#159: (Not so) Easy-to-Swallow: How to Approach Eosinophilic Esophagitis

November 19, 2025 | By Sam Masur

Audio

In this episode, Dr. Vincent Mukkada (Cincinnati) joins us to demystify eosinophilic esophagitis (EoE). Together, we explore how to take a good history in children in whom EoE is suspected, treatment strategies, and innovations for ongoing monitoring. Whether you’re managing the initial diagnosis or ongoing care for these patients, the conversation won’t get stuck thanks to an episode full of helpful information for you!

Eosinophilic Esophagitis Pearls

• Eosinophilic esophagitis often presents as dysphagia and food impaction in older children/adolescents, but should be considered in younger children with feeding difficulties, difficult to manage reflux, or picky eaters.
• It is more common in children with other atopic conditions, but can still be present in children without atopy.
• It is a chronic condition that cannot be cured but can be well managed by dietary modification and medications such as PPIs, topical steroids, or monoclonal antibody therapy. 
• Diagnosis is made by upper GI endoscopy and patients will need ongoing monitoring by endoscopy every few years as symptoms do not correlate well with disease severity.

Eosinophilic Esophagitis Notes 

Pathophysiology

Eosinophilic esophagitis (EoE) is a chronic disease characterized by infiltration of eosinophils into the esophageal epithelium resulting in dysfunction of the esophagus. It can occur at any age and has different clinical manifestations depending on age of onset.  (Barni et al., 2021)

Presentation

Infants and toddlers

• Reflux not responding to medications
• Feeding difficulties once introducing solid foods despite normal feeding when breast/formula-fed, had done well on thin purees but pushes away solid foods

School-aged children

• Picky Eater: only like softer-textured foods, such as ground meat, but dislike steak, chicken, pork chops, etc. 
• Abdominal pain, nausea, or vomiting. 

Adolescents or adults

• Dysphagia, likely because they have the language skills to express the sensation
• Food impaction requiring removal by endoscopy. 

Patients rarely experience pain with swallowing (odynophagia) unless in the context of food getting stuck. If odynophagia is persistently present, providers should consider infectious or caustic causes of esophagitis. 

Incidence and Risk Factors

Highest incidence of diagnosis is in adolescents and young adults, but should still be thought about in younger patients. There is a higher predominance of EoE in males compared to females in both adults and children.

Patients with atopy are at higher risk but EoE can occur in patients without other atopic disorders. Family history of EoE or other eosinophilic disorders also increases risk.

Differential for Feeding Difficulties/Dysphagia

• GERD
• EoE
• Infectious esophagitis 
• Caustic esophagitis
• Recurrent vomiting due to other causes

Evaluation

Diagnosis

The gold standard for diagnosis of EoE is upper GI endoscopy with biopsies. This is performed under anesthesia and patients/families should be counseled on what to expect. Patients 

Should be off of PPIs for at least 6 weeks if possible, as PPIs can have an anti-inflammatory response that directly affects eosinophils and may obscure diagnosis. 

If the family is hesitant to jump to endoscopy, providers could also do an esophagram (barium swallow) to evaluate for narrowing of the esophagus as an initial step.

Endoscopy

On endoscopy, there are characteristic findings of EoE, however no single finding is pathognomonic. If all features are present, though, the diagnosis is very likely to be EoE. The EREFS score is used to evaluate the severity of gross endoscopic findings, with higher scores indicative of more severe disease. The score takes into account:

• Edema: normally you should see blood vessels in the wall of the esophagus, but these will be blunted or difficult to visualize when the esophagus is edematous
• Rings: circumferential rings which are signs of fibrosis and remodeling
• Exudates: little white pinpoint spots that are clusters of eosinophils (eosinophilic microabscesses) 
• Furrows: “train-track-like” lines or creases that are going down the esophagus vertically
• Strictures: fixed narrowing of the esophagus, which is a marker of more advanced disease

Some patients have a “crepe-paper” esophagus, in which the lining of the tissue is very friable and easily damaged by the scope or by puffs of air during the procedure. This is because the tissue is very stiff/fibrotic and does not tolerate distention. This is rarely seen in other diseases and is highly suggestive of EoE.

About 10-30% of patients may have a normal-appearing esophagus, therefore biopsies are required to ultimately diagnose EoE. The disease can be very patchy, so the goal is to obtain at least five biopsies in varying locations from distal to proximal (including in the stomach and duodenum), often in areas where the most gross disease is visualized. 

Biopsy Pathology

Diagnostic threshold is the presence of 15 or more eos/HPF on microscopy. It is important to note that there are other disease processes that include eosinophils, so clinical symptoms and gross findings must be considered. Disease severity does not correlate with the number of eosinophils, it correlates better with the extent of disease involvement. Therefore it is more likely that patients are experiencing active disease if more biopsies demonstrate elevated eosinophils than if one biopsy has a very high number but all the rest are normal. 

Treatments

Typically providers can begin with one of the three first-line options, but these treatments can be used in combination with each other.

Proton Pump Inhibitors (PPIs)

First-line treatment includes acid suppression with high-dose PPIs daily or BID. Dr. Mukkada prefers to begin with once daily dosing as there are some concerns now about long-term use of PPIs. 

Dietary Elimination

Studies now show that the best approach is empiric elimination of foods that ARE known to be triggers for patients with EoE. Basing elimination on allergy testing has NOT been shown to be as effective, as there are foods that are triggers for patients despite negative allergy testing as well as foods that are not triggers despite a positive allergy test.

