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Diagnosis and Management of Eosinophilic Esophagitis: Updated ACG Clinical Guideline Summary

14 Jan, 2025 | 13:46h | UTC

Introduction: This summary highlights the updated American College of Gastroenterology (ACG) Clinical Guideline on eosinophilic esophagitis (EoE), a chronic, immune-mediated disease of the esophagus characterized by esophageal eosinophilia and clinical symptoms of esophageal dysfunction. Over the last decade, the incidence and prevalence of EoE have increased significantly. This guideline incorporates new diagnostic strategies, therapeutic advances, and monitoring practices, aiming to improve patient outcomes and minimize disease complications such as strictures, food impactions, and impaired quality of life. The document underscores the importance of assessing both the inflammatory and fibrostenotic components of EoE through endoscopy, histopathology, and symptom evaluation.

Key Recommendations:

Diagnosis:
- Diagnose EoE when patients present with symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (eos/hpf) on esophageal biopsies, after exclusion of other causes of esophageal eosinophilia.
- Use a systematic scoring tool such as the EoE Endoscopic Reference Score (EREFS) to assess edema, rings, exudates, furrows, and strictures at every endoscopy.
- Obtain at least six esophageal biopsies from two or more levels (e.g., distal and proximal) to minimize diagnostic miss rates; quantify peak eosinophil counts in each specimen.
Pharmacologic Therapy:
1. Proton Pump Inhibitors (PPIs):
  - Consider high-dose PPIs (e.g., twice daily) as a first-line treatment option. Although originally used for acid suppression, PPIs also reduce eotaxin-3 expression and improve esophageal barrier function in EoE.
  - Maintain therapy long term in patients who respond, as discontinuation frequently leads to disease recurrence.
2. Topical Corticosteroids (Swallowed Steroids):
  - Budesonide or fluticasone can be delivered via specially formulated suspensions/tablets or by swallowing inhaler medication.
  - Expect histologic remission rates of around 60%–70%.
  - Oral/esophageal candidiasis is the most common adverse event. Routine adrenal suppression testing is generally not necessary for short-term use.
3. Dietary Elimination:
  - Empiric elimination diets (e.g., 2-food or 6-food elimination) help identify specific food triggers. Histologic remission rates can exceed 70%, particularly with the 6-food approach.
  - Less-restrictive diets (e.g., milk-only elimination) may be tried first (the “step-up” approach).
  - Do not rely on currently available skin prick or Ig-based tests to guide elimination diets, as these have poor predictive value for EoE triggers.
4. Biologic Therapy:
  - Dupilumab (anti–IL-4 receptor alpha) is recommended in adolescents and adults (≥12 years, ≥40 kg) and is now approved for children as young as 1 year (≥15 kg) with moderate to severe, PPI-refractory EoE. Expect significant histologic, endoscopic, and symptom improvements in most patients, along with an overall favorable safety profile.
  - Other biologics (e.g., cendakimab, benralizumab, mepolizumab) remain under investigation; current data are insufficient for routine clinical use.
5. Esophageal Dilation:
  - Perform endoscopic dilation to treat symptomatic strictures or narrow-caliber esophagi. Dilation reduces dysphagia promptly but does not alter the underlying inflammation.
  - Combine dilation with anti-inflammatory therapy to address the disease’s inflammatory component and help prevent recurrent stricture formation.
Maintenance and Monitoring:
- Because EoE is chronic, continue effective therapy over the long term. Abrupt cessation of treatment often leads to relapses in symptoms and inflammation.
- Evaluate treatment response by assessing symptoms, endoscopic findings (e.g., EREFS), and histopathology (peak eosinophil counts).
- A target of <15 eos/hpf and near-normal endoscopic appearance (EREFS ≤2) is commonly used to define remission, although some patients aim for histologic normalization.
- In children, ensure regular assessment of growth, development, and feeding behaviors. Referral to a nutritionist or feeding therapist is recommended if feeding difficulties or failure to thrive are present.

Conclusion: These updated ACG guidelines underscore the importance of a comprehensive, individualized approach to EoE that encompasses diagnosis, treatment of the inflammatory state, dilation of fibrotic strictures, and ongoing monitoring to maintain long-term remission. The introduction of biologics (particularly dupilumab) expands treatment options for patients nonresponsive to PPIs or topical steroids. Clinicians should adopt a structured assessment strategy—integrating clinical history, endoscopic scoring, and histological evaluation—to guide therapy selection, document treatment response, and prevent complications. With improved understanding of disease pathogenesis and evolving therapeutic tools, outcomes for patients with EoE are expected to continue to improve.

Reference: Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. The American Journal of Gastroenterology. 2025;120(1):31–59. DOI: https://doi.org/10.14309/ajg.0000000000003194

AGA Clinical Practice Update on Potassium-Competitive Acid Blockers for Foregut Disorders

14 Jan, 2025 | 11:20h | UTC

Introduction: This summary presents the key points of a recently published American Gastroenterological Association (AGA) Clinical Practice Update that reviews the role of potassium-competitive acid blockers (P-CABs) in managing acid-related foregut disorders. P-CABs offer a unique mechanism of action compared with proton pump inhibitors (PPIs) and histamine_2-receptor antagonists, potentially delivering more rapid and prolonged acid suppression. The aim of this review is to provide clinicians with evidence-based guidance on P-CAB use in gastroesophageal reflux disease (GERD), Helicobacter pylori (HP) infection, and peptic ulcer disease (PUD), clarifying their benefits, limitations, and potential place in therapy.

Key Recommendations:

Overall Use of P-CABs: Clinicians should generally avoid using P-CABs as first-line therapy for acid-related conditions unless there is proven clinical superiority over PPIs. Factors such as higher costs, more limited availability, and less comprehensive long-term safety data often outweigh the advantages of P-CABs, particularly for milder disease.
Cost-Effectiveness: Current U.S. costs for P-CABs may not justify routine first-line use, even if modest clinical benefits exist compared with double-dose PPIs. Long-term data on cost-effectiveness and safety remain limited.
Nonerosive GERD: P-CABs are not recommended as initial treatment for heartburn without endoscopic findings (uninvestigated GERD) or nonerosive reflux disease. Clinicians may consider P-CABs for patients who have confirmed acid-related reflux and show inadequate response to twice-daily PPI therapy.
On-Demand Therapy: Rapid onset of P-CABs suggests potential utility in on-demand regimens for patients previously responsive to acid suppression. While limited data show efficacy compared to placebo, further trials against PPIs and histamine_2-receptor antagonists are needed before making firm recommendations.
Mild Erosive Esophagitis (LA Grade A/B): For Los Angeles classification (LA) grade A/B erosive esophagitis (EE), standard PPIs remain first-line treatment. P-CABs may be an option for patients whose esophagitis persists despite optimal PPI therapy, but initial evidence does not support routine, front-line use.
Severe Erosive Esophagitis (LA Grade C/D): In more advanced EE, P-CABs can be considered for healing and maintenance, as some data suggest superior efficacy compared with standard-dose PPI. However, the lack of comparative trials with high-dose PPIs and the higher cost of P-CABs complicate their routine use as first-line therapy in severe disease.
HP Eradication: P-CAB–based regimens for H pylori treatment often show higher or noninferior cure rates compared with PPI-based therapies, particularly in the presence of clarithromycin resistance. The more potent and prolonged acid suppression may enhance antibiotic efficacy, supporting the use of P-CABs in most patients with HP infection.
Peptic Ulcer Disease Treatment and Prophylaxis: Current evidence indicates that P-CABs are noninferior to PPIs for ulcer healing and prevention of recurrent ulcers in patients requiring aspirin or nonsteroidal anti-inflammatory drugs. However, in light of their higher cost and similar clinical outcomes, P-CABs should not replace PPIs as first-line therapy unless patients fail PPI regimens.
Ulcer Bleeding: Although data are preliminary, P-CABs may be useful following endoscopic hemostasis in high-risk ulcer bleeding. Their rapid and potent acid suppression suggests they could match or exceed high-dose PPI efficacy, but more robust comparative trials are needed.

Conclusion: Potassium-competitive acid blockers represent a valuable therapeutic option in selected patients who do not respond adequately to traditional PPIs or who have complex acid-related conditions (such as severe erosive esophagitis or antibiotic-resistant H pylori). While their more rapid onset of action and prolonged effect can be advantageous, the limited availability of long-term safety data, cost considerations, and lack of substantial clinical superiority over standard or double-dose PPIs in many indications currently limit widespread adoption. Further investigations are needed to establish cost-effectiveness, clarify safety profiles, and identify specific patient populations most likely to benefit from P-CABs.

Reference: Patel A, Laine L, Moayyedi P, Wu J. AGA Clinical Practice Update on Integrating Potassium-Competitive Acid Blockers Into Clinical Practice: Expert Review. Gastroenterology. 2024;167(6):1228–1238. https://doi.org/10.1053/j.gastro.2024.06.038

RCT: Milk Elimination Diet Comparable to Four-Food Elimination in Pediatric EoE

20 Oct, 2024 | 15:04h | UTC

Background: Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition characterized by eosinophil infiltration of the esophageal mucosa, leading to symptoms such as nausea, vomiting, abdominal pain, and dysphagia in children. While elimination of six common food allergens is effective, this approach is highly restrictive and may adversely affect quality of life (QoL). Less restrictive diets could potentially balance efficacy with improved QoL.

Objective: To compare the efficacy of a one-food elimination diet excluding milk (1FED) versus a four-food elimination diet excluding milk, egg, wheat, and soy (4FED) in treating pediatric EoE.

Methods: In this multicenter, randomized, nonblinded trial conducted at ten sites in the United States, 63 children aged 6 to 17 years with histologically active and symptomatic EoE were randomized 1:1 to either 1FED (n = 38) or 4FED (n = 25) for 12 weeks. The primary endpoint was symptom improvement measured by the Pediatric Eosinophilic Esophagitis Symptom Score (PEESS). Secondary endpoints included the proportion achieving histologic remission (<15 eosinophils per high-power field), changes in histologic features (histology scoring system), endoscopic severity (endoscopic reference score), transcriptome profiling (EoE diagnostic panel), QoL scores, and predictors of remission.

Results: Out of 63 participants, 51 completed the study (1FED, n = 34; 4FED, n = 17). The 4FED group showed a greater improvement in mean PEESS scores compared to the 1FED group (−25.0 vs. −14.5; P = .04). However, histologic remission rates were similar between 4FED and 1FED (41% vs. 44%; P = 1.00). Changes in the histology scoring system (−0.25 vs. −0.29; P = .77), endoscopic reference score (−1.10 vs. −0.58; P = .47), and QoL scores were comparable between groups. The withdrawal rate was higher in the 4FED group compared to the 1FED group (32% vs. 11%; P = .0496).

Conclusions: While the 4FED moderately improved symptoms more than the 1FED, both diets resulted in similar histologic, endoscopic, QoL, and transcriptomic outcomes. Given its comparable effectiveness, better tolerability, and simplicity, the 1FED is a reasonable first-choice therapy for pediatric EoE.

Implications for Practice: Eliminating cow’s milk alone may be preferable as initial dietary therapy for children with EoE due to its simplicity and similar efficacy compared to more restrictive diets. Clinicians should consider starting with a milk elimination diet before progressing to more restrictive elimination diets if necessary.

Study Strengths and Limitations: Strengths of the study include its randomized, multicenter design; standardized treatment instructions; and use of validated symptom and QoL instruments. Limitations include early termination due to low enrollment, a higher withdrawal rate in the 4FED group, nonblinded interventions, and potential bias from participant expectations.

Future Research: Further large-scale, randomized studies are needed to confirm these findings and to identify biomarkers that predict response to dietary therapy in pediatric EoE.

