Closing the Diagnostic Gap in Eosinophilic Esophagitis, With Walker Redd, MD

Diagnostic delays in eosinophilic esophagitis (EoE) remain a major challenge, often spanning years from symptom onset to confirmed diagnosis. While subtle symptoms, limited disease awareness, and brief primary care visits contribute, one of the most actionable barriers occurs during endoscopy for esophageal food impaction (EFI), a common first presentation of undiagnosed EoE.1

At the American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting, Walker Redd, MD, a gastroenterologist and assistant professor of medicine at UNC School of Medicine, presented real-world data examining the management of EFI cases during and after emergency department visits in the community setting, with study findings shedding light on infrequent esophageal biopsies at the index endoscopy and subsequent missed opportunities for EoE diagnosis.1

“One of the things we've been interested in, based on some smaller, single center studies, is the frequency with which biopsies are performed,” Redd explained to HCPLive. “When a patient gets food stuck in their esophagus, it's often a way that EoE presents–patients who have not been diagnosed often come in and have food stuck… but there's been some hesitancy, or just lack of knowledge that biopsies need to be performed after the food bolus is removed from the esophagus.”

Current EoE guidelines from the ACG recommend diagnosing EoE based on the presence of symptoms of esophageal dysfunction and ≥ 15 eosinophils per high-power field on esophageal biopsy, after evaluating for non-EoE disorders that cause or potentially contribute to esophageal eosinophilia. However, despite biopsy being required to make a diagnosis, a growing body of research suggests it is not being routinely done in clinical practice.2

Seeking to provide more robust real-world data on biopsy practices, Redd and colleagues conducted a retrospective cohort study using deidentified electronic medical records from a real-world data repository from 58 gastroenterology practices across 6 US states from January 2018 to June 2024. For inclusion, patients were required to have ≥1 ED visit with an associated ICD-10 diagnosis code for EFI, ≥12 months of data after index ED visit, and age ≥18 years at index.1

A total of 2566 patients with EFI-related ED visits were identified. Among the cohort, 2534 (98.8%) patients underwent EGD at the time of index ED visit, the mean age at presentation was 59 years, and 1231 (48.6%) were female. At the index EGD, investigators noted 108 (4.3%) patients underwent a dilation, 739 (29.2%) had a code for biopsies, and of these, 191 (25.8%) received an EoE diagnosis.1

Of the 1795 (70.8%) patients who did not have biopsies collected during the index EGD, 837 (46.6%) were lost to follow up and 206 (11.5%) had an outpatient follow up EGD performed within 1 year after the EFI-related ED visit.1

“These data basically demonstrate, in the largest data set that I think has been assessed so far, that the biopsy rate at time of food impaction remains unacceptably low,” Redd said. “While that is unfortunate on one hand, that the biopsy rate and the rate of follow up remain too low, it's actually a tremendous opportunity for quality improvement.”

Looking ahead, he points to the need for continued emphasis on taking esophageal biopsies at time of food impaction as well as a greater focus on ensuring biopsy results make it to both the physician and the patient so that shared decision-making conversations about therapy can ensue.

Editors’ note: Redd reports relevant disclosures with Sanofi.

References

1. Redd WD, Dellon ES, Bekal PK, et al. Real-World Study of Biopsy Practices During Food Impactions in the Emergency Department: Multi-State GI Practice. Presented at the American College of Gastroenterology (ACG)’s 2025 Annual Scientific Meeting. Phoenix, Arizona. October 27-29, 2025.

2. Dellon ES, Muir AB, Katzka DA, et al. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. The American Journal of Gastroenterology. doi:10.14309/ajg.0000000000003194