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Eosinophilic oesophagitis
Understanding symptoms, diagnosis and treatments
Eosinophilic oesophagitis (EoE) is a chronic inflammatory condition of the oesophagus. It can make it difficult for food to pass and may lead to narrowing over time. It can be treated, but symptoms alone are not always enough to tell whether inflammation is controlled.
In this sheet
The key message
It can be treated, but symptoms alone are not always enough to tell whether inflammation is controlled.
The essentials in 30 seconds
EoE is a chronic disease of the oesophagus
It is linked to eosinophil-rich immune inflammation. It is neither an infection nor simply reflux.
Difficulty swallowing may be subtle
Eating slowly, chewing thoroughly, drinking after each mouthful or avoiding certain foods may mask dysphagia.
Diagnosis requires biopsies
Symptoms, endoscopy and biopsies are interpreted together. A threshold of at least 15 eosinophils per high-power field contributes to the diagnosis.
Allergy tests do not determine the diet on their own
A positive skin-prick test or food-specific IgE result is not enough to identify the foods maintaining EoE.
Several treatments are available
PPIs, swallowed topical corticosteroids, an empirical elimination diet, biologic treatment in some situations, and dilation when narrowing is present.
Food genuinely stuck = potential emergency
If you can no longer swallow your saliva, discomfort is significant or breathing is difficult, urgent assessment is required.
What is eosinophilic oesophagitis?
EoE is a chronic, immune-mediated inflammatory disease that is mainly limited to the oesophagus. It may initially have an inflammatory component and, over time, a fibrostenotic component that can reduce the calibre of the oesophagus.
EoE ≠ simple reflux
Gastro-oesophageal reflux may coexist with EoE, but EoE is not simply reflux. A response to proton pump inhibitors (PPIs) no longer excludes a diagnosis of EoE.
Which symptoms may be warning signs?
Adolescent / adult
Difficulty swallowing solid foods, a feeling that food does not go down properly, food impaction, chest pain or sometimes associated heartburn.
Child
Long mealtimes, refusal of certain textures, vomiting, abdominal pain, feeding difficulties, dysphagia and sometimes an effect on nutrition or growth.
Compensatory strategies: very important to recognise
Some people have adapted the way they eat for a long time and no longer describe themselves as having ‘difficulty swallowing’. These habits may still be an important clue.
- Chewing for a very long time or cutting food into very small pieces.
- Drinking after almost every mouthful to help food go down.
- Spontaneously avoiding meat, bread or other dry/fibrous foods.
- Preferring soft foods or foods with sauce.
- Eating more slowly than others, sometimes always finishing last.
A useful question during the appointment
‘Have I changed the way I eat to prevent food from getting stuck?’ This information may be as important as the sensation of dysphagia itself.
How is it diagnosed?
Diagnosis is based on several elements: symptoms compatible with oesophageal dysfunction, upper gastrointestinal endoscopy with biopsies, and exclusion of other causes that could explain oesophageal eosinophilia.
The threshold of 15 eosinophils
A threshold of at least 15 eosinophils per high-power field in oesophageal biopsies is part of current diagnostic criteria. This number is never interpreted in isolation.
Can the endoscopy look normal?
Yes
Endoscopy may show furrows, rings, exudates, oedema or narrowing, but visual appearance alone is not enough. Biopsies are required even if the lining looks only mildly abnormal.
Recent guidance calls for several biopsies from several levels of the oesophagus; the endoscopy team adapts sampling to the context.
What about blood eosinophils?
Full blood count ≠ oesophageal biopsy
Blood eosinophil levels may sometimes be raised, but a blood test does not replace oesophageal biopsies for diagnosing or monitoring EoE.
‘If PPIs work, it was not EoE’
No. Failure of previous PPI treatment is no longer required to diagnose EoE. PPIs are now one of the treatment options for EoE in some patients.
EoE and food allergy: do not confuse them
EoE ≠ immediate food allergy
EoE is often associated with a history of atopy and some foods may maintain inflammation, but its mechanism is not that of a classic immediate IgE-mediated allergy. A patient may have EoE, an IgE-mediated allergy, or both.
Why do my skin-prick tests or IgE results not tell me what to remove?
Because standard allergy tests are poor at predicting which foods maintain EoE inflammation. A positive result indicates sensitisation but does not prove that the food is responsible for EoE.
Avoid
Do not remove several foods solely because skin-prick tests or IgE results are positive. Dietary elimination for EoE must be decided and monitored with the team managing the condition.
If an elimination diet is chosen
The current strategy often favours the least restrictive empirical approach possible, selected with the patient and adapted to the context. Effectiveness is assessed through clinical progress as well as endoscopy and biopsies.
- Avoid improvised, highly restrictive diets.
- Pay attention to nutritional intake, particularly in children and adolescents.
- Support from a dietitian can be very helpful.
- The aim is not to remove as many foods as possible, but to control the disease with a manageable and safe strategy.
