Eosinophilic Esophagitis (EoE)
Videos
Overview
Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease of the esophagus. In EoE, white blood cells called eosinophils — which normally are not found in the esophagus — build up in its lining in response to foods or environmental allergens. The inflammation causes swelling, rings and, over time, scarring and narrowing of the esophagus. The hallmark symptoms in adults are difficulty swallowing and food getting stuck.
Once considered rare, EoE is now recognized as one of the most common causes of difficulty swallowing and food impaction in young and middle-aged adults, and its prevalence has risen steadily over the past two decades. Diagnosis requires an endoscopy with biopsies showing at least 15 eosinophils per high-power field, after other causes have been excluded (Dellon et al., Gastroenterology, 2018).
EoE is often mistaken for acid reflux, and the two can coexist. Recognizing EoE matters for anyone considering anti-reflux surgery, because a fundoplication does not treat EoE — and an unrecognized narrow, inflamed esophagus can make swallowing after surgery more difficult. Effective treatments now include acid suppression, swallowed steroids, targeted diets, a biologic medication, and endoscopic dilation.
Causes
- Immune reaction to food antigens: milk, wheat, eggs, soy, nuts and seafood are the most common triggers.
- Environmental allergens: pollen and dust mites can worsen symptoms seasonally.
- Type 2 (allergic) inflammation driven by immune signals such as interleukin-4, -5 and -13.
- Genetic predisposition: EoE runs in families.
- Impaired esophageal barrier, which lets allergens penetrate the lining.
Risk Factors
- Male sex: men are affected about three times as often as women.
- Other allergic conditions: asthma, eczema, food allergies and allergic rhinitis.
- Family history of EoE.
- Age: most adults are diagnosed between their 20s and 40s, although EoE occurs at all ages.
- Living in colder or drier climates and early-life factors such as antibiotic exposure have been associated with EoE.
Who It Affects
EoE affects both children and adults. Children often present with feeding problems, vomiting or abdominal pain, while adults typically present with swallowing difficulty and food impaction. EoE is a frequent finding in adults who come to the emergency room with food stuck in the esophagus.
Complications
- Esophageal strictures and a narrow-caliber esophagus
- Food impaction requiring emergency endoscopy
- Tears or, rarely, perforation of the esophagus during impaction
- Weight loss and nutritional problems from avoiding foods
Symptoms
- Difficulty swallowing solid foods, especially meat and bread
- Food impaction: food that gets stuck and must be removed endoscopically
- Chest pain or heartburn that does not respond fully to acid medication
- Regurgitation
- Coping behaviors: eating slowly, chewing excessively, cutting food into tiny pieces, drinking a lot of water with meals, or avoiding certain foods
Because people adapt their eating habits gradually, many do not realize how much their swallowing has changed until it is treated.
Diagnosis
- Upper endoscopy with biopsies: typically at least six biopsies from different levels of the esophagus. Endoscopic findings include rings, furrows, white exudates, swelling and narrowing, which can be scored with the EREFS system. See diagnostic upper endoscopy.
- Pathology: 15 or more eosinophils per high-power field confirms the diagnosis when symptoms fit and other causes are excluded (Dellon et al., Gastroenterology, 2018).
- Barium esophagram: helps measure the diameter and length of narrowing.
- Allergy evaluation: can identify other allergic diseases, although standard skin and blood allergy tests are poor at predicting which foods trigger EoE.
- Repeat endoscopy after treatment to confirm the inflammation has resolved.
Differential Diagnosis
- GERD, which can also cause eosinophils in the lower esophagus
- Esophageal stricture from other causes
- Achalasia and other motility disorders
- Pill or infectious esophagitis
- Celiac disease, Crohn's disease and drug reactions
Lifestyle Modifications
- Chew thoroughly and take small bites.
- Drink water with meals.
- Follow an elimination diet under guidance from a gastroenterologist or dietitian when prescribed.
- Manage seasonal allergies, which can trigger flares.
- Keep follow-up endoscopies — symptoms alone do not reliably show whether inflammation is controlled.
Treatment Options
Treatment aims to control inflammation and restore the esophageal diameter (Hirano et al., Gastroenterology, AGA–JTF Guideline, 2020):
- Proton pump inhibitors: induce remission in about half of patients (Lucendo et al., Clinical Gastroenterology and Hepatology, 2016).
- Swallowed topical steroids: budesonide or fluticasone coat the esophagus and reduce inflammation with minimal absorption into the body.
- Elimination diets: removing one or more common trigger foods. In a randomized trial, removing milk alone was about as effective as eliminating six foods (Kliewer et al., Lancet Gastroenterology & Hepatology, 2023).
- Dupilumab: a biologic injection that blocks allergic inflammation, approved for EoE after a randomized trial showed improved histology and swallowing (Dellon et al., New England Journal of Medicine, 2022).
- Endoscopic dilation: stretches strictures and narrow segments, giving rapid relief of swallowing symptoms. Serious complications are rare, with perforation in fewer than 1 in 1,000 dilations (Moawad et al., Alimentary Pharmacology & Therapeutics, 2017). See esophageal dilation.
