Eosinophilic esophagitis (EoE) is a chronic immune condition where a specific type of white blood cell, called an eosinophil, builds up in the lining of the esophagus and causes inflammation. That inflammation makes swallowing difficult, can cause food to get stuck, and over time can narrow and scar the esophagus. Once considered rare, EoE now affects roughly 40 out of every 100,000 people globally, and its prevalence has increased nearly tenfold since it was first described in the late 1970s.
What Happens Inside the Esophagus
EoE is driven by an allergic-type immune response. When certain food proteins (and occasionally airborne allergens) contact the esophageal lining, the tissue sends out chemical alarm signals. Those signals activate a branch of the immune system that produces inflammatory messengers, most importantly two called IL-5 and IL-13. IL-5 tells the body to produce and deploy more eosinophils, while IL-13 reshapes the esophageal tissue itself, thickening it and making it stickier for those incoming eosinophils.
Once eosinophils arrive, they release toxic proteins that damage the surrounding tissue. Under a microscope, biopsies from people with EoE show these proteins scattered outside the cells, and the amount of protein deposited correlates with visible damage: swelling between cells, thickening of the tissue layers, and early scarring. Left unchecked, this cycle of inflammation and repair leads to fibrosis, where the esophagus becomes stiff and narrow.
Symptoms in Adults vs. Children
EoE looks different depending on age. In adults, the hallmark symptom is dysphagia, difficulty swallowing solid foods, reported in about 76% of cases. Many adults describe the sensation of food moving slowly or getting stuck partway down the chest. Some experience food impaction, where a piece of food lodges in the esophagus and won’t pass without medical help. Heartburn and chest pain are also common and often lead to an initial misdiagnosis of acid reflux.
Children are more likely to present with abdominal pain (roughly 29% of pediatric cases, compared to 8% in adults). Younger children and toddlers may refuse food, eat very slowly, gag, vomit, or prefer soft textures without being able to explain why. Infants sometimes fail to gain weight. Because these symptoms overlap with many other pediatric conditions, EoE in children is frequently missed or attributed to picky eating.
Common Triggers
Food is the primary driver of EoE for most people. The top culprits are cow’s milk and wheat. In clinical trials, removing milk alone led to remission in about 51% of children and 34% of adults. A combined milk-and-wheat elimination achieved remission in 43% of a mixed-age group. Eggs, soy, and nuts are also well-established triggers, though peanuts, tree nuts, fish, and shellfish play a smaller role in EoE than they do in classic food allergies. Less obvious foods like beef, chicken, and corn can also be triggers for some individuals.
Environmental allergens appear to play a supporting role. A small number of people with EoE experience seasonal flares that track with pollen counts, and elimination diets tend to be less effective during pollen season. About a third of adults with EoE also have oral allergy syndrome, where raw fruits and vegetables cause itching or tingling in the mouth. There is even a documented case of EoE resolving after allergy shots for airborne allergens, though that remains unusual.
How EoE Is Diagnosed
Diagnosis requires an upper endoscopy with biopsies. During the procedure, a gastroenterologist passes a thin, flexible scope down the esophagus and takes small tissue samples, typically from multiple spots. Under a microscope, a pathologist looks for elevated eosinophil counts. The diagnostic threshold is 15 or more eosinophils in a single high-power microscope field.
Older guidelines required a trial of acid-blocking medication before confirming an EoE diagnosis, since acid reflux can also draw eosinophils into the esophagus. That requirement has been dropped. Current American College of Gastroenterology guidelines now treat acid-blocking medication as one possible therapy for EoE rather than a diagnostic hurdle, which has streamlined the path to diagnosis considerably.
What Happens Without Treatment
EoE is chronic, and the inflammation does not resolve on its own. Over time, ongoing damage remodels the esophageal wall, replacing flexible tissue with stiff scar tissue and forming strictures (narrowed segments). Research tracking diagnostic delays shows a clear, time-dependent pattern: strictures are found in about 17% of people diagnosed within two years of symptom onset, but in over 70% of those whose diagnosis was delayed more than 20 years. That gap underscores why early recognition and sustained treatment matter.
Treatment Options
Acid-Blocking Medication
Proton pump inhibitors (PPIs), the same drugs used for acid reflux, are a first-line treatment. They reduce esophageal inflammation in a meaningful portion of EoE patients, possibly through anti-inflammatory effects beyond simple acid suppression. They’re widely available, inexpensive, and well tolerated, making them a common starting point.
Swallowed Steroids
Topical corticosteroids are another first-line option. The two most commonly used are fluticasone and budesonide, delivered as a swallowed formulation rather than inhaled. The medication coats the esophageal lining and reduces inflammation locally, with minimal absorption into the rest of the body. Treatment courses typically last at least 8 weeks, and because EoE tends to return when treatment stops, many people stay on a maintenance dose long term.
Elimination Diets
Removing trigger foods can put EoE into remission without any medication. The most studied approach is the six-food elimination diet, which removes milk, wheat, eggs, soy, fish/shellfish, and peanuts/tree nuts simultaneously. In a head-to-head trial, 40% of patients on the six-food diet achieved remission after six weeks, compared to 34% on a milk-only elimination. That relatively modest gap has shifted clinical practice toward starting with fewer foods removed (often just milk, or milk and wheat) and expanding only if needed, since the six-food diet is significantly harder to sustain.
For people who don’t respond to a milk-only elimination, stepping up to the full six-food diet still works. In the same trial, 43% of those who failed the one-food diet achieved remission when switched to the six-food version. Those who still don’t respond to diet often do well with medication: 82% of six-food-diet non-responders reached remission after switching to swallowed steroids.
Biologic Therapy
Dupilumab, a biologic injection that blocks IL-4 and IL-13 signaling, became the first FDA-approved medication specifically for EoE in 2022. It was initially approved for patients 12 and older, with approval expanded in 2024 to children as young as 1 year. Dupilumab is given as a subcutaneous injection, typically every one to two weeks, and is generally reserved for people who haven’t responded adequately to steroids or diet therapy, or who can’t tolerate those approaches.
Esophageal Dilation
When scarring has already narrowed the esophagus, stretching the narrowed area with a balloon or tapered dilator during an endoscopy can provide immediate symptom relief. Dilation does not treat the underlying inflammation, so it is used alongside other therapies. The procedure is safe in EoE: in outcome studies, there were no perforations, major bleeding events, or deaths. The overall complication rate was about 5%, consisting mainly of temporary chest pain afterward. People who need dilation tend to have had symptoms for much longer before diagnosis (an average of 11 years, compared to about 5 years for those who don’t need it), which reinforces the value of catching the disease early.
Living With EoE Long Term
Because EoE is chronic, treatment is generally ongoing. Current guidelines recommend monitoring with periodic endoscopies and biopsies to confirm that inflammation is controlled, not just that symptoms have improved. Symptoms and tissue inflammation don’t always track together: some people feel fine while still having active disease on biopsy, and that silent inflammation can still lead to scarring over time.
Clinicians now assess both the inflammatory component (active eosinophil buildup) and the fibrostenotic component (scarring and narrowing) when managing EoE. The goal is to suppress inflammation early and consistently enough to prevent the esophagus from remodeling. For many people, that means staying on a maintenance medication or diet indefinitely, with adjustments based on how the tissue looks at follow-up endoscopies.