Reference: Kliewer KL, Abonia JP, Aceves SS, et al. (2024) One-food versus 4-food elimination diet for pediatric eosinophilic esophagitis: A multisite randomized trial. Journal of Allergy and Clinical Immunology. DOI: http://doi.org/10.1016/j.jaci.2024.08.023

Network Meta-Analysis: Preoperative Chemoradiotherapy and Chemotherapy Equally Improve Survival in Esophagogastric Adenocarcinoma – JAMA Netw Open

17 Aug, 2024 | 19:21h | UTC

Study Design and Population: This network meta-analysis included 17 randomized clinical trials (RCTs) with a total of 2,549 patients, predominantly male (86.5%), with a mean age of 61 years. The study compared the effects of preoperative chemoradiotherapy (CRT) versus preoperative and/or perioperative chemotherapy, and surgery alone on overall survival and disease-free survival in patients with adenocarcinoma of the esophagus and esophagogastric junction (AEG).

Main Findings: Both preoperative CRT plus surgery (HR, 0.75) and preoperative/perioperative chemotherapy plus surgery (HR, 0.78) significantly improved overall survival compared to surgery alone. Disease-free survival was similarly prolonged with both treatments. No significant difference was observed between CRT and chemotherapy in overall survival, though CRT was associated with higher postoperative morbidity.

Implications for Practice: The findings suggest that both preoperative CRT and preoperative/perioperative chemotherapy are effective in extending survival in AEG patients, with no clear superiority of one approach over the other. Clinicians can consider either modality based on patient-specific factors, although the increased morbidity associated with CRT warrants careful consideration.

Reference: Ronellenfitsch U, Friedrichs J, Barbier E, et al. (2024). Preoperative Chemoradiotherapy vs Chemotherapy for Adenocarcinoma of the Esophagogastric Junction: A Network Meta-Analysis. JAMA Network Open, 7(8), e2425581. DOI: 10.1001/jamanetworkopen.2024.25581.

Systematic Review | Medical treatment of eosinophilic esophagitis

21 Jul, 2023 | 13:27h | UTC

Medical treatment of eosinophilic esophagitis – Cochrane Library

Summary: Medical treatments for eosinophilic esophagitis – Cochrane Library

M-A | Efficacy of elimination diets in eosinophilic esophagitis

RCT | Dupilumab in adults and adolescents with eosinophilic esophagitis

A meta-analysis on randomized controlled trials of treating eosinophilic esophagitis with budesonide – Annals of Medicine

A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions – Gastroenterology

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults – Gut

Consensus Paper | Transition of patients with esophageal atresia–tracheoesophageal fistula

19 Jun, 2023 | 13:44h | UTC

The International Network on Oesophageal Atresia (INoEA) consensus guidelines on the transition of patients with oesophageal atresia–tracheoesophageal fistula – Nature Reviews Gastroenterology & Hepatology (if the link is paywalled, try this one)

Podcast | Dysphagia pearls

18 May, 2023 | 13:42h | UTC

#395 Dysphagia with Dr. Diana Snyder – The Curbsiders

RCT | Per-oral endoscopic myotomy outperforms pneumatic dilation for post-laparoscopic heller myotomy achalasia

16 May, 2023 | 14:36h | UTC

The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial – Gastroenterology

RCT | Long versus short peroral endoscopic myotomy for the treatment of achalasia

11 May, 2023 | 11:40h | UTC

Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial – Gut (link to abstract – $ for full-text)

AGA Practical Guidance | Diagnosis and management of extraesophageal gastroesophageal reflux disease

25 Apr, 2023 | 14:50h | UTC

AGA Clinical Practice Update on the Diagnosis and Management of Extraesophageal Gastroesophageal Reflux Disease: Expert Review – Clinical Gastroenterology and Hepatology

Commentary: Guidance offered on management of extraesophageal GERD – ACP Gastroenterology

Commentary on Twitter (thread – click for more)

https://twitter.com/joanwchen/status/1648804839600668675

RCT | Over-the-scope clips show lower rebleeding rates in nonvariceal GI bleeding

