Diagnosis and management of eosinophilic esophagitis and esophageal food impaction in adults
ÖGGH · 2024 · Austria
Source and licence
- Authors
- Hansjörg Schlager, Franziska Baumann-Durchschein, Karin Steidl et al.
- Title
- Diagnosis and management of eosinophilic esophagitis and esophageal food impaction in adults
- Journal
- Wiener Klinische Wochenschrift, 2024
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC11387459
Licence statement of the original publication
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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Diagnosis
- Recommendation 1.1In adult patients with esophageal symptoms, especially dysphagia, PPI-refractory symptoms and non-cardiac chest pain, an esophagogastroduodenoscopy (EGD) should be performed.
- Recommendation 1.2Atopic diathesis, IgE-mediated food allergy and other signs of TH2 inflammation (atopic dermatitis, asthma, chronic rhinosinusitis and pollinosis) should be systematically documented.
- Recommendation 1.3An oral allergen immunotherapy may induce or exacerbate EoE and should be actively asked for.
- Recommendation 1.4Esophageal biopsies must be taken even in cases of a macroscopically normal esophagus. If endoscopic features are present, directed biopsies of this lesions should be performed due to higher eosinophilic counts in these areas. At least six biopsies should be taken, including three biopsies from the distal and three biopsies from middle/proximal esophagus. The distal biopsies should not include the transition zone.
- Recommendation 1.5As treatment with proton pump inhibitors may mask EoE, patients should be actively asked about the PPI intake in the last weeks prior to diagnostic endoscopy.
- Recommendation 1.6At index endoscopy, additional biopsies (at least eight biopsies of the stomach and four biopsies of the duodenum) should be taken to rule out eosinophilic gastritis and/or eosinophilic duodenitis, especially in patients with diarrhea, abdominal pain or bloating.
- Recommendation 1.7Diagnostic criteria for EoE are symptoms of esophageal dysfunction and esophageal eosinophilia (mucosal and/or submucosal). The threshold for the histological diagnosis of EoE is 15 eos/hpf (standard size of ∼0.3 mm2) in any biopsy specimen.
- Recommendation 1.8In cases of clinical suspicion of EoE but not fulfilling the histological criteria of at least 15 eos/hpf, the biopsy samples should be re-evaluated by an expert in GI pathology. A sampling error should be suspected as well as a potentially underlying EoE variant.
- Recommendation 1.9Endoscopic features of EoE are edema, rings, exudates, furrows and strictures. These signs should be evaluated with the EREFS score. The most affected area should be documented in the endoscopy report.
- Recommendation 1.10Allergy testing with a skin prick test (SPT), atopy patch test (APT) or antigen-specific IgE antibodies is not recommended to identify the culprit food allergen.
- Recommendation 1.11Blood or urinary tests in eosinophilic esophagitis are not generally recommended due to low sensitivity or specificity for diagnosis of eosinophilic esophagitis.
- Recommendation 1.12EoE and GERD are two distinct disease entities that can co-exist in one individual patient and can impact each other.
Therapy
- Recommendation 2.1In all patients with the diagnosis of EoE, an induction therapy should be started.
- Recommendation 2.2Therapeutic options for treating EoE are swallowed topical corticosteroids (STC), high dose proton pump inhibitors, dupilumab or elimination diet.
- Recommendation 2.2.1Swallowed topical corticosteroids (STC) are effective in achieving clinical histological remission and may be considered as first line induction therapy for 6–12 weeks. As maintenance therapy, STCs can be safely used as long-term treatment.
- Recommendation 2.2.2In patients with simultaneous GERD or other indications for acid suppression, PPI should be considered as induction and maintenance therapy.
- Recommendation 2.2.3Elimination diet can be considered as induction and maintenance treatment. If this treatment option is considered, a consultation with a dietician is mandatory. Due to less restriction and improvement of quality of life a 1FED (animal milk) or a step-up approach with 2FED (animal milk and wheat/gluten) is preferred.
- Recommendation 2.2.4Dupilumab can be considered as induction and maintenance treatment in EoE. Mostly used in patients refractory or intolerant to STC, it may be used as first line therapy in patients with other clinically relevant type 2 inflammatory diseases or contraindications for corticosteroids.
- Recommendation 2.3After 12 weeks of induction therapy, an endoscopic follow-up with biopsies is necessary to demonstrate histologic response.
- Recommendation 2.4In order to avoid long-term complications such as fibrosis, to improve quality of life and to reduce the risk of esophageal food impaction, maintenance therapy is mandatory.
- Recommendation 2.5In the majority of patients, combination therapies cannot be recommended. This option can be considered in selected cases with partial response to the first therapy.
- Recommendation 2.6After every major change of treatment, a clinical and histological re-evaluation should be performed to ensure maintenance of remission.
- Recommendation 2.7Due to high risk of recurrence and esophageal food impaction, a trial of withdrawal of treatment is not recommended.
- Recommendation 2.8Patients with STC-refractory disease should be evaluated and managed in institutions experienced with management of EoE.
Dilation
- Recommendation 3.1In patients with clinically relevant fibrostenosis and with the necessity of dilation, a combination with anti-inflammatory treatment is required.
- Recommendation 3.2Regardless of the used technique, esophageal dilation is safe and effective in patients with EoE.
- Recommendation 3.3In patients with persistent dysphagia despite histological remission and lack of a visible stricture an empirical dilation may be performed.
