Recommended Diagnostic Procedures for EoE

EoE is diagnosed as a clinicopathological disorder requiring both clinical symptoms and histological confirmation. The diagnosis necessitates characteristic esophageal dysfunction symptoms combined with pathological evidence of 15 or more eosinophils per high-power field on esophageal biopsy. Upper endoscopy with biopsy remains the gold standard diagnostic procedure, as it provides essential histological evidence while also revealing characteristic endoscopic findings that support the diagnosis.

During endoscopy, clinicians should conduct a detailed examination of the esophageal mucosa rather than quickly passing through to the stomach. Key endoscopic features include edema with loss of normal vascular patterns, concentric rings extending down the esophageal length, white exudates appearing as small specks, longitudinal furrows resembling spokes when viewed down the esophageal barrel, and strictures or narrowing from fibrotic scarring. These strictures can be subtle, requiring careful observation rather than simply noting when the endoscope encounters resistance. However, patients can have EoE with completely normal-appearing esophageal mucosa, emphasizing the importance of histological confirmation.

Pediatric presentations typically show more acute exudative patterns with white exudates, vascular pattern loss, and edema compared to the strictures and rings more commonly seen in adults. Diagnostic challenges include biopsy variability because EoE presents as a patchy disease, potentially leading to sampling errors. The 2011 diagnostic guidelines acknowledge that patients may have fewer than 15 eosinophils if they are receiving concurrent treatment for other atopic conditions, as inhaled or intranasal steroids can partially treat esophageal inflammation. Additional challenges include parental skepticism when symptoms are intermittent, such as infrequent food impactions, and determining appropriate age thresholds for performing endoscopy in young children to balance diagnostic necessity against procedural risks and anesthesia exposure.