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gi.eosinophilic-esophagitis.core.v1

Eosinophilic Esophagitis

gastroenterologychronicadultoutpatient
Start encounter →Print handoutPRODUCTION

Primary guideline: AGA-JTF 2020 (Hirano 2020, PMID 32359562 verified via PubMed MCP 2026-05-26). Three first-line pillars (shared decision-making): topical corticosteroid (swallowed fluticasone or budesonide oral viscous), PPI (omeprazole/esomeprazole), dietary elimination (six-food or one-food milk-only). Diagnosis: symptoms + ≥15 eos/hpf on ≥1 esophageal biopsy with exclusion of other causes; PPI no longer excludes EoE (AGREE consensus update). Dupilumab (LIBERTY-EoE TREET Dellon NEJM 2022 PMID 36546624) — phase 3 RCT: 300 mg SC weekly achieved histologic remission (≤6 eos/hpf) in 59-60% vs 5-6% placebo at week 24; FDA-approved for EoE in patients ≥12 yrs and ≥40 kg. Budesonide oral suspension (EoHilia) FDA-approved 2024 as first oral EoE-specific corticosteroid formulation. Food impaction may be first EoE presentation; emergent EGD with same-session biopsies; do NOT push bolus blindly (perforation risk). Long-term maintenance recommended — EoE relapses on cessation; periodic EGD to assess histologic remission. RxCUIs verified live via RxNav 2026-05-26: fluticasone-propionate=50121, budesonide=19831, omeprazole=7646, esomeprazole-magnesium=283562, dupilumab=1876376.

Entry points (5)

  • symptom
    Dysphagia to solids ± food impaction in adolescent/adult (AGA-JTF 2020)
    dysphagia_solids
  • symptom
    Food bolus impaction requiring endoscopic removal (AGA-JTF 2020)
    food_impaction
  • symptom
    Refractory reflux / heartburn not responding to PPI (AGA-JTF 2020)
    refractory_reflux_heartburn
  • lab_abnormality
    Esophageal biopsy ≥15 eosinophils/hpf (AGA-JTF 2020 diagnostic threshold)
    eosinophils_15_per_hpf_esophagus
  • history
    Atopic patient (asthma, eczema, food allergy, allergic rhinitis) with esophageal symptoms (AGA-JTF 2020)
    atopic_diathesis

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Pediatric onset (feeding difficulty / vomiting / failure to thrive) vs adult (dysphagia / impaction) (AGA-JTF 2020)
  • dysphagia_food_impaction_historyrequired
    symptom • used at ENTRY
    Cardinal symptoms; impaction may be first presentation (AGA-JTF 2020)
  • atopic_comorbiditiesrequired
    history • used at CONTEXT
    Asthma, eczema, food allergy, rhinitis common; informs dupilumab eligibility (AGA-JTF 2020)
  • prior_ppi_trialrequired
    history • used at CONTEXT
    Diagnosis requires persistent eosinophils despite PPI; AGREE consensus updated (PPI no longer excludes EoE) (AGA-JTF 2020)
  • food_triggers_history
    history • used at CONTEXT
    Top-6 elimination (milk, wheat, egg, soy, nuts, seafood) common dietary therapy (AGA-JTF 2020)
  • egd_with_biopsiesrequired
    imaging • used at INITIAL_WORKUP
    EGD with ≥6 biopsies (proximal + distal) — diagnostic gold standard; ≥15 eos/hpf (AGA-JTF 2020)
  • eref_endoscopic_features
    symptom • used at INITIAL_WORKUP
    EREFS score (edema, rings, exudates, furrows, strictures) tracks activity (AGA-JTF 2020)
  • cbc_eosinophil_count
    lab • used at INITIAL_WORKUP
    Peripheral eosinophilia not required but supports (AGA-JTF 2020)
  • allergy_testing_history
    history • used at CONTEXT
    Allergy testing may guide elimination diet; SPT / patch poor predictive value but useful in select pediatric cases (AGA-JTF 2020)

12-phase flow (12)

  1. 1FRAME
    EoE = chronic Th2-immune-mediated esophageal disease; defined by symptoms + esophageal eosinophilia (≥15 eos/hpf) persisting after exclusion of other causes (AGA-JTF 2020)
    inputs: age
    advance: EoE plausible by symptoms + atopy
  2. 2ENTRY
    Recognize dysphagia to solids, food impaction, refractory reflux in atopic patient (AGA-JTF 2020)
    inputs: dysphagia_food_impaction_history
    advance: one entry trigger present
  3. 3CONTEXT
    Atopic comorbidities, PPI history, food triggers / diet history, family history of EoE/atopy, prior endoscopy, allergy testing (AGA-JTF 2020)
    inputs: atopic_comorbidities, prior_ppi_trial, food_triggers_history, allergy_testing_history
    advance: context captured
  4. 4RED_FLAGS
    Food impaction requiring emergent EGD; severe strictures; failure to thrive in pediatric (AGA-JTF 2020)
    advance: red flags addressed
  5. 5INITIAL_WORKUP
    EGD with ≥6 biopsies (proximal + distal esophagus); ≥15 eos/hpf in ≥1 biopsy; EREFS endoscopic scoring; CBC; exclude other eosinophilia causes (AGA-JTF 2020)
    inputs: egd_with_biopsies, eref_endoscopic_features, cbc_eosinophil_count
    actions: panel.cbc
    advance: diagnosis confirmed (symptoms + ≥15 eos/hpf + exclude alternatives)
  6. 6BRANCHING_WORKUP
    Allergy testing in select cases; barium swallow if severe stricturing; manometry if motility concern; EndoFLIP for distensibility (AGA-JTF 2020)
    advance: phenotype clarified (inflammatory vs fibrostenotic)
  7. 7DIFFERENTIAL
    Distinguish from GERD (PPI-responsive), eosinophilic gastroenteritis, achalasia, mechanical stricture, eosinophilic granulomatosis with polyangiitis (AGA-JTF 2020)
    advance: EoE confirmed
  8. 8RISK_STRATIFICATION
    Inflammatory predominant vs fibrostenotic phenotype (rings, strictures); pediatric severity; impact on QOL (AGA-JTF 2020)
    advance: phenotype + severity documented
  9. 9TREATMENT
    Three pillars: (1) topical corticosteroid (swallowed fluticasone or budesonide oral viscous), (2) PPI (esomeprazole / omeprazole), (3) dietary elimination (six-food / one-food milk / empiric); + dupilumab for ≥12 yrs / ≥40 kg with persistent disease (LIBERTY-EoE TREET Dellon NEJM 2022); + esophageal dilation for strictures (AGA-JTF 2020)
    advance: treatment plan agreed
  10. 10DISPOSITION
    Outpatient management primarily; emergent EGD for food impaction; surgical consult NOT typically indicated (AGA-JTF 2020)
    advance: destination set
  11. 11MONITORING
    Repeat EGD with biopsies 8-12 weeks after starting therapy to assess histologic remission (<15 eos/hpf); EREFS scoring; symptom score (DSQ) (AGA-JTF 2020)
    advance: monitoring cadence set
  12. 12FOLLOWUP
    Long-term maintenance (EoE is chronic with high relapse); periodic EGD to confirm sustained remission; reassess dilation for fibrostenotic disease; transition pediatric→adult (AGA-JTF 2020)
    advance: long-term plan documented