Introduction Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by progressive esophageal inflammation that can evolve into fibrostenotic complications such as strictures and food impaction. Endoscopy plays a central role not only in diagnosis but also in long-term disease monitoring and therapeutic decision-making.
Introduction
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by progressive esophageal inflammation that can evolve into fibrostenotic complications such as strictures and food impaction. Endoscopy plays a central role not only in diagnosis but also in long-term disease monitoring and therapeutic decision-making. This American Society for Gastrointestinal Endoscopy consensus document expands prior guidance by focusing on disease assessment, monitoring strategies, and pediatric-specific considerations, reflecting the evolving understanding of EoE as a lifelong condition requiring structured and multidisciplinary care.
Summary
This consensus emphasizes that eosinophilic esophagitis should be approached as a disease requiring integrated assessment across symptoms, endoscopic findings, and histology, as no single domain reliably reflects disease activity. Initial diagnostic endoscopy should be performed off treatment to avoid false-negative results and must include adequate biopsies, with at least six samples from multiple esophageal levels. The guideline highlights that symptoms alone are unreliable due to adaptive eating behaviors and poor correlation with inflammation, reinforcing the need for objective monitoring.
A key advancement is the growing role of less invasive monitoring tools such as transnasal endoscopy and esophageal string testing, which can reduce procedural burden but are not suitable for initial diagnosis or for patients with suspected strictures. Structured monitoring intervals are recommended based on treatment type, with earlier reassessment for dietary and pharmacologic therapies and longer intervals for biologics. The document also underscores that endoscopic detection of strictures is often insensitive, requiring adjunctive methods such as esophagography or functional lumen assessment.
In pediatric populations, early recognition based on feeding difficulties and growth concerns is critical, and transition planning to adult care is essential to prevent loss of follow-up. The guideline strongly emphasizes that gaps in monitoring are associated with progression to fibrostenosis, making continuous follow-up a cornerstone of care.
Conclusion
This ASGE consensus provides a comprehensive, practice-oriented framework for the endoscopic management of eosinophilic esophagitis beyond diagnosis. The key message is that effective care requires structured, longitudinal monitoring using a combination of clinical, endoscopic, and histologic parameters, with selective integration of less invasive tools. By standardizing assessment and minimizing gaps in care, these recommendations aim to prevent disease progression and improve long-term outcomes in both adult and pediatric patients.
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