Advanced Practice Provider EoE Program (Live/Virtual) | October 2025-ARTICLE_clinical_guideline__diagnosis_and

ARTICLE_clinical_guideline__diagnosis_and_management.16

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The American College of Gastroenterology (ACG) updated its Clinical Guideline for eosinophilic esophagitis (EoE), a chronic immune-mediated esophageal disease characterized by symptoms of esophageal dysfunction and eosinophilic infiltration. EoE's incidence has rapidly increased, emphasizing the need for standardized diagnosis and treatment approaches.<br /><br />Diagnosis requires symptoms plus ≥15 eosinophils per high-power field on esophageal biopsy, excluding other causes. Endoscopic assessment using the EoE Endoscopic Reference Score (EREFS) and obtaining at least six biopsies from multiple esophageal levels are recommended for accurate diagnosis and monitoring. Eosinophil counts should be quantified every endoscopy, with emerging recognition that other histologic features (e.g., basal zone hyperplasia) also impact disease activity.<br /><br />Treatment includes proton pump inhibitors (PPIs), topical swallowed steroids (budesonide or fluticasone), empiric food elimination diets (FEDs), biologics (notably dupilumab), and esophageal dilation for fibrostenotic disease. PPIs are suggested as initial pharmacologic treatment, often at double the reflux dose, with demonstrated efficacy beyond acid suppression. Topical steroids are strongly recommended, with evidence supporting formulated budesonide preparations and fluticasone inhalers adapted for esophageal delivery. Empiric FEDs, such as 1-food (dairy), 2-food, 4-food, and 6-food elimination diets, are conditionally suggested, emphasizing shared decision-making and dietitian involvement. Allergy testing to direct diets is not recommended due to poor predictive value. Dupilumab is conditionally recommended for patients ≥12 years with PPI nonresponse and recently approved for ages 1–11.<br /><br />Esophageal dilation is conditionally suggested for symptomatic strictures but should be combined with anti-inflammatory therapy as it does not address underlying inflammation. Maintenance therapy is strongly recommended due to high relapse rates off treatment. Monitoring requires symptom assessment, endoscopy with EREFS scoring, and histology (goal <15 eos/hpf), as symptoms alone may not correlate with disease activity. Minimally invasive monitoring methods like transnasal endoscopy and Cytosponge show promise.<br /><br />Pediatric considerations include using esophagram to detect fibrostenosis and integrating feeding therapy for feeding dysfunction or food aversion. The guidelines advocate individualized, patient-centered care using shared decision-making, considering comorbidities and patient preferences. Future research priorities include comparative effectiveness studies, identification of biomarkers and predictors of response, minimally invasive monitoring techniques, and development of novel therapeutics.

Keywords

eosinophilic esophagitis

ACG clinical guideline

esophageal biopsy

EoE Endoscopic Reference Score

proton pump inhibitors

topical swallowed steroids

food elimination diets

dupilumab

esophageal dilation

pediatric eosinophilic esophagitis