Important
A conventional oral food challenge used for IgE-mediated allergy cannot, on its own, identify the food maintaining EoE. The two issues must not be confused.
Which treatments are available?
PPIs
They can reduce inflammation in some patients. Their effectiveness does not mean that the condition was simply reflux.
Swallowed topical corticosteroids
They act locally on the oesophagus. The formulation and administration technique must follow the prescription exactly.
Empirical elimination diet
This may be offered as part of a gradual, shared strategy, ideally with nutritional support.
Biologic treatment
A biologic may be offered in some forms according to the patient’s profile, previous treatments and current guidance.
What about dilation?
It treats narrowing, not inflammation
Endoscopic dilation can improve the passage of food when narrowing or a stricture is present. It must be combined with an appropriate anti-inflammatory strategy and does not replace maintenance treatment for EoE.
‘I feel better: am I cured?’
Not necessarily
Symptoms and inflammation do not always change in parallel. Some people also compensate for dysphagia by changing the way they eat. Follow-up therefore does not rely on symptoms alone.
Depending on the situation, follow-up combines clinical assessment, endoscopy and biopsies. Effective treatment is often continued long-term to prevent recurrence of inflammation and limit the risk of fibrostenotic remodelling.
Do not change your treatment on your own
Personalised treatment
Do not stop or change a PPI, swallowed corticosteroid, elimination diet or biologic without discussing it with the team managing your EoE. Dosing and monitoring are personalised.
Food stuck: when should you act quickly?
Complete food impaction = emergency
If food remains stuck and you can no longer swallow your saliva, if you are drooling, pain is severe or breathing difficulty develops, urgent assessment is required. Call 15 or 112 as appropriate.
- Do not try to push the obstruction down with more food.
- Do not swallow large amounts of liquid to force it through.
- Do not continue the meal hoping it will clear.
- After an episode of impaction, even if it resolves, assessing the cause is important.
Why?
EoE is an important cause of food impaction. Complete obstruction of the oesophagus may require urgent endoscopy.
Common misconceptions
- ‘EoE is just reflux.’
- No. Reflux may coexist, but EoE is a distinct inflammatory condition.
- ‘My endoscopy looked normal, so I do not have EoE.’
- False. Biopsies are essential for diagnosis.
- ‘My positive IgE results show which foods to remove.’
- No. Standard allergy tests cannot determine the EoE diet on their own.
- ‘If I feel better, I can stop treatment.’
- Not without medical advice. Symptoms do not always reflect inflammation.
- ‘Dilation cures EoE.’
- No. It improves the calibre when narrowing is present but does not treat inflammation.
- ‘EoE automatically means a risk of food anaphylaxis.’
- No. EoE and IgE-mediated food allergy are different conditions, although they can coexist.
- ‘Many foods must be removed.’
- Not necessarily. Current strategies often seek to begin with the least restrictive relevant empirical approach.
When should I discuss it again with my doctor?
- You regularly feel that food does not go down properly.
- Food has been stuck before or you have needed urgent care because of it.
- You have substantially changed the way you eat to avoid discomfort.
- Your child has very long mealtimes, avoids certain textures or has nutritional consequences.
- Symptoms persist despite treatment or return after improvement.
- An elimination diet becomes difficult to follow or very restrictive.
Key points
- EoE is a chronic inflammatory disease of the oesophagus.
- Dysphagia may be masked by compensatory eating strategies.
- Diagnosis relies on endoscopy with biopsies; the threshold of 15 eosinophils is never interpreted alone.
- A positive skin-prick test or IgE result does not automatically show which foods maintain EoE.
- Several treatments are available and follow-up does not rely on symptoms alone.
- Food completely stuck, especially with inability to swallow saliva, is an emergency.
More on SOS Allergo
Main references
- Dellon ES, Muir AB, Katzka DA, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. Am J Gastroenterol. 2025;120(1):31-59. DOI: 10.14309/ajg.0000000000003194. PMID: 39745304.
- Amil-Dias J, Oliva S, Papadopoulou A, et al. Diagnosis and management of eosinophilic esophagitis in children: An update from ESPGHAN. J Pediatr Gastroenterol Nutr. 2024;79(2):394-437. DOI: 10.1002/jpn3.12188. PMID: 38923067.
- Oliva S, Arrigo S, Bramuzzo M, et al. Eosinophilic esophagitis in children and adolescents: a clinical practice guideline. Ital J Pediatr. 2025;51:242. DOI: 10.1186/s13052-025-02056-x. PMID: 40702503.
- American College of Gastroenterology. Diagnosis and Management of Eosinophilic Esophagitis - Guideline Highlights and patient resources. 2025.
- ASGE. Esophageal food impaction: practical guidance on urgent endoscopic management. 2024.
Important information
This sheet provides general guidance. It does not replace a gastroenterology/allergy consultation or personalised instructions given after your endoscopy. Do not begin an elimination diet or change your treatment without medical advice.