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Recommendations for the diagnosis and management of eosinophilic esophagitis in adults and children in Canada: a Delphi consensus project

CAG/CSACI Delphi consensus · 2025 · Canada

Source and licence

Authors
Vishal Avinashi, Milli Gupta, Beth A Payne et al.
Title
Recommendations for the diagnosis and management of eosinophilic esophagitis in adults and children in Canada: a Delphi consensus project
Journal
Journal of the Canadian Association of Gastroenterology, 2025
DOI
10.1093/jcag/gwaf022
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12698229

Licence statement of the original publication

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Definition

  • Statement #1EoE is a chronic inflammatory condition of the esophagus, characterized by eosinophilic inflammation. Pathophysiologic mechanisms include barrier dysfunction, delayed (non-IgE mediated) allergic responses to food (and/or environmental allergens), type 2 inflammation, and tissue remodeling.Agreement n (%): 31 (100)
  • Statement #2EoE is increasing in prevalence, which can be partially attributed to increased awareness. The true prevalence is not well defined in Canada.Agreement n (%): 29 (93.5)
  • Statement #3EoE occurs in all genders and ethnic backgrounds but is more commonly diagnosed in white males. It is often associated with allergic conditions such as IgE-mediated food allergy, asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and allergic rhinitis. EoE can be associated with family history of EoE in first-degree relatives.Agreement n (%): 28 (90.3)
  • Statement #4Long-term complications of EoE include fibrosis and stricture development. Risks for these complications are increased with diagnostic delay and untreated EoE.Agreement n (%): 31 (100)

Diagnosis

  • Statement #5EoE is defined clinically by symptoms of esophageal dysfunction together with esophageal biopsies showing ≥15 eosinophils/hpf.Agreement n (%): 28 (90.3)
  • Statement #6Common EoE symptoms in adolescents and adults include dysphagia and food impaction. Adaptive behaviours are frequently seen including drinking fluids to help swallow foods, cutting food into small pieces or pureeing, excessive chewing, prolonged mealtimes, avoiding hard textures, and turning away tablets/pills.Agreement n (%): 29 (93.5)
  • Statement #7Common EoE symptoms and signs in younger children additionally to those listed in Statement #6, include feeding difficulties, abdominal pain, failure to thrive, and vomiting.Agreement n (%): 29 (93.5)
  • Statement #8Severe symptoms such as food impaction with obstruction (inability to swallow secretions) need urgent care for endoscopic removal of food bolus. Taking esophageal biopsies at the same time as endoscopy is strongly encouraged. If food bolus impaction passes without need for emergency gastroscope, patients should be referred to GI for either new consultation or a follow-up appointment for endoscopic evaluation.Agreement n (%): 29 (93.5)
  • Statement #9In situations where access to GI is delayed or unavailable, for example in rural and remote regions of Canada, general surgeons may provide access to endoscopy and biopsy for EoE diagnosis. This endoscopy should follow the same standards outlined in this guideline. Postendoscopy, surgeons may collaborate with the allergist and GI to coordinate management.Agreement n (%): 29 (93.5)
  • Statement #10A trial of proton pump inhibitors (PPIs) is not required for diagnosis of EoE.Agreement n (%): 29 (93.5)
  • Statement #11Endoscopic findings for EoE can include Edema, Rings, Exudates, linear Furrows, and Stricture. Finding should be reported as EREFS including subscores. Macroscopic features are absent in some patients with increased eosinophils and are not required to make a diagnosis of EoE.Agreement n (%): 31 (100)
  • Statement #12Endoscopic biopsies are required for the diagnosis of EoE, regardless of endoscopic appearance. There should be ≥2 biopsies per level from at least 2 segments (distal, mid, and proximal esophagus), for a total of ≥4-6 biopsies. Biopsies of the stomach and duodenum should be considered at initial endoscopic exam.Agreement n (%): 28 (90.3)
  • Statement #13Histology should be reported as eosinophil counts per 0.3 mm2 (=per hpf), with EoE diagnosis requiring ≥15 eosinophils/hpf.Agreement n (%): 31 (100)
  • Statement #14Classic histologic features beyond esophageal eosinophilia can include dilated intercellular spaces, basal zone hyperplasia, eosinophilic abscesses as well as lamina propria fibrosis, and can strengthen a diagnosis.Agreement n (%): 31 (100)
  • Statement #15The differential diagnosis of EoE includes gastroesophageal reflux disease, eosinophilic gastrointestinal disease, Crohn’s disease, achalasia, hypermobility syndromes, drug hypersensitivity disorder, and others.Agreement n (%): 30 (96.8)

