The American College of Gastroenterology (ACG) released clinical guidelines for diagnosing and managing eosinophilic esophagitis. Published in the January 2025 issue of The American Journal of Gastroenterology, these are the first updates since 2013.
The guidelines emphasize treating both inflammatory and fibrostenotic aspects of eosinophilic esophagitis (EoE), and detail changes in treatment protocols. PPIs are now listed as a treatment option rather than a required diagnostic step. The guidelines include protocols for using topical steroids, empiric diet elimination, biologics, and esophageal dilation.
Dupilumab is included as a treatment option for EoE patients 12 years and older who do not respond to PPI therapy. In phase 3 trials, 60% of patients achieved histologic remission with dupilumab versus 5% with placebo. The guidelines note several novel therapeutic agents are under development, including treatments targeting TSLP, mast cells, IL-15, and Janus kinase inhibitors.
The guidelines address maintenance therapy, stating that disease activity returns when treatment stops. They specify continuing dietary or pharmacologic therapy to prevent symptom recurrence and disease progression.
Diagnostic criteria require symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field on esophageal biopsy. Endoscopy procedures should include 6 or more biopsies from at least 2 esophageal levels.
For pediatric patients, the guidelines emphasize monitoring growth, development, and proper nutrition alongside symptom improvement. They recommend feeding therapist evaluation for children with feeding dysfunction, and esophagram evaluation for those with dysphagia. The guidelines note quality of life considerations for both patient and family should influence management plans.
On dietary treatment, the guidelines include empiric food elimination diets but do not support using current allergy testing to guide food choices. Single or 2-food elimination diets may serve as initial dietary therapy.
Treatment monitoring requires clinical, endoscopic, and histologic assessments. The guidelines note that symptoms alone do not correlate with disease activity. They call for systematic endoscopic scoring at each procedure.
The ACG developed these guidelines using GRADE methodology. Recommendations received either strong or conditional ratings based on evidence quality, which ranged from very low to moderate.
