Eosinophilic esophagitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 24 Nov 2025

Last updated: 16 Dec 2025

Eosinophilic esophagitis (EoE) is a chronic immune-mediated/allergen-mediated condition characterized by infiltration of eosinophils in the esophageal mucosa.

To consider the diagnosis, there must be an esophageal epithelial infiltrate of ≥15 eosinophils per high-power microscopy field on esophageal biopsy.

Incidence and prevalence are increasing at a rate that is outpacing increased recognition and diagnosis; it is more commonly seen in children and young adults.

Pharmacotherapy (topical corticosteroids, proton-pump inhibitors [PPIs], or dupilumab) or dietary elimination can be used as a first-line treatment. Endoscopic dilation is reserved for patients with esophageal strictures or fibrostenotic complications.

Prognosis is good, with the majority of patients having a good response to either pharmacologic or dietary elimination therapy.

Definition

EoE is a chronic, immune-mediated/allergen-mediated clinicopathologic condition. It is characterized clinically by symptoms of esophageal dysfunction (e.g., dysphagia and food impaction in adolescents and adults, and vomiting, regurgitation, heartburn, abdominal pain, failure to thrive, or feeding intolerance in children), and histologically by an eosinophilic infiltration of the esophageal epithelium of ≥15 eosinophils per high-power microscopy field in the absence of other causes of local or systemic eosinophilia.[1][2][3] To account for the increasing use of digital optical microscopy, the joint consensus guidelines from the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition recommend using an updated peak eosinophil count of ≥15 per 0.3 mm².[2] The condition is also abbreviated to EoO.

History and exam

Key diagnostic factors

dysphagia
food avoidance and modification behaviors

Full details

Other diagnostic factors

heartburn
chest discomfort
nausea/vomiting
regurgitation
abdominal pain
failure to thrive
irritability

Full details

Risk factors

family history of eosinophilic esophagitis (EoE)
male sex
atopic disease
children and younger adults
white ancestry

Full details

Diagnostic investigations

1st investigations to order

esophagogastroduodenoscopy
esophageal biopsy
CBC with differential

Full details

Investigations to consider

barium swallow (esophagram)

Full details

Emerging tests

unsedated transnasal endoscopy
esophageal string test
cytosponge
esophageal physiological testing
eosinophilic esophagitis (EoE) diagnostic panel

Treatment algorithm

ACUTE

at initial diagnosis

ONGOING

response to initial therapy

nonresponse or relapse

Contributors

Authors

Jenny Epstein, MB ChB MRCPCH PhD

Consultant Paediatric Gastroenterologist

Chelsea and Westminster Hospital

London

Disclosures

JE is a member of the advisory board for Dr Falk Pharma, manufacturer of Jorveza, a new formulation of budesonide licensed for adults with eosinophilic esophagitis (EoE), and Nurtricia for infant functional bowel disorders. She has received honoraria from Dr Falk Pharma to speak on EoE and has been sponsored by Dr Falk Pharma, Abbvie and Nutricia to attend national and international meetings. JE is a member of BSPGHAN IBD working group, medical advisor to CICRA and Coeliac UK, member of CCUK IBD working group, member of BSG EoE Guideline development group, member of NICE Guideline update committee for Crohn disease and ulcerative colitis, member of NICE Diagnostics, and sits on the NICE advisory committee for personalized treatment in Crohn disease.

Acknowledgements

We would like to acknowledge our Gastroenterology expert panel member, Dr Brooks D.Cash, for his contribution to this topic. Dr Jenny Epstein wishes to gratefully acknowledge Dr Evan S. Dellon, the previous contributor to this topic.

Disclosures

BDC declares that he has no competing interests. ESD is an author of a number of references cited in this topic.

Peer reviewers

David Katzka, MD

Professor of Medicine

Mayo Clinic

Rochester

Disclosures

DK has served on advisory boards (Adare, Receptos) and received research funding (Covidien).

Alexandra Papadopoulou, MD

Honorary Professor

Chief of the Division of Gastroenterology and Hepatology

First Department of Pediatrics

University of Athens

Agia Sofia Children’s Hospital

Athens

Greece

Disclosures

AP has received speaker’s honorariums from Nestle and Nutricia; research grants from Biogaia/Nutricia/Abbvie; consultant’s fee from Receptos.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Dhar A, Haboubi HN, Attwood SE, et al. British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults. Gut. 2022 Aug;71(8):1459-87.Full text Abstract

Dellon ES, Muir AB, Katzka DA, et al. ACG clinical guideline: diagnosis and management of eosinophilic esophagitis. Am J Gastroenterol. 2025 Jan 1;120(1):31-59.Full text Abstract

Amil-Dias J, Oliva S, Papadopoulou A, et al. Diagnosis and management of eosinophilic esophagitis in children: an update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr. 2024 Aug;79(2):394-437.Full text Abstract

Hirano I, Chan ES, Rank MA, et al. AGA institute and the joint task force on allergy-immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis. Ann Allergy Asthma Immunol. 2020 May;124(5):416-23.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Gastroesophageal reflux disease (GERD)
- Eosinophilic gastroenteritis
- Achalasia
More Differentials
Guidelines
- Diagnosis and management of eosinophilic esophagitis
- Diagnosis and management of eosinophilic esophagitis in children
More Guidelines
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Eosinophilic esophagitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

at initial diagnosis

response to initial therapy

nonresponse or relapse

Contributors

Authors

Jenny Epstein, MB ChB MRCPCH PhD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

David Katzka, MD

Disclosures

Alexandra Papadopoulou, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice