Think It's Just Reflux? Eosinophilic Esophagitis Is Often Mistaken for GERD for Years

Key Takeaways

• Eosinophilic esophagitis, or EoE, is a chronic allergic condition of the esophagus, and diagnosed cases have risen substantially over the past decade, partly, though not entirely, due to greater awareness and more endoscopies being performed.
• Because its symptoms overlap heavily with acid reflux, EoE is frequently misdiagnosed as GERD for years before the correct diagnosis is made.
• Diagnosis requires an upper endoscopy with biopsy, confirmed by finding 15 or more eosinophils per high-power field of esophageal tissue.
• Treatment often involves both an allergist and a gastroenterologist, and can include acid-suppressing medication, topical steroids, dietary changes, or a biologic medication for appropriate patients.

A condition that hides behind common symptoms

Eosinophilic esophagitis is a chronic condition in which a type of white blood cell called an eosinophil builds up in the lining of the esophagus, the tube connecting the mouth to the stomach, causing inflammation. In adults, it commonly shows up as difficulty swallowing, a sensation of food getting stuck, or chest discomfort, while in children it's more likely to present as feeding difficulties, poor growth, or vomiting. The number of people diagnosed with EoE has risen substantially over the past decade, a trend that reflects both a true increase in the condition and greater recognition of it by physicians who might previously have attributed the same symptoms to reflux.

That overlap with reflux is exactly what makes EoE so easy to miss. Both conditions can cause heartburn-like discomfort and swallowing difficulty, and EoE is now recognized as the second most common cause of chronic esophagitis after GERD itself. It isn't unusual for patients to spend years being treated for reflux, sometimes with only partial or no relief, before an endoscopy finally reveals the eosinophilic inflammation underneath.

How EoE is actually diagnosed

A diagnosis of EoE requires an upper endoscopy, a procedure in which a gastroenterologist passes a thin camera down the esophagus, along with biopsies of the esophageal tissue. The defining threshold is finding 15 or more eosinophils per high-power field under the microscope, combined with symptoms consistent with EoE and ruling out other causes of esophageal eosinophilia. This biopsy step is the only way to confirm the diagnosis, imaging or symptoms alone aren't sufficient.

What triggers it

EoE is generally considered a food allergy-driven condition, with the most common trigger foods being dairy, wheat, egg, soy, nuts, and seafood. Many patients with EoE also have other allergic conditions, such as seasonal allergies, asthma, or eczema. It's worth noting that standard allergy testing, such as skin prick or blood IgE testing, isn't reliable for identifying which specific foods are driving a person's EoE, so those tests generally aren't used to select an elimination diet for this condition.

The patients I see with EoE often describe years of adapting around their symptoms without realizing it, cutting food into small pieces, avoiding dry foods, chewing extensively, or drinking liquids with every bite. Those workarounds are actually a meaningful clue, and once we get an endoscopy and biopsy, we finally have an answer and a real treatment plan instead of another round of reflux medication.

— Dr. Robert Tamayev, MD, PhD, Allergy Asthma

How EoE is treated

Treatment for EoE typically starts with one or more of several approaches: proton pump inhibitors, the same class of acid-suppressing medication used for reflux, swallowed topical corticosteroids such as budesonide or fluticasone that coat and treat the esophagus directly, or a dietary elimination approach that removes suspected trigger foods. For patients with moderate to severe disease that doesn't respond adequately to these options, a biologic medication called dupilumab is approved for EoE starting at 1 year of age for patients who meet the appropriate weight threshold, expanding treatment access to younger children than when the medication was first approved.

Because EoE symptoms can improve without the underlying inflammation fully resolving, feeling better isn't the same as being in remission. A repeat endoscopy with biopsy is typically used to confirm that treatment is actually working at the tissue level, not just relieving symptoms. Left unaddressed over time, chronic EoE inflammation can lead to narrowing, or strictures, of the esophagus and an increased risk of food getting physically stuck, which is part of why ongoing, coordinated care between an allergist and a gastroenterologist matters.

When to book a visit

If you've been diagnosed with reflux but aren't getting full relief from standard treatment, or you regularly experience swallowing difficulty, a sensation of food sticking, or find yourself avoiding certain food textures, it's worth scheduling an evaluation to discuss whether EoE could be part of the picture.

Disclaimer: This content is educational and does not substitute for medical advice. Always consult your physician for personal medical questions.