phase 3 trial demonstrating 60% histologic remission with weekly dupilumab vs. 5% with placebo; pivotal trial supporting FDA approval of dupilumab for EoE in May 2022. It offers an option for people who do not respond to diet or swallowed steroids.

Esophageal dilation

When the esophagus has narrowed enough to cause persistent severe dysphagia, a gastroenterologist can dilate it during an endoscopy — gently stretching the narrowed area. Dilation relieves symptoms but does not treat the underlying inflammation, so it is typically combined with one of the other approaches 1Ref 1Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I (2025).ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis.EoE definition, diagnostic criteria (≥15 eosinophils/HPF), characteristic endoscopic findings, dietary elimination, topical steroid therapy (budesonide, fluticasone), dilation, and monitoring.

Getting the right specialist for EoE

EoE is diagnosed and managed by a gastroenterologist. If food allergy testing or an allergen-driven elimination plan is needed, collaboration with an allergist is also helpful. Your primary care clinician can evaluate whether your swallowing symptoms warrant a referral and help you prepare for the specialist visit. Gale's clinicians are glad to coordinate that next step.