Eosinophilic Esophagitis (EoE)
Diagnosis, EREFS scoring, treatment guidelines & case-based clinical scenarios — ACG 2025 & GIE Top Tips
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What is EoE?
Eosinophilic esophagitis (EoE) is a chronic, allergen-driven, type 2 immune-mediated disease of the esophagus. Once considered rare, it is now one of the most common causes of dysphagia in young adults and a major cause of food impaction across all ages.
• Prevalence: ~1 in 2,000 (rapidly increasing)
• More common in males (3:1), white race, atopic individuals
• Classic presentation: young male with dysphagia or food impaction
• 60–80% have concomitant atopic disease (eczema, asthma, allergic rhinitis)
• Mean diagnostic delay: 4–6 years from symptom onset
• Food allergens penetrate a defective esophageal barrier
• T-cell mediated type 2 immune response (IL-4, IL-5, IL-13)
• Eosinophils are effector cells — cause inflammation and remodeling
• Progression: Inflammatory → Fibrostenotic phenotype
• NOT IgE-mediated — allergy testing does not predict food triggers
Disease Phenotype Spectrum
The "IMPACT" Acronym — Always Assess These Adaptive Behaviors
Imbibe fluids
Drinks lots of liquid to wash food down
Modify foods
Cuts food small, avoids tough textures
Prolong meal times
"Last one at the table"
Avoid hard textures
No meats, crusty bread, sticky foods
Chew excessively
Chews to a mush-like consistency
Turn away tablets/pills
Pill dysphagia — a subtle but specific clue
Critical Nuance
IMPACT behaviors mask symptom severity. A patient reporting 'mild' dysphagia may be extensively avoiding hard foods, chewing excessively, and always ordering soft meals. Symptoms alone CANNOT be used to monitor EoE — endoscopy with biopsy is required.