Management

  • Statement #16EoE care should be a collaborative effort between multiple providers (ie, gastroenterologists, allergists, surgeons, pathologists, dietitians, and other practitioners) and includes shared decision-making with the patient.Agreement n (%): 28 (90.3)
  • Statement #17It is important to transition care from paediatric to adult services to support patients through this high-risk period.Agreement n (%): 29 (93.5)
  • Statement #18Initial management options for controlling symptoms, reducing inflammation, and preventing complications include PPI, empiric dietary elimination, and swallowed topical corticosteroids. If dilation is required, it must be used as complementary to other treatments as it will not control underlying inflammation.Agreement n (%): 31 (100)
  • Statement #19Empiric dietary elimination is best started with 1 (cow’s milk) or 2 (cow’s milk and wheat) food elimination, balancing efficacy, convenience, and adherence. Starting with a 6-food elimination may result in higher rates of remission but is not recommended as first-line treatment due to limited convenience, poor adherence, impaired quality of life, and other adverse outcomes.Agreement n (%): 29 (93.5)
  • Statement #20Consultation with a dietitian is essential for patients on dietary elimination.Agreement n (%): 31 (100)
  • Statement #21An elemental diet is rarely recommended for management of EoE due to poor taste, frequent need for enteral tube, high cost, and significant impact on quality of life.Agreement n (%): 27 (87.1)
  • Statement #22Patients with allergic conditions who have undergone prolonged and extensive dietary elimination for the treatment of EoE are at a heightened risk of developing IgE-mediated food allergies to the specific foods they have avoided.Agreement n (%): 28 (90.3)
  • Statement #23Mode of medication delivery is a shared decision-making process between patient and provider to ensure adherence but prescribers should recognize that patients with EoE frequently have challenges with pills such as tablets and capsules.Agreement n (%): 30 (96.8)
  • Statement #24Systemic or long-term corticosteroids (eg, oral prednisone) are not recommended for routine use in treatment of EoE.Agreement n (%): 28 (90.3)
  • Statement #25Budesonide orodispersible tablet is approved by Health Canada for the treatment of EoE in adults. Off-label swallowed topical corticosteroid options include viscous budesonide and fluticasone MDI.Agreement n (%): 30 (96.8)
  • Statement #26Dupilumab (anti IL-4/13) is a Health Canada approved biologic for EoE and can be considered for disease (1) refractory to conventional treatments; or (2) those experiencing side effects with conventional therapy; (3) and/or patients with currently approved concurrent severe allergic conditions.Agreement n (%): 25 (80.6)
  • Statement #27The cost of Health Canada-licensed EoE medications can be high. Due to variable coverage by third party prescription programs and lack of current coverage by provincial prescription drug plans, a coordinated effort is needed to ensure patients with EoE receive appropriate treatments regardless of location.Agreement n (%): 31 (100)
  • Statement #28Development of luminal narrowing and/or stricture can be a complication of EoE. Some narrowing may respond to medical treatment while others may require dilation. While endoscopic dilation may alleviate symptoms, it is important to address mucosal inflammation and prevent recurrence of narrowing through treatment with anti-inflammatory therapies.Agreement n (%): 29 (93.5)
  • Statement #29Allergy testing (skin prick tests, sIgE blood tests, or patch tests) to uncover food triggers of EoE is not recommended. Rather, if chosen, dietary elimination should be done empirically. The purpose of food allergy testing is to rule out potentially anaphylactic IgE-mediated food allergy when the history is suggestive of it.Agreement n (%): 30 (96.8)
  • Statement #30In addition to shared understanding and experience in the pathophysiology and management of EoE with gastroenterologists, allergists have unique experience in their ability to manage concurrent and complicating allergic conditions, such as IgE-mediated food allergy and determination of relevant aeroallergen sensitization.Agreement n (%): 28 (90.3)
  • Statement #31A subset of patients sensitized to pollen may experience seasonal intensification of EoE due to pollen allergy. Allergists can help patients distinguish between EoE and Pollen Food Allergy Syndrome to better manage symptoms.Agreement n (%): 29 (93.5)
  • Statement #32It is unclear whether sublingual or oral immunotherapy causes or unmasks EoE, or whether the disease is simply associated with the therapy. Immunotherapy should be based on weighing benefits/risks and shared decision-making.Agreement n (%): 28 (90.3)
  • Statement #33When feasible, single medical interventions or monotherapy (Diet/STC) should be evaluated in isolation to know their effectiveness. Combination therapies may be considered for more severe diseases.aAgreement n (%): 28 (90.3)
  • Statement #34Clinical evaluation alone is not sufficient to assess treatment efficacy. Repeat endoscopy and biopsy to assess treatment efficacy after a change in management ideally should occur at 6-12 weeks.Agreement n (%): 27 (87.1)
  • Statement #35It is important to ensure follow-up of EoE. The interval for follow-up including endoscopy may vary depending on symptoms (frequency and severity), phenotype including history of strictures, and amount of inflammation, with uncontrolled EoE requiring more frequent follow-up.Agreement n (%): 28 (90.3)
  • Statement #36Disease activity indices for symptomatic, endoscopic, histologic, and quality-of-life measures are available and can be used, although may not always be feasible to adopt in routine clinical settings.Agreement n (%): 28 (90.3)
  • Statement #37EoE has a negative impact on psychosocial status. Monitoring the overall well-being of EoE patients is an important part of follow-up.Agreement n (%): 30 (96.8)
  • Statement #38The ultimate duration of therapy for patients who achieve control of their EoE is unclear in the literature. Given this is a long-term condition, the decision to continue treatment and in what form is dependent on severity of symptoms and disease, as well as shared decision-making with the patients and family; balancing risk and benefits of the treatment with the risks of complications (eg, fibrostenotic disease).Agreement n (%): 28 (90.3)

