Eosinophilic Esophagitis: Clinical Pearls for Primary Care Providers and Gastroenterologists

Eosinophilic esophagitis (EoE) is a chronic and progressive immune-mediated esophageal disorder. Given its increasing incidence, it is now a leading cause of dysphagia and food impaction in the United States. Eosinophilic esophagitis is most common in adult White men and has a high concurrence rate with other atopic conditions like allergic rhinitis, bronchial asthma, and eczema. The initial presentation includes symptoms of esophageal dysfunction, classically solid -food dysphagia. Without treatment, in fl ammation can progress to fi brosis with the formation of strictures, leading to complications such as food impaction. It is a clinico- pathologic disease requiring compatible clinical symptoms and histologic evidence of eosinophil-predominant in fl ammation of the esophageal epithelium with more than 15 eo- sinophils per high -power fi eld. The mainstay of management includes the 3 d ' s (diet, drugs, dilation): dietary modi fi cations to eliminate trigger food groups; medications including proton pump inhibitors, swallowed topical glucocorticoids, and dupilumab; and esophageal dilation to manage strictures. Various elimination diets have been found to be effective, including 1 -food, 2 -food, 4 -food, and 6 -food elimination diets. Dupilumab, a humanized monoclonal antibody that regulates interleukin 4 and 13 signaling pathways, has shown promising results in clinical trials and was approved by the Food and Drug Administration in 2022 for use in EoE. Symptom alleviation, although important, is not the sole end point of treatment in EoE as persistent in fl ammation, even in the absence of symptoms, can lead to esophageal fi brosis and stricture formation over time. The chronic nature and high recurrence rates of EoE warrant maintenance therapy in patients with EoE after initial remission is achieved.