Eosinophilic Esophagitis: The Underdiagnosed Condition Behind Chronic Swallowing Problems

Eosinophilic esophagitis (EoE) is a chronic, immune-driven condition in which eosinophils (a type of white blood cell) build up in the lining of the esophagus. Over time, this inflammation can lead to persistent swallowing difficulties, chest discomfort, and food impactions. Although awareness of EoE has grown in recent years, it remains underdiagnosed and often mistaken for acid reflux (GERD) or other esophageal disorders.

What Is Eosinophilic Esophagitis?

• EoE is defined by:
  • ≥15 eosinophils per high-power field on esophageal biopsy
  • Symptoms of esophageal dysfunction (e.g., dysphagia, food impaction)
  • Exclusion of other causes of esophageal eosinophilia (e.g., GERD, infections)
• It's considered an antigen-mediated disease, often linked to food triggers or aeroallergens.
• Left untreated, chronic inflammation may cause esophageal remodeling (narrowing or strictures).

How Common Is EoE?

• Estimated prevalence: 30–60 cases per 100,000 people in North America and Europe.
• Incidence is rising, possibly due to:
  • Better awareness among clinicians
  • Improved diagnostic techniques
• Affects all ages but is most often diagnosed in:
  • Children and adolescents
  • Men (male:female ratio ~3:1)

Why EoE Is Underdiagnosed

• Symptom overlap with GERD: Heartburn and chest pain lead many doctors initially to prescribe acid-suppressive therapy.
• Variable symptoms by age: Young children may present with feeding aversion or slow eating rather than classic heartburn.
• Lack of routine endoscopy: Without an upper endoscopy and biopsy, EoE can be missed.
• Misattribution to behavior: In kids, "picky eating" may actually reflect discomfort from EoE.

Recognizing the Signs and Symptoms

Symptoms can vary by age group:

• Children
  • Vomiting or regurgitation
  • Abdominal pain
  • Feeding refusal or slow eating
  • Failure to thrive or poor weight gain
• Adolescents and Adults
  • Difficulty swallowing (dysphagia), especially with solids
  • Food "getting stuck" (food impaction)
  • Chest or upper abdominal pain
  • Persistent heartburn unresponsive to proton-pump inhibitors (PPIs)

Even mild symptoms can impact quality of life—slow eating to avoid discomfort, anxiety around meals, and social avoidance.

Diagnosing Eosinophilic Esophagitis

1. Clinical evaluation
   – Detailed history of symptoms, food reactions, and atopic conditions (asthma, eczema, allergic rhinitis)
2. Upper endoscopy with esophageal biopsy
   – Collection of multiple tissue samples from different esophageal levels
   – Histologic confirmation of eosinophil infiltration
3. Exclusion of other causes
   – Trial of high-dose PPIs to rule out reflux-induced eosinophilia
   – Consideration of infectious, medication-related, or systemic causes
4. Allergy assessment
   – Skin prick testing or serum IgE testing for common food allergens
   – Interpretation by an allergist in context with clinical findings

Treatment Options

Treatment aims to control inflammation, relieve symptoms, and prevent complications.

1. Dietary Therapy
   • Six-food elimination diet: Removes dairy, wheat, eggs, soy, nuts, and seafood
   • Targeted elimination: Based on allergy testing
   • Elemental diet: Amino acid–based formula (used when other diets fail or in young children)
2. Medications
   • Topical corticosteroids (swallowed fluticasone or budesonide) to reduce esophageal inflammation
   • Proton-pump inhibitors (PPIs): May help in a subset of patients with PPI-responsive esophageal eosinophilia
3. Endoscopic Dilation
   • For patients with strictures or persistent narrowing
   • Performed carefully to minimize risk of perforation
4. Emerging Therapies
   • Biologics targeting interleukins (e.g., IL-5, IL-13) under clinical investigation

Most patients require a combination of diet modification and medical therapy. Regular follow-up with endoscopy and biopsies helps monitor response.

Living Well with EoE

• Work with a multidisciplinary team: gastroenterologist, allergist, dietitian
• Keep a food and symptom diary to identify potential triggers
• Practice safe swallowing habits:
  • Chew thoroughly
  • Take small bites
  • Drink water with meals
• Seek support: patient advocacy groups and online communities can reduce feelings of isolation

When to Consider a Symptom Check

If you or your child have ongoing swallowing difficulties, unexplained chest discomfort, or repeated episodes of food "sticking," it's important to understand what might be causing these symptoms. Try Ubie's free AI-powered symptom checker to get personalized insights in just minutes and be better prepared for your conversation with a healthcare provider.

Don't Delay—Talk to Your Doctor

Eosinophilic esophagitis is manageable, but early diagnosis and treatment are key to preventing long-term complications, such as esophageal strictures. If you experience any of the following, see a physician promptly:

• Sudden inability to swallow saliva or liquids
• Recurrent food impactions requiring emergency care
• Severe chest pain or weight loss
• Any life-threatening or alarming symptoms

Always consult with a healthcare professional for personalized advice. A proper evaluation—a detailed history, endoscopy, and biopsy—will determine the right treatment plan for you. Taking action early can help you maintain a healthy, active life without the constant worry of swallowing problems.