What is eosinophilic oesophagitis and what causes it?

Eosinophilic oesophagitis (EoE) is a chronic condition where the lining of the oesophagus (the food pipe) becomes chronically inflamed by a type of allergy-related white blood cell called an eosinophil. The inflammation is triggered by food proteins — most commonly cow's milk and wheat — and sometimes environmental allergens like pollens. It is part of the same atopic (allergic) family as asthma, hayfever, and eczema, and often co-exists with these conditions. The inflammation makes swallowing increasingly difficult over time and, if untreated, can cause scarring and narrowing of the oesophagus.

How do I know if my swallowing difficulty could be EoE?

The typical adult pattern is difficulty swallowing solid food — particularly meat, bread, and dry foods — while liquids go down easily. Many people adapt unconsciously: eating very slowly, chewing 30 or more times, always drinking water with meals, cutting food into tiny pieces, or avoiding steaks and crusty bread. Food getting stuck partway down (food impaction, sometimes requiring emergency endoscopy) affects about half of adults with EoE and is often the event that leads to diagnosis. If you have heartburn that does not respond well to standard reflux treatment, that is another reason EoE is worth investigating. Discuss these symptoms with your GP.

What tests are needed to diagnose EoE?

Diagnosis requires a gastroscopy (endoscopy) with biopsies — there is no blood test or breath test that can diagnose EoE. The gastroscopist looks for characteristic appearances including circular rings, white spots (exudates), linear furrows, and narrowings in the oesophagus. Biopsies are taken from both the upper and lower oesophagus — at least six samples in total. The pathologist counts eosinophils under the microscope; 15 or more eosinophils per high-power field in at least one sample confirms EoE. A proton pump inhibitor (acid tablet) trial before or alongside endoscopy is often used, since some patients respond to PPI alone.

What are the treatment options for EoE in Australia?

Three approaches are used, often in combination. First, medications: a proton pump inhibitor (PPI, such as omeprazole at double the usual dose) achieves histological remission in about 40% of patients. Swallowed topical corticosteroids — budesonide in an oral viscous slurry or fluticasone from an inhaler swallowed (not inhaled) — work in 60–80%. Dupilumab (Dupixent), a biologic injection approved by the TGA and listed on the PBS Section 100 since 2024, is available for adults and adolescents with severe EoE. Second, dietary elimination — removing common trigger foods (typically starting with cow's milk and wheat) and re-challenging with biopsies to identify individual triggers. Third, endoscopic dilation for established strictures causing significant dysphagia.

Is EoE curable, and do I need treatment forever?

EoE is a chronic lifelong condition rather than a curable one, but it is very manageable. Without ongoing treatment, inflammation and symptoms relapse in over 70% of patients within a year of stopping therapy. With appropriate treatment — whether medication, dietary elimination of identified triggers, or a combination — symptoms can be very well controlled and progression to irreversible scarring and strictures can be prevented. If dietary triggers are identified through an elimination and re-challenge process, long-term avoidance of those specific foods (rather than all eliminated foods) is the maintenance approach. Regular review with your gastroenterologist — including periodic repeat endoscopy — guides ongoing management.

Eosinophilic oesophagitis

Eosinophilic oesophagitis: dysphagia, food triggers, and modern treatment

By Dr HB Lo, FACRRM Reviewed 30 July 2026 11 min read

Eosinophilic oesophagitis (EoE) is a chronic, immune-mediated inflammation of the oesophagus driven by food allergens. It is increasingly common — affecting around 1 in 1,000–2,000 Australians — and is strongly linked with asthma, hayfever, and eczema.

In adults, the hallmark symptom is dysphagia — difficulty swallowing solid food — with food impaction episodes. In children, symptoms include vomiting, food refusal, and growth problems. Many adults adapt for years before diagnosis.

Treatment follows three approaches: medications (PPI, topical corticosteroids, or dupilumab), dietary elimination of trigger foods, and endoscopic dilation for strictures.

Eosinophilic oesophagitis (EoE) is a chronic, immune-mediated inflammatory condition of the oesophagus driven by a Th2 allergic response to food and, in some patients, environmental allergens. The hallmark is eosinophil-predominant infiltration of the oesophageal lining — defined diagnostically as 15 or more eosinophils per high-power field on biopsy. Prevalence is rising rapidly: approximately 1 in 1,000–2,000 Australians now have EoE, representing a five-to-seven-fold increase over the past 20 years, mirroring the broader rise in atopic disease. Men are affected three times more often than women, with peak diagnosis in adults aged 30–50, although paediatric and older-adult presentations are increasingly recognised.

The GP’s role is to recognise the condition from a clinical pattern that many patients have adapted to for years without realising it, refer for gastroscopy, and support ongoing management in shared care with gastroenterology and, where relevant, allergy/immunology and a dietitian.

