Clinical Commander

Back to dossier
gi.eosinophilic-esophagitis.core.v1PRODUCTION
gi.eosinophilic-esophagitis.core.v1

Eosinophilic Esophagitis

gastroenterologychronicadult
Hard-required inputs
0 / 5
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
1
Actions
0
Advance rule
Set
Advance when

EoE plausible by symptoms + atopy

Patient inputs (9)

Pediatric onset (feeding difficulty / vomiting / failure to thrive) vs adult (dysphagia / impaction) (AGA-JTF 2020)

Asthma, eczema, food allergy, rhinitis common; informs dupilumab eligibility (AGA-JTF 2020)

Diagnosis requires persistent eosinophils despite PPI; AGREE consensus updated (PPI no longer excludes EoE) (AGA-JTF 2020)

Cardinal symptoms; impaction may be first presentation (AGA-JTF 2020)

EGD with ≥6 biopsies (proximal + distal) — diagnostic gold standard; ≥15 eos/hpf (AGA-JTF 2020)

Top-6 elimination (milk, wheat, egg, soy, nuts, seafood) common dietary therapy (AGA-JTF 2020)

Allergy testing may guide elimination diet; SPT / patch poor predictive value but useful in select pediatric cases (AGA-JTF 2020)

EREFS score (edema, rings, exudates, furrows, strictures) tracks activity (AGA-JTF 2020)

Peripheral eosinophilia not required but supports (AGA-JTF 2020)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalseverefood_impaction_acute
    Acute food bolus impaction — unable to swallow / drooling / vomiting (AGA-JTF 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefibrostenotic_disease_severe_stricture
    Symptomatic severe stricture or narrow-caliber esophagus on EGD (AGA-JTF 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_failure_to_thrive
    Pediatric EoE with growth failure / inadequate intake / feeding aversion (AGA-JTF 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterefractory_eoe_failed_two_pillars
    No histologic remission after trial of two pillars (e.g., topical steroid AND PPI both failed) (AGA-JTF 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateeoe_relapse_post_discontinuation
    Symptom or histologic recurrence after stopping maintenance therapy (AGA-JTF 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

EoE three-pillar therapy: topical steroid, PPI, dietary elimination + dupilumab for refractory (AGA-JTF 2020 + LIBERTY-EoE TREET 2022)
axis: eoe_three_pillar_pathwaystep 1 - Step 1 — Induction (choice of 3 pillars by shared decision-making)
Selected step "Step 1 — Induction (choice of 3 pillars by shared decision-making)" — Confirmed EoE (symptoms + ≥15 eos/hpf)
  • fluticasone_propionate_swallowed
    first line
    topical_corticosteroid_swallowed
    Adults: 880-1760 mcg/day (440 mcg BID — TID swallowed from MDI without spacer); rinse mouth; no food/drink for 30 min • oral_swallowed_topical • BID
    triggers: confirmed_EoE, topical_steroid_pathway
    AGA-JTF 2020 — strong recommendation for topical corticosteroid; swallowed fluticasone first studied; histologic remission ~50-65%
    rxcui 50121
  • budesonide_oral_viscous
    first line
    topical_corticosteroid_swallowed
    Adults: 1-2 mg PO BID swallowed (mixed with sucralose to viscous slurry; FDA-approved orodispersible 1 mg BID in EU); rinse mouth • oral_swallowed_viscous • BID
    triggers: confirmed_EoE, topical_steroid_pathway
    AGA-JTF 2020 — equally first-line topical steroid; budesonide oral suspension EoHilia FDA-approved 2024
    rxcui 19831
  • omeprazole
    first line
    PPI
    20-40 mg PO BID × 8-12 weeks • PO • BID
    triggers: confirmed_EoE, PPI_pathway
    AGA-JTF 2020 — PPI now accepted first-line therapy; ~30-50% histologic remission; AGREE consensus updated (PPI-REE no longer separate)
    rxcui 7646
  • esomeprazole_magnesium
    first line
    PPI
    20-40 mg PO BID × 8-12 weeks • PO • BID
    triggers: confirmed_EoE, PPI_pathway
    AGA-JTF 2020 — equally acceptable PPI option
    rxcui 283562
  • six_food_elimination_diet
    first line
    dietary_therapy
    Empiric elimination of cow milk, wheat, egg, soy, nuts, seafood × 6 weeks then sequential reintroduction with biopsy • dietary • continuous
    triggers: dietary_therapy_pathway
    AGA-JTF 2020 — six-food elimination ~70% histologic remission; step-down to 1-food (milk-only) reasonable per recent evidence (Kliewer Gastro 2023)
  • one_food_elimination_milk_only
    first line
    dietary_therapy
    Cow milk elimination × 6 weeks then biopsy • dietary • continuous
    triggers: dietary_therapy_pathway, simplified_diet
    Step-up dietary strategy; one-food (milk) remission ~40-50%, escalate if non-responder

outpatient playbook — drug actions (6)

