Illustration depicting the contrast between a healthy and inflamed esophagus in eosinophilic esophagitis.

Beyond Heartburn: Understanding Eosinophilic Esophagitis and the Latest Diagnostic Criteria

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Elliot Brynn in Health & Wellness August 2025 • 4 min read.

"Navigating the complexities of EoE: New guidelines offer clarity for diagnosis and management of this often misunderstood condition."


For many, heartburn is an occasional nuisance, easily dismissed with an over-the-counter remedy. But for a growing number of people, discomfort when swallowing, food getting stuck, and chest pain aren't just random occurrences; they're symptoms of a condition called eosinophilic esophagitis, or EoE. Once considered rare, EoE is now recognized as a global health issue that significantly impacts the quality of life for those affected. Understanding this condition and its diagnostic criteria is crucial for effective management.

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by inflammation of the esophagus, the tube that carries food from your mouth to your stomach. This inflammation is driven by an accumulation of white blood cells called eosinophils in the esophageal lining. These eosinophils release substances that can damage the esophagus, leading to a variety of symptoms.

Recognizing the need for clearer guidance, a panel of experts convened the AGREE (A working Group on ppi-REE) Conference. The result? Updated international consensus diagnostic criteria for EoE, designed to improve accuracy and consistency in diagnosis. Let's dive into what these new criteria mean for patients and healthcare providers.

Decoding the Updated Diagnostic Criteria for Eosinophilic Esophagitis

Illustration depicting the contrast between a healthy and inflamed esophagus in eosinophilic esophagitis.

The diagnosis of EoE isn't always straightforward, as its symptoms can overlap with other conditions, such as GERD (gastroesophageal reflux disease). Traditionally, EoE was suspected when individuals experienced esophageal dysfunction and had a high number of eosinophils in their esophageal biopsies (≥15 eosinophils per high power field, or eos/hpf). However, the role of proton pump inhibitors (PPIs), medications that reduce stomach acid, complicated the picture.

Previously, it was thought that if someone with suspected EoE responded to PPIs, they likely had GERD, not EoE. But research revealed that many people with EoE also experience symptom improvement with PPIs, leading to the term PPI-responsive esophageal eosinophilia (PPI-REE). The updated criteria address this overlap and provide a more nuanced approach to diagnosis. Here’s a breakdown:

  • Clinical Presentation: The updated criteria emphasize the importance of chronic esophageal symptoms, such as difficulty swallowing (dysphagia), food impaction, chest pain, and abdominal discomfort.
  • Eosinophil Count: A key diagnostic feature remains the presence of ≥15 eosinophils per high power field (eos/hpf) in esophageal biopsies.
  • Exclusion of Other Causes: It's crucial to rule out other conditions that can cause esophageal eosinophilia, such as infections, Crohn's disease, and certain drug reactions.
  • PPI Considerations: The new guidelines acknowledge that PPIs can improve symptoms in some EoE patients. A PPI trial is no longer mandatory for diagnosis but can be a helpful tool in certain cases.
The updated diagnostic algorithm suggests that if a patient presents with suggestive clinical symptoms and at least 15 eos/hpf on biopsy, further evaluation for non-EoE disorders should be conducted. Only after excluding these other causes and confirming the presence of esophageal dysfunction alongside the elevated eosinophil count can a diagnosis of EoE be confirmed. Ultimately, the updated criteria aim to provide a clearer and more consistent approach to diagnosing EoE, taking into account the complexities of PPI responsiveness and the need to exclude other potential causes.

Moving Forward: A Brighter Future for EoE Patients

The updated international consensus diagnostic criteria represent a significant step forward in the understanding and management of eosinophilic esophagitis. By providing a more refined approach to diagnosis, these guidelines pave the way for earlier and more accurate diagnoses, leading to improved treatment strategies and a better quality of life for individuals living with this challenging condition. If you suspect you or someone you know may have EoE, talk to your doctor. Early diagnosis and appropriate management are key to controlling symptoms and preventing long-term complications.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

Everything You Need To Know

1

What is eosinophilic esophagitis (EoE) and why is it important to understand?

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease where the esophagus becomes inflamed due to a build-up of white blood cells called eosinophils. This inflammation can damage the esophagus, leading to symptoms like difficulty swallowing, food impaction, and chest pain. Early diagnosis and proper treatment are key to managing the condition and avoiding long-term health issues.

2

What are the key diagnostic criteria used to identify eosinophilic esophagitis (EoE) according to the latest guidelines?

The key diagnostic criteria for eosinophilic esophagitis (EoE) include: 1) chronic esophageal symptoms like difficulty swallowing or chest pain, 2) a high eosinophil count (≥15 eos/hpf) in esophageal biopsies, 3) exclusion of other conditions that can cause similar symptoms, and 4) consideration of proton pump inhibitors (PPIs) response, which, while not mandatory, can be a helpful tool. The updated diagnostic algorithm suggests that if a patient presents with suggestive clinical symptoms and at least 15 eos/hpf on biopsy, further evaluation for non-EoE disorders should be conducted.

3

How do proton pump inhibitors (PPIs) fit into the diagnosis of eosinophilic esophagitis (EoE), and why has this understanding evolved?

Proton pump inhibitors (PPIs) are medications that reduce stomach acid production. In the context of eosinophilic esophagitis (EoE), their role is complex. Previously, a response to PPIs suggested GERD rather than EoE. However, it's now recognized that many EoE patients also experience symptom relief with PPIs, leading to the term PPI-responsive esophageal eosinophilia (PPI-REE). Now a PPI trial is not mandatory for diagnosis but can be a helpful tool in certain cases.

4

How do updated international consensus diagnostic criteria refine the diagnosis approach of Eosinophilic Esophagitis(EoE)?

The updated international consensus diagnostic criteria for eosinophilic esophagitis (EoE) refine the diagnostic approach by emphasizing chronic esophageal symptoms alongside the eosinophil count. It also acknowledges the role of proton pump inhibitors (PPIs) and addresses the complexities of PPI responsiveness, providing a more consistent approach to diagnosing EoE. This helps doctors differentiate EoE from conditions like GERD more accurately.

5

What steps should I take if I suspect I or someone I know might have eosinophilic esophagitis (EoE)?

If you suspect you or someone you know may have eosinophilic esophagitis (EoE) based on symptoms like difficulty swallowing, food impaction, or chest pain, it's essential to consult with a doctor for proper evaluation. Early diagnosis and appropriate management are key to controlling symptoms and preventing long-term complications. Diagnostic steps may involve an examination of the esophagus, a biopsy to check for eosinophils, and consideration of other conditions that can mimic EoE.

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