6 Apr, 2023 | 12:57h | UTC

Comparison of Over-the-Scope Clips to Standard Endoscopic Treatment as the Initial Treatment in Patients With Bleeding From a Nonvariceal Upper Gastrointestinal Cause: A Randomized Controlled Trial – Annals of Internal Medicine (link to abstract – $ for full-text)

Commentaries:

Over-the-Scope Clip Beneficial for Nonvariceal Upper GI Bleeding – HealthDay

Over-the-scope clips superior to standard treatment of nonvariceal upper GI bleeding – Physician’s Weekly

Commentary on Twitter

A new RCT found that over-the-scope-clips may be more effective than standard treatment for some patients with nonvariceal upper #GastrointestinalBleeding: https://t.co/GWG70CWmlt pic.twitter.com/Foq2qQZTEc

— Annals of Int Med (@AnnalsofIM) March 7, 2023

RCT | Study finds both one-food and six-food elimination diets are effective initial options for eosinophilic esophagitis

7 Mar, 2023 | 13:17h | UTC

Summary:

The article describes a multicenter randomized trial that compared the effectiveness of a one-food elimination diet (1FED – eliminating animal milk) versus a six-food elimination diet (6FED – eliminating animal milk, wheat, egg, soy, fish and shellfish, and peanut and tree nuts) for treating eosinophilic esophagitis in adults.

The study found that both diets were equally effective at achieving histological remission, although the 6FED resulted in a higher proportion of patients achieving complete remission. Patients who did not achieve histological remission with the 1FED could proceed to the 6FED, and 43% had histological remission. For those without response to the 6FED, topical fluticasone propionate induced remission in 82%.

Overall, the study suggests that eliminating animal milk alone is an acceptable initial dietary therapy for eosinophilic esophagitis.

Article: One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial – The Lancet Gastroenterology & Hepatology (link to abstract – $ for full-text)

News Release: Forgoing one food treats eosinophilic esophagitis as well as excluding six – National Institutes of Health

Commentary on Twitter

New research – Kliewer et al – One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial https://t.co/Tpm0EPPfx0 #EoE #GItwitter #RareDiseaseDay #CEGIR pic.twitter.com/iUcqIt9Pg5

— The Lancet Gastroenterology & Hepatology (@LancetGastroHep) February 28, 2023

Review | Platelet aggregation inhibitors and anticoagulants in gastroenterological and visceral surgical procedures

1 Mar, 2023 | 14:03h | UTC

Platelet Aggregation Inhibitors and Anticoagulants in Gastroenterological and Visceral Surgical Procedures – Deutsches Ärzteblatt international

M-A | Efficacy of elimination diets in eosinophilic esophagitis

24 Feb, 2023 | 13:47h | UTC

Summary: This systematic review and meta-analysis evaluated the effectiveness of various dietary treatment regimens for eosinophilic esophagitis (EoE). After analyzing 34 studies with 1762 patients, it was concluded that dietary therapy is a viable and efficacious option for individuals with EoE of all ages, with an overall histological remission rate of 53.8% and a clinical response rate of 80.8%. The study also found that highly restrictive dietary regimes, such as a six-food elimination diet, may not be superior to less restrictive dietary regimens, such as a four-food elimination diet or one-food elimination diet, in achieving histological remission, supporting less restrictive dietary regimens as a treatment option. The study has several limitations, such as the observational nature of most studies included.

