Eosinophilic oesophagitis

Eosinophilic oesophagitis is an immune-allergic pathology of multifactorial aetiology (genetic and environmental) that affects both paediatric and adult patients. Eosinophilic oesophagitis (EoO) incidence and prevalence are increasing at a rate that is outpacing increased recognition or detection. (1)

Epidemiological studies indicate a multifactorial origin for, where environmental and genetic factors both occur.

It is associated with other atopic conditions including asthma, atopic dermatitis, allergic rhinitis/sinusitis, and food allergies, and up to 80% of children and 60% of adults with EoO have been reported to have concomitant allergic conditions. (2)

The mean estimate of prevalence throughout Europe and North America since 2017 is 63 per 100,000 people (rising from 15 per 100,000 people before 2007), with a pooled incidence rate of 6.2 per 100,000 people per year (rising from 2.6 per 100,000 before 2007) (3)

It affects both children and adults, and a diagnosis of coeliac disease also increases the risk of eosinophilic oesophagitis (4)

Symptoms include heartburn, regurgitation, and oesophageal stenosis (with dysphagia being more frequent in eosinophilic oesophagitis in young adults and children). These are similar to those of gastro-oesophageal reflux disease, causing delays in diagnosis and treatment

Endoscopic findings such as furrows, oesophageal mucosa trachealization, and whitish exudates may suggest its presence. This diagnosis should be confirmed histologically based on the presence of more than 15 eosinophils per high-power field and the exclusion of other causes of eosinophilia (parasitic infections, hypereosinophilic syndrome, inflammatory bowel disease, among others) for which treatment could be initiated.

• The presence of the following diagnostic criteria is required for the diagnosis:
  • (a) symptoms of oesophageal dysfunction; (b) eosinophilic oesophageal inflammation,
  • with >15 eosinophils per high-power field (eos/hpf), affecting the oesophagus alone;
  • and (c) excluding other causes of oesophageal eosinophilia
    
    

• the 3 "D"s ("Drugs, Diet, and Dilation") are considered the fundamental components of treatment
  • the first 2 components, which involve the use of proton pump inhibitors, corticosteroids, immunosuppressants and empirical diets or guided food elimination based on allergy tests, are more useful in the initial phases, whereas endoscopic dilation is reserved for oesophageal strictures
    • primary drugs used in the treatment of eosinophilic oesophagitis are proton pump inhibitors (PPIs), topical corticosteroids and dupilumab (5)
      • PPIs reduce the secretion of gastric acid by inhibiting parietal cell H+-K+ATPases and reducing the expression of eotaxin-3, a Th-2 cytokine involved in inflammation. They can also inhibit the expression and inflammatory functions of adhesion molecules, such as oxidative burst. The optimal dose in adults is 20–40 mg of omeprazole or an equivalent twice per day for 8 weeks
      • there are various topical corticosteroid formulations available, and availability depends on geographic location. Budesonide is commercially available for this indication as an oral suspension, or as an orodispersible tablet. An oral viscous formulation may also be prepared, and is an option for children who cannot receive the commercially available formulations. There is no commercially available formulation of fluticasone for this indication and existing asthma formulations must be used.
  • NICE state (4):
    • budesonide as an orodispersible tablet (ODT) is recommended as an option for inducing remission of eosinophilic oesophagitis in adults
    • UK guidelines do not recommend systemic corticosteroids for adult or paediatric patients with non-stricturing disease (6)

Dupilumab, an interleukin (IL)-4 receptor antagonist monoclonal antibody, is approved by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for the treatment of EoO in adults and children aged ≥1 year and weighing ≥15 kg body weight. (7) However, it may be less preferred by some patients as it involves injections. (8)

Reference:

1. Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterol Clin North Am. 2014 Jun;43(2):201-18.
2. Dellon ES, Liacouras CA. Advances in clinical management of eosinophilic esophagitis. Gastroenterology. 2014 Dec;147(6):1238-54.
3. Navarro P, Arias Á, Arias-González L, et al. Systematic review with meta-analysis: the growing incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther. 2019 May;49(9):1116-25
4. NICE. Budesonide orodispersible tablet for inducing remission of eosinophilic oesophagitis. Technology appraisal guidance TA708. Published June 2021
5. Dellon ES, Muir AB, Katzka DA, et al. ACG clinical guideline: diagnosis and management of eosinophilic esophagitis. Am J Gastroenterol. 2025 Jan 1;120(1):31-59.
6. Dhar A, Haboubi HN, Attwood SE, et al. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut. 2022 Aug;71(8):1459-87.
7. Dellon ES, Rothenberg ME, Collins MH, et al. Dupilumab in adults and adolescents with eosinophilic esophagitis. N Engl J Med. 2022 Dec 22;387(25):2317-30.
8. Aceves SS, Dellon ES, Greenhawt M, et al. Clinical guidance for the use of dupilumab in eosinophilic esophagitis: a yardstick. Ann Allergy Asthma Immunol. 2023 Mar;130(3):371-8.