Synopsis
Recognise eosinophilic oesophagitis across food impaction and subtle adaptive eating, confirm it with adequate biopsies and combine anti-inflammatory and stricture treatment.
- EoE is a chronic immune-mediated oesophageal disease defined by symptoms of dysfunction and eosinophil-predominant inflammation after competing causes are considered.
- Adults commonly present with intermittent solid-food dysphagia, food impaction or chest discomfort; children may present with feeding difficulty, vomiting or poor growth.
- Patients often adapt by chewing excessively, drinking with every mouthful, avoiding meat or bread and taking much longer to eat, so ask how they eat rather than only whether they swallow.
- Atopy, asthma, eczema, allergic rhinitis and immediate food allergy are common associations but their absence does not exclude EoE.
- Endoscopic rings, longitudinal furrows, white exudates, oedema, narrowing and fragile crepe-paper mucosa support EoE, yet the oesophagus may look normal.
- Take at least six biopsies from at least two oesophageal levels under the BSG pathway because inflammation is patchy.
- A peak of at least 15 eosinophils per high-power field supports diagnosis in the correct symptomatic context after alternative causes are assessed.
- A PPI trial is a treatment option rather than a mandatory diagnostic exclusion; PPI-responsive eosinophilia sits within the EoE spectrum.
- Effective options include PPI, swallowed topical corticosteroid and dietetic-led food elimination; response should be checked histologically because symptoms correlate poorly.
- Dilation treats fixed narrowing but not mucosal inflammation, so combine it with anti-inflammatory management and warn about post-procedural chest pain and perforation symptoms.
Key red flags
Meat or bread lodges after a history of intermittent solid-food dysphagia; inability to manage saliva indicates complete obstruction and requires urgent endoscopic care.
Severe persistent pain, fever, tachycardia, breathlessness, subcutaneous emphysema or pleural signs after intervention requires emergency imaging and upper-GI surgical involvement.
Rapidly progressive dysphagia, weight loss, anaemia, bleeding or an irregular mass requires urgent cancer and structural assessment even when eosinophilia is present.
Investigation priorities
Assess impaction, inflammatory signs, calibre and focal narrowing.
Management branches
A patient cannot swallow food or saliva after a solid-food impaction.
- Assess airway and aspiration risk, keep nil by mouth and arrange urgent endoscopy; investigate perforation first if severe pain, sepsis or subcutaneous emphysema is present.
- Remove the bolus with appropriate airway support rather than repeated blind pushing or delaying for unproven pharmacological therapy.
- At safe endoscopy, document rings, furrows, calibre and stricture and obtain multi-level biopsies when feasible, because EoE is a common underlying cause.
- Provide soft-diet safety advice, urgent return criteria and gastroenterology follow-up for histology and anti-inflammatory treatment.
Key medicines
Budesonide orodispersible tabletFor adult induction, the licensed dose is 1 mg allowed to dissolve on the tongue twice daily, morning and evening, for six weeks; inadequate responders may continue to twelve weeks under specialist direction.Do not eat, drink or perform oral hygiene for at least thirty minutes after dosing under the SmPC. Oropharyngeal or oesophageal Candida can occur; review adrenal, interaction, hepatic and systemic steroid risks, and distinguish induction commissioning from maintenance access.
Proton pump inhibitorA gastroenterologist selects a full-dose licensed PPI regimen, often once or twice daily during induction according to local EoE practice, reflux burden and the current BNF; reassess rather than continuing blindly.Response does not mean the original diagnosis was merely GORD. Review adherence, interactions and long-term need; biopsy is usually required to demonstrate mucosal response because symptoms alone are unreliable.