Section 1: Definition

  • Statement #1EoE is a chronic inflammatory condition of the esophagus, characterized by eosinophilic inflammation. Pathophysiologic mechanisms include barrier dysfunction, delayed (non-IgE mediated) allergic responses to food (and/or environmental allergens), type 2 inflammation and tissue remodelling.
  • Statement #3EoE occurs in all genders and ethnic backgrounds but is more commonly diagnosed in White males. It is often associated with allergic conditions such as IgE-mediated food allergy, asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyps and allergic rhinitis. EoE can be associated with a history of EoE in first-degree relatives.
  • Statement #4Long-term complications of EoE include fibrosis and stricture development. Risks for these complications are increased with diagnostic delay and with untreated EoE.

Section 2: Diagnosis

  • Statement #8Severe symptoms such as food impaction with obstruction (inability to swallow secretions) need urgent care for endoscopic removal of food bolus. Taking esophageal biopsies at the same time as endoscopy is strongly encouraged. If food bolus impaction passes without need for emergency gastroscope, patients should still be referred to gastrointestinal (GI) for either a new consultation or a follow-up endoscopic evaluation.
  • Statement #9In situations where access to GI is delayed or unavailable, for example in rural and remote regions of Canada, general surgeons may provide endoscopy and biopsy for EoE diagnosis. This endoscopy should follow the same standards outlined in this guideline. Post-endoscopy, surgeons may collaborate with the allergist and GI to coordinate management.
  • Statement #11Endoscopic findings for EoE can include edema, rings, exudates, linear furrows, and stricture. Findings should be reported as EREFS including subscores. Macroscopic features are absent in some patients with increased eosinophils and are not required to make a diagnosis of EoE.
  • Statement #15The differential diagnosis of EoE includes, GERD, EGID, Crohn’s disease, achalasia, hypermobility syndromes, drug hypersensitivity disorder, and others.

Section 3: Management

  • Statement #25Budesonide orodispersible tablet is approved by Health Canada for the treatment of EoE in adults. Off-label swallowed topical corticosteroid options include viscous budesonide and fluticasone Metered-Dose Inhaler (MDI).
  • Statement #26Dupilumab (anti IL-4/13) is a Health Canada approved biologic for EoE and can be considered for disease (1) refractory to conventional treatments; or (2) those not tolerating conventional therapy; (3) and/or patients with currently approved concurrent severe allergic conditions.
  • Statement #33When feasible, single medical interventions or monotherapy (Diet/medications) should be evaluated in isolation to know their effectiveness. Combination therapies may be considered for more severe disease.
  • Statement #38The ultimate duration of therapy for patients who achieve control of their EoE is unclear in the literature. Given this is a long-term condition, the decision to continue treatment and in what form is dependent on severity of symptoms and disease, as well as shared decision-making with the patients and family, and balancing risk and benefits of the treatment with the risks of complications (eg, fibrostenotic disease).

Abstract

Background: Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus that effects both pediatrics and adult patients in Canada and is increasing in prevalence. No Canadian focused best practice recommendations currently exist to guide clinical practice.

Methods: The study used a modified Delphi technique to develop evidence and expert opinion-based recommendations for providing care for patients with EoE. The Delphi process consisted of 3 rounds of quantitative surveys and qualitative consensus meetings. Experts were included in the Delphi if they had experience caring for EoE patients in Canada within one of the following professional groups: allergist, adult gastroenterologists, pathologists, pediatric gastroenterologists, and dieticians.

Results: Delphi rounds were completed between May 1, 2024, and June 30, 2024. A total of 31 experts in EoE care from across Canada were recruited to participate in the Delphi consensus process. All participants completed all 3 rounds of Delphi surveys. The final statement includes 38 recommendations for the care of patients with EoE organized into 3 sections: definition, diagnosis, and management. A table of research gaps is provided to stimulate further knowledge development on this topic.

Conclusion: This consensus statement includes actionable recommendations to support quality care of patients with EoE at any age across Canada. We encourage EoE centres in Canada to come together in a multidisciplinary form to not only provide clinical care but also do much needed research on Canadian specific topics and gaps in EoE care.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Methods
  • Recommendation development process
  • Results
  • Final consensus statements with evidence summaries
  • Canadian context, advocacy, and future research

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