 Bryan Sauer, MD, MSc 

Role of Inflammation and Atopic Presentations in EoE

The role of inflammation in EoE is complex, as inflammation serves beneficial functions in health but becomes problematic when excessive. In EoE, chronic inflammation manifests through multiple pathways, including symptomatic presentation, distinctive endoscopic findings, and characteristic histologic changes. The tissue shows increased eosinophil infiltration along with epithelial proliferation and progressive fibrosis. While establishing direct correlations between inflammation severity and symptom intensity remains challenging in research models, clinical evidence strongly suggests that reducing eosinophil levels and healing inflammatory processes leads to symptom improvement in patients.

The primary concern with untreated inflammation centers on preventing long-term complications. Chronic inflammatory processes can result in structural damage including esophageal strictures, recurrent food impactions, and, in pediatric cases, potential malnutrition affecting growth and development. This understanding drives the therapeutic focus on controlling inflammation to prevent irreversible complications while addressing immediate symptomatic relief.

EoE demonstrates strong associations with other atopic conditions, reflecting its position within the broader spectrum of type 2 inflammatory disorders. Patients commonly present with comorbid conditions, including eczema, asthma, food allergies, and allergic rhinitis, though the severity and combination of these conditions vary significantly among individuals. This atopic overlap creates opportunities for earlier detection, as gastroenterologists often receive referrals from allergy specialists, and conversely, patients with established atopic diseases represent a higher-risk population for EoE development. The multidisciplinary approach between gastroenterology and allergy specialists becomes crucial for comprehensive care. Additionally, there is significant potential for improved early detection through systematic screening, particularly in primary care settings where patients with known atopic conditions should routinely be questioned about swallowing difficulties, as many patients normalize these symptoms or attribute them to familial patterns rather than seeking appropriate medical evaluation.

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Panelists discuss how inflammation in eosinophilic esophagitis (EoE) correlates with symptoms and long-term complications such as strictures, while emphasizing the importance of screening patients with other atopic conditions such as eczema, asthma, and food allergies for potential EoE given the shared type 2 inflammatory process.

Clinical Features of EoE and Overall Prevalence

This clinical discussion features gastroenterology experts reviewing the evolving management of EoE, focusing on clinical presentation, diagnostic challenges, and treatment approaches. The panel includes specialists from major academic medical centers discussing adult and pediatric perspectives on this increasingly recognized condition.

In adults, EoE primarily presents as dysphagia, where patients experience difficulty swallowing with food “slowing down” or not passing easily. A significant subset presents with acute food impaction requiring emergency intervention, though these patients typically have ignored earlier warning signs. Many patients unconsciously develop adaptive behaviors over years, including avoiding certain foods, cutting food into smaller pieces, chewing excessively, prolonging mealtimes, using liquids or sauces to aid swallowing, and modifying food textures. These compensatory mechanisms often mask the severity of symptoms, making diagnosis challenging as patients may deny swallowing difficulties when directly questioned.

Pediatric presentations vary by developmental stage. Younger children may exhibit feeding difficulties, food refusal, or reluctance to advance to age-appropriate textures, with parents often needing to encourage eating. Adolescents present similarly to adults with dysphagia and food impaction, but pill-swallowing difficulties serve as an important diagnostic clue. Children often report symptoms that parents are unaware of when questioned directly. Growth problems occur in approximately 16% of pediatric cases, though many children maintain adequate nutrition through adaptive eating strategies. The epidemiology of EoE shows rapidly increasing prevalence from 1 in 2000 fifteen years ago to current estimates of 1 in 700 or higher. This increase appears to outpace diagnostic awareness, suggesting environmental factors, early-life antibiotic or antacid exposure, and interactions with other atopic conditions may contribute to disease development beyond improved recognition alone.

Panelists discuss how eosinophilic esophagitis (EoE) presents with dysphagia and adaptive eating behaviors in adults and feeding difficulties in children and has increasing prevalence rates potentially driven by environmental factors and early life exposures rather than just improved awareness.

Bryan Sauer, MD, MSc

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