- Recommendation 3.4If dilation is necessary, a luminal diameter of ≥ 16 mm should be aimed for to reduce long-term complications.
Esophageal food impaction
- Recommendation 4.1Patients with EFI should not induce vomiting and should preferably attend an endoscopy unit/emergency department within 2 h.
- Recommendation 4.2Patients with EFI should preferably undergo esophagogastroduodenoscopy within 6 h. Before EGD, radiological evaluation or medications to resolve EFI is not advisable.
- Recommendation 4.3There is lacking evidence whether general anesthesia with endotracheal intubation or conscious sedation should be used in cases of EFI.
- Recommendation 4.4Push or pull technique with or without endoscopic devices may be used depending on physicians’ expertise.
- Recommendation 4.5In patients presenting with EFI, sufficient biopsies of the esophagus should be taken during the index endoscopy to diagnose or exclude eosinophilic esophagitis.
- Recommendation 4.6In patients with spontaneous resolution of EFI or in patients where sufficient esophageal biopsies have not been performed during index endoscopy, an endoscopy without PPI or STC should be repeated within 2–3 weeks.
- Recommendation 4.7Any patient presenting with EFI to the emergency department should receive an appointment within the next 4 weeks in the gastroenterology outpatient clinic.
Follow-up
- Recommendation 5.1Patients with EoE in clinicopathological remission should have clinical and endoscopic follow-up every 1–2 years.
Diagnosis
- Recommendation 1.2Atopic diathesis, IgE-mediated food allergy and other signs of TH2 inflammation (atopic dermatitis, asthma, chronic rhinosinusitis and pollinosis) should be documented systematically.
- Recommendation 1.3An oral allergen immunotherapy may induce or exacerbate EoE and should be actively questioned.
- Recommendation 1.4Esophageal biopsies must be taken even in case of a macroscopically normal esophagus. If endoscopic features are present, directed biopsies of this lesions should be performed due to higher eosinophilic counts in these areas. At least six biopsies should be taken, including three biopsies from the distal and three biopsies from middle/proximal esophagus. The distal biopsies should not include the transition zone.
- Recommendation 1.5As treatment with proton pump inhibitors may mask EoE, patients should be ctively asked about the PPI intake in the last weeks prior to diagnostic endoscopy.
- Recommendation 1.7Diagnostic criteria for EoE are symptoms of esophageal dysfunction and esophageal eosinophilia (mucosal and/or submucosal). The threshold for the histologic diagnosis of EoE is 15 eos/hpf (standard size of ∼0.3 mm2) in any biopsy specimen.
Therapy
- Recommendation 2.2Therapeutic options for treating EoE are swallowed topical corticosteroids (STCs), high dose proton pump inhibitors, dupilumab or an elimination diet. A therapeutic algorithm as described in Fig. 1 can be used as guidance for induction therapy.
- Recommendation 2.2.1Swallowed topical corticosteroids (STCs) are effective in achieving clinical histological remission and may be considered as first line induction therapy for 6–12 weeks. As maintenance therapy STCs can be safely used as long-term treatment.
- Recommendation 2.2.3Elimination diet can be considered as induction and maintenance treatment. If this treatment option is considered, a consultation of a dietician is mandatory. Due to less restriction and improvement of quality of life a 1FED (animal milk) or a step-up approach with 2FED (animal milk and wheat/gluten) is preferred.
Esophageal food impaction
- Recommendation 4.2Patients with EFI should preferably have esophagogastroduodenoscopy within 6 h. Before EGD, radiological evaluation or medications to resolve EFI is not advisable.
Follow-up
- Recommendation 5.1Patients with EoE in clinicopathologic remission should have clinical and endoscopic follow-up every 1–2 years.
Abstract
This position paper deals with an expert consensus on diagnosis and management of eosinophilic esophagitis and esophageal food impaction issued by the Austrian Eosinophilic Esophagitis Network, a working group under the patronage of the Austrian Society of Gastroenterology and Hepatology (ÖGGH). In need of a standardized approach on the management of EoE, recommendations were made based on international guidelines and landmark studies.
Contents of the original publication
The section headings of the original.
- Summary of recommendations
- Diagnosis
- Therapy
- Dilation
- Esophageal food impaction
- Follow-up
- Introduction
- Diagnosis
- Recommendation 1.1
- Recommendation 1.2
- Recommendation 1.3
- Recommendation 1.4
- Recommendation 1.5
- Recommendation 1.6
- Recommendation 1.7
- Recommendation 1.8
- Recommendation 1.9
- Recommendation 1.10
- Recommendation 1.11
- Recommendation 1.12
- Therapy
- Recommendation 2.1
- Recommendation 2.2
- Recommendation 2.2.1
- Recommendation 2.2.2
- Recommendation 2.2.3
- Recommendation 2.2.4
- Recommendation 2.3
- Recommendation 2.4
- Recommendation 2.5
- Recommendation 2.6
- Recommendation 2.7
- Recommendation 2.8
- Dilation
- Recommendation 3.1
- Recommendation 3.2
- Recommendation 3.3
- Recommendation 3.4
- Esophageal food impaction
- Recommendation 4.1
- Recommendation 4.2
- Recommendation 4.3
- Recommendation 4.4
- Recommendation 4.5
- Recommendation 4.6
- Recommendation 4.7
- Follow-up
- Recommendation 5.1
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