  1. 1. topical fluticasone swallowed
    rxcui 50121
    880-1760 mcg/day BID swallowed; rinse mouth • oral swallowed • BID
    trigger: EoE diagnosis confirmed (AGA-JTF 2020)
    First-line topical corticosteroid; ~50-65% remission
  2. 2. budesonide oral viscous (alternative steroid)
    rxcui 19831
    1-2 mg PO BID viscous slurry • oral swallowed • BID
    trigger: EoE diagnosis confirmed; alternative topical steroid (AGA-JTF 2020)
    Equally first-line; EoHilia FDA-approved 2024
  3. 3. PPI (omeprazole or esomeprazole)
    rxcui 7646
    20-40 mg PO BID x 8-12 wk • PO • BID
    trigger: EoE diagnosis; PPI pathway (AGA-JTF 2020)
    ~30-50% remission
  4. 4. six-food elimination diet (dietary pathway)
    Eliminate milk, wheat, egg, soy, nuts, seafood x 6 wk then sequential reintroduction • dietary • continuous
    trigger: Dietary therapy preferred (AGA-JTF 2020)
    ~70% remission
  5. 5. dupilumab
    rxcui 1876376
    300 mg SC weekly (age ≥12 and weight ≥40 kg) • SC • weekly
    trigger: Refractory EoE on topical steroid or PPI (Dellon 2022)
    LIBERTY-EoE TREET 59-60% remission vs 5-6% placebo
  6. 6. esophageal dilation
    Gradual dilation to 15-18 mm • endoscopic • as needed
    trigger: Strictures + persistent dysphagia after medical remission (AGA-JTF 2020)
    Symptom relief; pair with medical therapy

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Dysphagia to solids ± food impaction in adolescent/adult (AGA-JTF 2020); Food bolus impaction requiring endoscopic removal (AGA-JTF 2020); Refractory reflux / heartburn not responding to PPI (AGA-JTF 2020).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Eosinophilic Esophagitis** (gi.eosinophilic-esophagitis.core.v1).
Phenotype framing: Distinguish from GERD (PPI-responsive), eosinophilic gastroenteritis, achalasia, mechanical stricture, eosinophilic granulomatosis with polyangiitis (AGA-JTF 2020)
Scope: EoE = chronic Th2-immune-mediated esophageal disease; defined by symptoms + esophageal eosinophilia (≥15 eos/hpf) persisting after exclusion of other causes (AGA-JTF 2020)

No severity triggers fired against current inputs.

Plan

Regimen axis: **EoE three-pillar therapy: topical steroid, PPI, dietary elimination + dupilumab for refractory (AGA-JTF 2020 + LIBERTY-EoE TREET 2022)** — step "Step 1 — Induction (choice of 3 pillars by shared decision-making)".
1. fluticasone_propionate_swallowed Adults: 880-1760 mcg/day (440 mcg BID — TID swallowed from MDI without spacer); rinse mouth; no food/drink for 30 min oral_swallowed_topical BID (topical_corticosteroid_swallowed, first line) — AGA-JTF 2020 — strong recommendation for topical corticosteroid; swallowed fluticasone first studied; histologic remission ~50-65%
2. budesonide_oral_viscous Adults: 1-2 mg PO BID swallowed (mixed with sucralose to viscous slurry; FDA-approved orodispersible 1 mg BID in EU); rinse mouth oral_swallowed_viscous BID (topical_corticosteroid_swallowed, first line) — AGA-JTF 2020 — equally first-line topical steroid; budesonide oral suspension EoHilia FDA-approved 2024
3. omeprazole 20-40 mg PO BID × 8-12 weeks PO BID (PPI, first line) — AGA-JTF 2020 — PPI now accepted first-line therapy; ~30-50% histologic remission; AGREE consensus updated (PPI-REE no longer separate)
4. esomeprazole_magnesium 20-40 mg PO BID × 8-12 weeks PO BID (PPI, first line) — AGA-JTF 2020 — equally acceptable PPI option
5. six_food_elimination_diet Empiric elimination of cow milk, wheat, egg, soy, nuts, seafood × 6 weeks then sequential reintroduction with biopsy dietary continuous (dietary_therapy, first line) — AGA-JTF 2020 — six-food elimination ~70% histologic remission; step-down to 1-food (milk-only) reasonable per recent evidence (Kliewer Gastro 2023)
6. one_food_elimination_milk_only Cow milk elimination × 6 weeks then biopsy dietary continuous (dietary_therapy, first line) — Step-up dietary strategy; one-food (milk) remission ~40-50%, escalate if non-responder

