American College of Gastroenterology Releases Updated Guidelines for Eosinophilic Esophagitis

The American College of Gastroenterology (ACG) has issued updated guidelines for diagnosing, treating, and monitoring eosinophilic esophagitis (EoE), reflecting significant advancements over the past decade.

“This ACG clinical guideline is an update of the 2013 version,” Evan S. Dellon, MD, MPH, director, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, and colleagues wrote in the American Journal of Gastroenterology. “Since that time, there have been paradigm-shifting changes in disease diagnosis and management, increases in knowledge about EoE risk factors, natural history and pathogenesis, development of validated outcome metrics, a disease severity classification system and updated nomenclature.”

Dellon and colleagues used the Grading of Recommendations, Assessment, Development and Evaluation framework to develop 19 recommendations related to the diagnosis, management, and monitoring of people with EoE. They additionally addressed concerns related to maintenance therapy and considerations for pediatric patients.

Each recommendation accounted for the quality of evidence, risks versus benefits, feasibility, and cost as well as perceived patient and population-based factors. The terms “recommendations” and “suggestions” indicated strong and conditional recommendations, respectively.

Key recommendations

• The ACG recommends EoE be diagnosed based on symptoms of esophageal dysfunction and the presence of at least 15 eosinophils per high-power field (eos/hpf) on esophageal biopsy, after ruling out other disorders that may cause eosinophilia.
• The ACG recommends the use of a systematic endoscopic scoring system, such as the EoE Endoscopic Reference Score, during each endoscopy to characterize findings.
• The ACG recommends at least 6 esophageal biopsies from at least 2 levels (proximal/mid and distal) should be obtained to assess for histologic features consistent with EoE.
• The ACG suggests the use of proton pump inhibitors (PPIs) and recommends the use of swallowed topical steroids (eg, fluticasone propionate or budesonide) for the treatment of EoE.
• The ACG suggests the use of dupilumab for both pediatric patients (1-11 years) and those aged 12 years and older who are nonresponsive to PPI therapy.
• The ACG recommends evaluating treatment response through symptomatic, endoscopic, and histologic outcomes assessment.
• The ACG suggests enlisting a feeding therapist and/or dietitian as an adjunctive therapy intervention for children with EoE and feeding dysfunction.

Dellon and colleagues identified several knowledge gaps that need to be addressed. These included a lack of comprehensive data on the long-term outcomes of various treatment strategies, optimal monitoring practices, and the unique aspects of EoE in pediatric patients. Additionally, while dietary management is recommended, there is limited evidence regarding the effectiveness of specific dietary interventions and the role of allergy testing. The efficacy and safety of biologic therapies like dupilumab, particularly in younger populations, also require further investigation.

“Despite these needs, tremendous advancements have been made in the field over the past decade to the benefit of both patients and providers, and the field is poised for more advances in the coming years,” investigators concluded.

Reference: Dellon ES, Muir AB, Katzka DA, et al. ACG clinical guideline: Diagnosis and management of eosinophilic esophagitis. Am J Gastroenterol. Published online January 2, 2025. doi:10.14309/ajg.0000000000003194