Article: Efficacy of elimination diets in eosinophilic esophagitis: a systematic review and meta-analysis – Clinical Gastroenterology and Hepatology

Commentary: Elimination diets effective for patients with eosinophilic esophagitis – ACP Gastroenterology

Commentary on Twitter

Efficacy of dietary therapy in eosinophilic esophagitis for (1) histologic remission & (2) clinical response

6⃣-food elimination diet: 61%, 93%
4⃣-food elimination diet: 49%, 74%
1⃣-food elimination diet: 51%, 87%
Targeted elimination diet: 46%, 69%#EoE https://t.co/VKXgCQO9O6 pic.twitter.com/KfpSburuwN

— John Damianos, M.D. (@john_damianosMD) February 1, 2023

Article under a Creative Commons Attribution (CC BY 4.0) license

Guideline | Barrett’s esophagus and stage 1 esophageal adenocarcinoma: monitoring and management

13 Feb, 2023 | 12:49h | UTC

Barrett’s oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management – National Institute for Health and Care Excellence

RCT | Dupilumab in adults and adolescents with eosinophilic esophagitis

11 Jan, 2023 | 14:27h | UTC

Dupilumab in Adults and Adolescents with Eosinophilic Esophagitis – New England Journal of Medicine (link to abstract – $ for full-text)

Commentary: Weekly Dupilumab Beneficial in Eosinophilic Esophagitis – HealthDay

SR | Fundoplication in laparoscopic Heller’s cardiomyotomy for achalasia.

14 Dec, 2022 | 14:53h | UTC

Fundoplication in laparoscopic Heller’s cardiomyotomy for achalasia – Cochrane Library

Summary: Addition of a stomach wrap (fundoplication) around the food pipe (oesophagus) in keyhole (laparoscopic) surgery to treat achalasia – Cochrane Library

Guideline Summary | Evaluation and management of gastroesophageal reflux disease.

5 Dec, 2022 | 00:18h | UTC

Evaluation and management of gastroesophageal reflux disease: A brief look at the updated guidelines – Cleveland Clinic Journal of Medicine

Original Guideline: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease – American Journal of Gastroenterology

Related Guidelines:

Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2021 – Journal of Gastroenterology

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease.

SAGES guidelines for the surgical treatment of gastroesophageal reflux.

Guideline on Screening for Esophageal Adenocarcinoma in Patients with Chronic GERD

NICE Guideline: Gastro-esophageal Reflux Disease and Dyspepsia in Adults

NICE Guideline: Gastroesophageal Reflux Disease in Children and Young People

RCT | The effects of modifying amount and type of dietary carbohydrate on esophageal reflux symptoms.

21 Nov, 2022 | 14:42h | UTC

The Effects of Modifying Amount and Type of Dietary Carbohydrate on Esophageal Acid Exposure Time and Esophageal Reflux Symptoms: A Randomized Controlled Trial – The American Journal of Gastroenterology

Commentary: Study finds that reducing intake of simple sugars improves GERD – Vanderbilt University

UEG and EAES rapid guideline | Recommendations on surgical management of gastroesophageal reflux disease.

6 Oct, 2022 | 13:45h | UTC

UEG and EAES rapid guideline: Update systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on surgical management of GERD – UEG Journal

Commentary: Updated GERD Guidelines Recommend Posterior Partial Fundoplication – HCP Live

Consensus Paper | Use of indocyanine green fluorescence imaging in thoracic and esophageal surgery.

26 Sep, 2022 | 12:04h | UTC

Use of Indocyanine Green Fluorescence Imaging in Thoracic and Esophageal Surgery – The Annals of Thoracic Surgery

RCT | Circular stapled technique vs. modified collard technique for cervical esophagogastric anastomosis after esophagectomy.

21 Sep, 2022 | 13:08h | UTC

Circular Stapled Technique Versus Modified Collard Technique for Cervical Esophagogastric Anastomosis After Esophagectomy: A Randomized Controlled Trial – Annals of Surgery (link to abstract – $ for full-text)

Severity of Esophageal Anastomotic Leak in patients after esophagectomy: the SEAL score.

1 Sep, 2022 | 11:47h | UTC

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score – British Journal of Surgery

Commentary on Twitter (thread – click for more)

1/3 This week our SEAL Score manuscript was published in @BJSurgery:https://t.co/MUNmaf7l6B
A major milestone for TENTACLE – Esophagus, and first step towards finding evidence for treatment of anastomotic leak. More to come!

— TENTACLE study (@tentaclestudy) July 2, 2022