Setting playbook (outpatient) — Confirm EoE diagnosis (EGD + biopsies ≥15 eos/hpf); shared decision-making on three pillars (topical steroid, PPI, dietary); 8-12 wk repeat EGD; dupilumab for refractory; dilation for strictures; long-term maintenance (AGA-JTF 2020)
7. topical fluticasone swallowed 880-1760 mcg/day BID swallowed; rinse mouth oral swallowed BID — EoE diagnosis confirmed (AGA-JTF 2020) (First-line topical corticosteroid; ~50-65% remission)
8. budesonide oral viscous (alternative steroid) 1-2 mg PO BID viscous slurry oral swallowed BID — EoE diagnosis confirmed; alternative topical steroid (AGA-JTF 2020) (Equally first-line; EoHilia FDA-approved 2024)
9. PPI (omeprazole or esomeprazole) 20-40 mg PO BID x 8-12 wk PO BID — EoE diagnosis; PPI pathway (AGA-JTF 2020) (~30-50% remission)
10. six-food elimination diet (dietary pathway) Eliminate milk, wheat, egg, soy, nuts, seafood x 6 wk then sequential reintroduction dietary continuous — Dietary therapy preferred (AGA-JTF 2020) (~70% remission)
11. dupilumab 300 mg SC weekly (age ≥12 and weight ≥40 kg) SC weekly — Refractory EoE on topical steroid or PPI (Dellon 2022) (LIBERTY-EoE TREET 59-60% remission vs 5-6% placebo)
12. esophageal dilation Gradual dilation to 15-18 mm endoscopic as needed — Strictures + persistent dysphagia after medical remission (AGA-JTF 2020) (Symptom relief; pair with medical therapy)

Non-pharmacologic actions:
- Shared decision-making on three pillars based on patient preference, atopy, severity (AGA-JTF 2020)
- Dietary counseling + RD referral if elimination diet chosen (AGA-JTF 2020)
- Rinse mouth after swallowed steroid; no food/drink 30 min (AGA-JTF 2020)
- Atopic comorbidity coordination (asthma, eczema) (AGA-JTF 2020)
- Allergy / immunology referral in select cases (AGA-JTF 2020)
- Patient education on food impaction prevention + emergency plan (AGA-JTF 2020)
- Long-term maintenance plan — EoE relapses (AGA-JTF 2020)

AVOID / contraindication checks:
- Do_not_push_food_bolus_blindly_in_acute_food_impaction (AGA JTF 2020)
- Rinse_mouth_after_swallowed_steroid_to_prevent_oral_candidiasis (AGA JTF 2020)
- Dupilumab_requires_age_>=12_and_weight_>=40kg_per_FDA_label (Dellon 2022)
- Dilation_does_not_treat_inflammation_pair_with_medical_or_dietary_therapy (AGA JTF 2020)
- Long_term_high_dose_swallowed_steroid_monitor_for_systemic_absorption_and_adrenal_axis (AGA JTF 2020)
- PPI_long_term_caution_per_GI_safety_advisory_no_absolute_contraindication

Monitoring

Regimen monitoring:
- repeat EGD with biopsies 8 to 12 weeks post treatment for histologic remission (AGA-JTF 2020)
- EREFS endoscopic score each EGD (AGA-JTF 2020)
- symptom score DSQ or patient reported (AGA-JTF 2020)
- oral candidiasis screening on swallowed steroid (AGA-JTF 2020)
- dupilumab injection site reactions and conjunctivitis (Dellon 2022)
- growth and nutritional status in pediatric (AGA-JTF 2020)

