A Disease on the Rise
Eosinophilic oesophagitis (EoE) is a chronic, immune-mediated condition characterised by eosinophilic infiltration of the oesophageal mucosa — defined as 15 or more eosinophils per high-power field on oesophageal biopsy. Its prevalence has increased dramatically over the past three decades, now estimated at 1 in 2,000 adults in Western countries. Whether this reflects a true increase in incidence or improved recognition remains debated, though the rise parallels increases in other allergic conditions and has been linked to changing microbial exposures.
Symptoms Across Ages
In children, EoE typically presents with feeding difficulties, vomiting, abdominal pain, and failure to thrive. In adults, the dominant symptom is dysphagia (difficulty swallowing), particularly with solid foods, often accompanied by food impaction episodes where a food bolus becomes stuck in the oesophagus — requiring emergency endoscopic removal in severe cases. Heartburn-like symptoms can overlap with GORD, leading to frequent misdiagnosis and years of inadequate PPI therapy before EoE is identified.
Pathogenesis
EoE is driven by a Th2-mediated immune response — the same pathway underlying allergic asthma, eczema, and allergic rhinitis. Food antigens (and possibly aeroallergens) stimulate thymic stromal lymphopoietin (TSLP) and IL-33 production from oesophageal epithelium, activating Th2 cells that produce IL-5 and IL-13. IL-5 recruits and activates eosinophils; IL-13 disrupts epithelial barrier function and promotes tissue remodelling. Over time, chronic inflammation leads to oesophageal strictures and fibrosis.
Diagnosis
Diagnosis requires oesophagogastroduodenoscopy (OGD) with biopsies from multiple oesophageal levels. Visual findings may include linear furrows, white exudates, concentric rings ("trachealization"), and strictures — but the oesophagus can appear macroscopically normal in up to 10 percent of cases, making biopsies essential.
Treatment Options
Three evidence-based treatment approaches exist. Dietary elimination (empiric 6-food elimination diet or allergy-test-directed elimination) can achieve histological remission in 50 to 70 percent of patients but requires systematic reintroduction to identify trigger foods. Proton pump inhibitors — now recognised as first-line therapy for EoE (not just acid reflux) — achieve histological remission in approximately 50 percent of patients through anti-inflammatory mechanisms independent of acid suppression. Topical corticosteroids (swallowed fluticasone or budesonide) are the most effective medical therapy, achieving remission in 60 to 80 percent. Dupilumab — a biologic targeting IL-4/IL-13 — was approved by the FDA for EoE in 2022, providing a new option for refractory cases.