The six main foods/food groups that trigger EoE are as follows, with the approximate percentage of patients who go into remission with eliminating this food alone:

• Dairy (effective for about 30-40% of patients)
• Wheat (25%)
• Eggs (25%)
• Soy (20%)
• Peanuts/tree nuts (5-10%)
• Fish/shellfish (<5%)

These foods can be eliminated one at a time, two at a time, or all together, depending on provider and patient/family preference. For patients who eliminate all of these foods at once, about 70% are put into remission. Foods can then be added back into the diet one at a time (typically recommend starting at the bottom of the list and workup back up), with endoscopy after three months to monitor for disease progression as symptoms are not always reliable. If the food is confirmed to be tolerated, the next food can be added back in.

Elemental Diet

Another dietary option is to put the patient on an amino-acid based formula only, which is effective for putting about 90% of patients into remission. However, this is a more intense approach and can be difficult to tolerate in older children since they need a significant volume of formula to meet caloric needs and are aware of the poor taste. This may result in requiring a G-tube for long-term formula feeding, which is often a concern that parents raise when they research EoE. The elemental diet does not help to identify which foods were triggers for the patient.

Topical Steroids

Treatment with topical steroids has been shown to be an effective way to induce remission by reducing inflammation in the esophagus. Typically dosed BID. There are several ways that topical treatment can be achieved: 

• Inhaled steroids in HFA formulation (cannot be DPI inhaler) – patients spray the back of their throat, swallow, and then cannot eat or drink for 30 minutes afterwards. 

Note: This is the exact opposite of the instructions for proper use of inhalers for asthma treatment, so Dr. Mukkada prefers not to use this in patients with asthma or who are requiring frequent rescue inhaler use as it can get too confusing. It is also difficult to use in patients less than 7 years old. 

• Nebulizer formulation of steroids, mixed with something to make it thicker. Again, patients should not eat or drink for 30 minutes following use. 
• Premixed steroid suspension – there is a newly approved (in 2024) pre-mixed oral budesonide suspension available for patients 11 years and older that is flavored and typically well tolerated. 

Side effects of topical steroids are typically fairly minimal, but patients may develop thrush or esophageal candidiasis. Some parents raise concern about poor growth while their children are on steroids, but they can be reassured that this is not typically seen in patients who receive topical treatment (more often seen for systemic treatment). In fact, some studies have shown that patients with EoE receiving topical steroids may grow better than those treated with dietary elimination alone.

Other Treatment Options

Dupilumab

This is a newer, monoclonal antibody therapy that binds IL-4R, blocking IL-4 and IL-13. First approved for treatment of asthma, eczema, and allergic rhinitis, and now indicated for use in EoE and chronic urticaria. Dupilumab is a subcutaneous injection that can be given once every 1-2 weeks (dosing based on age, weight, and indication). It must be obtained from a specialty pharmacy.

Patients must first fail first-line therapy for approval by insurance as treatment is considered second-line, however this is a very good option for patients who are already meeting other criteria for use. Patients do tend to report that this is a painful injection due to me medication viscosity, but otherwise treatment is well tolerated. Common side effects include allergic conjunctivitis, joint pain, and skin rashes. 

Systemic Steroids

These are rarely indicated for treatment of EoE, but a short course (such as 5 days) may be used for patients who are acutely hospitalized for food impaction and still have significant discomfort and dysphagia after removal of the food bolus. However, these patients will still benefit most from other treatments.

Endoscopic Dilation

Patients with significant strictures or narrowing may need endoscopic dilation. It can be difficult to determine visually what is a fixed, fibrotic stricture and what is edema, so patients should first be treated with other therapies and then reassessed for improvement prior to dilation. To avoid perforation, patients may require gradual dilation.

Complications

It is difficult to predict outcomes for patients with EoE as they are highly variable. Some patients may never develop severe symptoms even if completely untreated. However, the longer patients remain untreated, the higher risk they are at for fibrous stenotic disease, particularly if they are already symptomatic. Fibrous stenotic disease can include strictures, muscle dysfunction and motility abnormalities, and poor distensibility. Patients with significant disease may need dilations every few years, which is not ideal particularly for young patients. 

The good news is EoE is not associated with malignancy! Most cases of Barrett’s esophagus are most likely linked to concomitant reflux disease. 

Monitoring

Patients are typically monitored by endoscopy every 3 months while making changes to treatments, with the exception of dupilumab which may take longer to show effect. Once patients are in remission, endoscopy can be spaced to once yearly and then to every 2-3 years. It is important to remember that children may outgrow their medication dosages and need changes. Furthermore, symptoms are not a reliable indicator of disease progression so ongoing monitoring by endoscopy is still recommended even if the patient is asymptomatic. 

Newer options for endoscopy include nasal endoscopy, which can be performed in the office without sedation, and the esophageal string test.

Goal

Listeners will explain the basic pathophysiology, diagnosis, and management of eosinophilic esophagitis and feel comfortable discussing care with patients and their families.

Learning Objectives

After listening to this episode listeners will…  

1. Describe the clinical presentation of EoE, including how presentation may vary across age groups.
2. Differentiate EoE from other causes of dysphagia based on history, presentation, and endoscopic findings.
3. Discuss management strategies for EoE, including dietary management, pharmacologic therapies, and monitoring.
4. Identify common concerns raised by parents and develop strategies for discussing diagnosis, treatment, and ongoing management with families.
5. Recognize the impact of EoE on patients and their families.

Disclosures

Dr. Mukkada consults for takeda, regeneron, senophy, and phathon. All efforts have been made to present balanced information about treatment options.

Citation

Holloway R, Campbell T, Chisholm J, Mukkada V, Chiu C, Masur S. “#159: (Not so) Easy-to-Swallow: How to Approach Eosinophilic Esophagitis”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ November 19, 2025