Setting (outpatient) monitoring:
- Symptom score (DSQ) at each visit (AGA-JTF 2020)
- Repeat EGD + biopsies 8-12 weeks after starting therapy (AGA-JTF 2020)
- EREFS score on every EGD (AGA-JTF 2020)
- Periodic EGD on long-term maintenance per response (AGA-JTF 2020)
- Oral candidiasis check on swallowed steroid (AGA-JTF 2020)
- Dupilumab injection site reactions / conjunctivitis (Dellon 2022)
- Pediatric growth + nutrition (AGA-JTF 2020)

Follow-up plan: 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)
- Close-out criterion: long-term plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Confirm EoE diagnosis (EGD + biopsies ≥15 eos/hpf); shared decision-making on three pillars (topical steroid, PPI, dietary); 8-12 wk repeat EGD; dupilumab for refractory; dilation for strictures; long-term maintenance (AGA-JTF 2020)

Disposition criteria:
- Continue outpatient with maintenance therapy + periodic EGD (AGA-JTF 2020)
- Refractory disease → biologic (dupilumab) (Dellon 2022)

Escalation triggers (move to higher acuity):
- Food impaction → emergent EGD (AGA-JTF 2020)
- Severe stricture preventing PO → urgent EGD + dilation (AGA-JTF 2020)
- Failure of all three pillars → dupilumab consideration (Dellon 2022)

Patient Action Plan

**Eosinophilic esophagitis action plan**
Personalised values: chosen_treatment_pillar, identified_food_triggers, prior_food_impactions, atopic_comorbidities.

**In remission — continue maintenance** (green):
Triggers:
- No dysphagia or impactions
- Eating diverse diet (within identified triggers)
- Recent EGD with histologic remission (<15 eos/hpf)
Actions:
- Take maintenance therapy as prescribed (do not skip swallowed steroid or PPI)
- Continue identified food trigger avoidance if dietary pathway
- Keep follow-up EGD appointments
- Rinse mouth after swallowed steroid

**Caution — symptoms returning, contact team** (yellow):
Triggers:
- Increased solid-food dysphagia
- Need to chew thoroughly / take small bites
- Sticking sensation but no impaction
- Reflux returning
Actions:
- Continue current therapy
- Avoid hard / dry / sticky foods (bread, rice, meat)
- Chew thoroughly; small bites; sip water with meals
- Contact GI within 1-2 weeks for assessment
- Possible repeat EGD + dose escalation
Contact provider when:
- Symptoms worsening over days-weeks
- New trigger foods identified
- Need to adjust therapy

**Medical alert — food impaction, go to ED now** (red):
Triggers:
- Food bolus stuck — cannot swallow saliva
- Drooling, vomiting, severe chest pain
- Persistent regurgitation > 30 min
Actions:
- Go to ED immediately — do NOT push food down (perforation risk)
- Bring medication list
- Notify GI team after stabilization
- Plan EGD with biopsies during impaction removal
Contact provider when:
- Food impaction — ED now

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Acute food bolus impaction — unable to swallow / drooling / vomiting (AGA-JTF 2020)
- [SEVERE] Symptomatic severe stricture or narrow-caliber esophagus on EGD (AGA-JTF 2020)
- [SEVERE] Pediatric EoE with growth failure / inadequate intake / feeding aversion (AGA-JTF 2020)

Citations

- AGA Institute and Joint Task Force on Allergy-Immunology Practice Parameters 2020 Clinical Guidelines for the Management of Eosinophilic Esophagitis (Hirano et al, Gastroenterology 2020) + LIBERTY-EoE TREET dupilumab phase 3 (Dellon NEJM 2022) [PMID:32359562](https://pubmed.ncbi.nlm.nih.gov/32359562/)
- Cited evidence (PMID 32336462) [PMID:32336462](https://pubmed.ncbi.nlm.nih.gov/32336462/)
- Cited evidence (PMID 36546624) [PMID:36546624](https://pubmed.ncbi.nlm.nih.gov/36546624/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AGA Institute and Joint Task Force on Allergy-Immunology Practice Parameters 2020 Clinical Guidelines for the Management of Eosinophilic Esophagitis (Hirano et al, Gastroenterology 2020) + LIBERTY-EoE TREET dupilumab phase 3 (Dellon NEJM 2022) — PMID:32359562
  • Cited evidence (PMID 32336462) — PMID:32336462
  • Cited evidence (PMID 36546624) — PMID:36546624