Introduction Eosinophilic oesophagitis is an increasingly recognized type 2 inflammatory disorder characterized by oesophageal eosinophilia, dysphagia and food-related symptoms. Although EoE occurs across all age groups, differences in immunologic drivers and clinical phenotype between paediatric-onset and adult-onset disease remain incompletely understood.
Introduction
Eosinophilic oesophagitis is an increasingly recognized type 2 inflammatory disorder characterized by oesophageal eosinophilia, dysphagia and food-related symptoms. Although EoE occurs across all age groups, differences in immunologic drivers and clinical phenotype between paediatric-onset and adult-onset disease remain incompletely understood.
Problem Statement
Current management strategies for EoE are largely uniform across age groups despite growing evidence suggesting biologic heterogeneity. Clarifying whether paediatric-onset and adult-onset EoE represent distinct atopic endotypes could improve diagnostic evaluation, allergen assessment and personalized therapeutic approaches.
Summary
This large population-based cohort study demonstrates that paediatric-onset and adult-onset EoE possess clearly distinct atopic and clinical profiles, supporting the concept of divergent disease endotypes. Paediatric-onset EoE was strongly associated with systemic allergic disease, particularly asthma, atopic dermatitis and food allergy, alongside higher peripheral eosinophil counts. These findings support a predominantly food antigen–driven inflammatory phenotype with broader systemic type 2 immune activation in younger patients. In contrast, adult-onset EoE showed stronger associations with allergic rhinitis and nasal polyposis, suggesting greater involvement of aeroallergen sensitization and upper airway allergic inflammation. The persistence of these findings after matched analysis reinforces that these differences are unlikely to be explained solely by demographic variation. The study highlights that EoE may evolve through distinct immunologic pathways depending on age at onset, potentially explaining differences in symptom presentation, trigger profiles and treatment responsiveness observed in clinical practice. Recognition of these divergent endotypes may have important implications for allergy testing, dietary therapy selection and biologic treatment strategies. The findings also support closer integration between gastroenterology, allergy and airway disease management, particularly in patients with overlapping atopic disorders. Overall, the study advances understanding of EoE heterogeneity and strengthens the rationale for precision medicine approaches tailored to age-specific inflammatory mechanisms.
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