Diagnosis and Management of Eosinophilic Esophagitis (EoE)
Official 2025 guideline from the American College of Gastroenterology.
Diagnosis
Diagnosis
We recommend that EoE is diagnosed based on the presence of symptoms of esophageal dysfunction and at least 15 eos/hpf on esophageal biopsy, after evaluating for non-EoE disorders that cause or potentially contribute to esophageal eosinophilia.
Strong recommendation
Low quality evidence
We recommend using a systematic endoscopic scoring system (e.g., the EoE Endoscopic Reference Score) to characterize endoscopic findings of EoE at every endoscopy.
Strong recommendation
Low quality evidence
We recommend obtaining at least 6 esophageal biopsies from at least 2 esophageal levels (e.g., proximal/ mid and distal), targeting EoE endoscopic findings, if possible, to assess for histologic features consistent with EoE.
Strong recommendation
Low quality evidence
We recommend that eosinophil counts be quantified on esophageal biopsies from every endoscopy performed for EoE.
Strong recommendation
Low quality evidence
Treatment
PPIs
We suggest PPIs as a treatment for EoE.
Conditional recommendation
Low quality evidence
Topical Steroids
We recommend the use of swallowed topical steroids as a treatment for EoE.
Strong recommendation
Moderate quality evidence
We suggest the use of either fluticasone propionate or budesonide in patients with EoE being treated with topical steroids.
Conditional recommendation
Low quality evidence
Dietary Elimination
We suggest an empiric food elimination diet as a treatment for EoE.
Conditional recommendation
Low quality evidence
We do not suggest currently available allergy testing to direct food elimination diets for treatment of EoE.
Conditional recommendation
Very low quality evidence
Biologics
We suggest dupilumab as a treatment for EoE in individuals 12 years of age or older who are nonresponsive to PPI therapy.
Conditional recommendation
Moderate quality evidence
We suggest dupilumab as a treatment for EoE in pediatric patients (ages 1–11 years) who are nonresponsive to PPI therapy.
Conditional recommendation
Low quality evidence
We cannot make a recommendation for or against cendakimab, benralizumab, lirentelimab, mepolizumab, or reslizumab as a treatment for EoE.
We suggest against using omalizumab as a treatment for EoE.
Conditional recommendation
Low quality evidence
Small Molecules
We suggest against the use of cromolyn and montelukast as a treatment for EoE.
Conditional recommendation
Very low quality evidence
Esophageal Dilation
We suggest the use of endoscopic dilation as an adjunct to medical therapy as a treatment for esophageal strictures causing dysphagia in patients with EoE.
Conditional recommendation
Low quality evidence
Maintenance Therapy
We suggest continuation of effective dietary or pharmacologic therapy for EoE to prevent recurrence of symptoms, histologic inflammation, and endoscopic abnormalities.
Strong recommendation
Low quality evidence
Monitoring
Evaluating Response
We recommend evaluating response to treatment of EoE with assessment of symptomatic and endoscopic and histologic outcomes.
Strong recommendation
Low quality evidence
Pediatric Considerations
Evaluation
In children with EoE and dysphagia, we suggest an esophagram for evaluation of fibrostenotic disease.
Conditional recommendation
Very low quality evidence
We suggest evaluation by a feeding therapist and/or dietician as an adjunctive therapeutic intervention in children with EoE and feeding dysfunction.
Conditional recommendation
Very low quality evidence
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.High quality evidence
Further research unlikely to change guideline authors' confidence in estimate of effect.
Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low quality evidence
Effect is very uncertain.