- Emergency endoscopy to remove impacted food.
Dilation treats the narrowing but not the inflammation, so it is combined with medical or dietary therapy.
When to See a Doctor
See a doctor if food sticks when you swallow, if you have changed how you eat to get food down, or if heartburn does not respond to acid medication. Go to the emergency room if food is stuck and you cannot swallow your saliva.
When to Seek Treatment
Seek specialist care after any food impaction, when swallowing problems persist, or before anti-reflux surgery if you have allergies and swallowing difficulty. Biopsies to rule out EoE should be part of the evaluation.
Long-Term Outlook
Most patients need maintenance treatment, since symptoms and inflammation usually return when therapy stops. Periodic endoscopy confirms that the disease remains controlled, and occasional dilation may be needed for residual narrowing. With modern treatments, most people with EoE eat normally and lead full lives.
Related Reading and Videos
Watch The Reflux Talk Every Patient Needs: Hiatal Hernias, Warning Signs & What Doctors Don’t Explain on our video library. Related conditions include Esophageal Stricture (Peptic Stricture & Schatzki Ring) and Achalasia. Treatments that may be involved include Esophageal Dilation (Endoscopic Balloon & Bougie Dilation for Strictures & Dysphagia).
More Foregut and Reflux Conditions
Explore related topics in our foregut patient library: Esophageal Stricture, Strictures of the Esophagus, Pylorus and Duodenum, Esophageal Ulcer, Jackhammer Esophagus, Stomach Cancer and Reflux Hypersensitivity. For an overview of surgical options, see anti-reflux surgery and hiatal and paraesophageal hernia repair.
Prognosis
EoE is a chronic condition, but it does not increase the risk of esophageal cancer. With treatment, most patients achieve good symptom control. Without treatment, inflammation tends to progress to scarring and narrowing over years, which is why ongoing therapy is recommended.
Why Choose Dr. de la Cruz‑Muñoz
Eosinophilic esophagitis is easy to miss when swallowing problems are assumed to be reflux. Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, is a board-certified surgeon specializing in minimally invasive foregut and bariatric surgery in Miami who directed a bariatric surgery fellowship for 10 years, training 13–14 fellows who also gained experience in foregut surgery. He evaluates every swallowing complaint with endoscopy, biopsies and, when needed, manometry and esophagram before recommending any surgery. He performs endoscopic dilation and works with gastroenterology and allergy colleagues on long-term medical management, and he makes sure EoE is identified and treated before anti-reflux surgery is considered. Patients traveling from outside South Florida are welcome.
Dr. de la Cruz-Muñoz has performed more than 15,000 minimally invasive procedures over more than 25 years in practice, including complex foregut, hernia, gallbladder and abdominal operations as well as bariatric surgery.
Featured Procedures
FAQ
Both can cause heartburn, chest pain and trouble swallowing, but they are different diseases. GERD is caused by stomach acid flowing back into the esophagus. Eosinophilic esophagitis is an allergic inflammation in which eosinophils build up in the esophageal lining, usually triggered by foods. EoE is more likely in younger adults, in men, and in people with asthma, eczema or food allergies, and it often causes food to get stuck. The only way to tell them apart reliably is an endoscopy with biopsies, and the two can coexist.
The most common triggers are milk, wheat, eggs, soy, nuts and seafood, with milk being the single most frequent trigger in adults. Standard skin-prick and blood allergy tests do a poor job of predicting EoE triggers, so they are usually identified by removing foods and repeating endoscopy to see whether inflammation resolves. In a randomized trial, removing milk alone worked about as well as eliminating six foods for many adults (Kliewer et al., Lancet Gastroenterology & Hepatology, 2023), so many patients start with a simpler diet.
EoE is a chronic condition, so it is controlled rather than cured. Symptoms and inflammation usually return if treatment is stopped. The good news is that current treatments — proton pump inhibitors, swallowed steroids, diet changes and the biologic dupilumab — control the disease in most patients, and dilation quickly relieves any narrowing that has already formed. With ongoing treatment, most people with EoE eat normally, and EoE does not increase the risk of esophageal cancer.
Yes. Dilation is safe and effective in EoE when done gradually. Serious complications are rare, with perforation in fewer than 1 in 1,000 dilations in a large analysis (Moawad et al., Alimentary Pharmacology & Therapeutics, 2017). Some chest discomfort for a day or two afterward is common. Dilation relieves narrowing quickly but does not treat the underlying inflammation, so it is combined with medical or dietary therapy to keep the esophagus from narrowing again.
Not to treat EoE. A fundoplication controls acid reflux but does not treat the allergic inflammation of EoE, and an inflamed or narrowed esophagus can make swallowing after a wrap more difficult. That is why biopsies to look for EoE are part of a careful evaluation before anti-reflux surgery. Patients who have both EoE and proven, significant reflux — for example, with a large hiatal hernia — can still be good surgical candidates once the EoE is controlled and the esophagus has been properly evaluated.