A. Core clinical — the AU general-practice framework

Recognising EoE in general practice

Many adults with EoE carry the diagnosis for years after symptom onset because their symptoms are subtle or they have adapted their eating behaviour without seeking assessment. The key is asking the right questions.

Adult presentation — what to ask:

Dysphagia for solid food: Does food feel like it slows down or sticks when swallowing? Is swallowing liquids easier than solids?
Food impaction: Has food ever become completely stuck and required going to hospital to have it removed endoscopically?
Eating adaptations: Do you chew your food an unusually long time? Do you always need water with meals? Do you avoid certain foods (steak, bread, apples, raw vegetables) because they tend to stick?
Heartburn: Present in many EoE patients, but often poorly responsive to standard proton pump inhibitor doses.
Atopic history: Asthma, allergic rhinitis, eczema, food allergies in the patient or first-degree relatives.

The ACG 2022 EoE Guideline identifies dysphagia as the cardinal symptom in adults and notes that food impaction requiring emergency endoscopy occurs in approximately 50% of adults with EoE — often the event that first leads to diagnosis.

Paediatric presentation — different symptoms: Children rarely report dysphagia and instead present with: vomiting or regurgitation (often misdiagnosed as gastro-oesophageal reflux disease); food refusal and selective eating; abdominal pain; growth failure or failure to thrive; and behavioural changes around mealtimes. Paediatric EoE warrants paediatric gastroenterology referral.

Examination: Physical examination in adults is generally normal. Look for eczema, allergic rhinitis signs, or signs of asthma — atopic features in about 70% of patients. In children, assess growth parameters against age-appropriate charts.

Investigations and diagnosis

Gastroscopy with biopsies — mandatory for diagnosis:

EoE cannot be diagnosed clinically or on blood tests alone. The Gastroenterological Society of Australia (GESA) endorses current international standards requiring:

Endoscopic assessment using the EREFS scoring system: oedema (loss of vascular pattern), rings (circular, concentric — “trachealisation”), exudates (white spots — eosinophilic microabscesses), furrows (longitudinal linear grooves), and strictures.
A minimum of six biopsies — at least three from the proximal oesophagus and three from the distal oesophagus — to account for patchy disease distribution.
Histology confirming ≥15 eosinophils per high-power field in at least one sample, with other causes of oesophageal eosinophilia excluded (Candida infection, herpes, drug reaction, GORD-only).

The PPI question: Per the AGREE 2018 Diagnostic Consensus, a proton pump inhibitor response does not exclude EoE — patients who achieve histological remission on PPI are now classified as having PPI-responsive EoE (a phenotype of EoE, not a separate condition). PPI is therefore used as both a diagnostic trial and a first-line treatment.

Bloods: FBC (peripheral eosinophilia in approximately 50% — not diagnostic but supportive); total IgE and specific IgE (for concurrent IgE-mediated food allergy assessment); serum ferritin if anaemia or growth concerns.

Allergy testing: Skin prick testing and specific IgE testing for food allergens have limited reliability in identifying EoE food triggers (EoE is predominantly non-IgE-mediated, driven by delayed Th2 responses rather than immediate IgE reactions). Results should not guide dietary elimination in EoE without specialist interpretation. Allergy/immunology referral via ASCIA is appropriate for concurrent IgE-mediated food allergy or management of significant atopic comorbidities.

Differential diagnosis — conditions that mimic EoE:

GORD — often coexists with or predates EoE; PPI treatment overlaps; biopsy distinguishes.
Achalasia and oesophageal motility disorders — manometry is diagnostic.
Peptic or malignant oesophageal stricture — biopsy and imaging.
Pill-induced oesophagitis — drug history; resolves on cessation (particularly bisphosphonates, doxycycline, NSAIDs).
Candida oesophagitis — characteristic white plaques; immunocompromised context.

GP referral pathway

Any adult with dysphagia — especially solid-food dysphagia — requires gastroenterology referral for gastroscopy and biopsy, and should not be managed empirically as GORD without investigation. Food impaction is a medical emergency requiring urgent endoscopy within 12–24 hours; do not attempt to push a food bolus with more food or drinks. Refer to emergency department immediately for complete impaction.

B. Treatment — the three D’s: drugs, diet, and dilation

Drugs

1. Proton pump inhibitor (PPI): Omeprazole 20–40 mg twice daily (or equivalent — pantoprazole, esomeprazole, lansoprazole) for 8–12 weeks. Histological remission in approximately 40% of patients. First-line in many Australian gastroenterology centres because of availability, PBS listing, and simplicity. PPIs are available as generic medicines on the PBS. The Lucendo Lancet 2017 prospective data confirmed PPI responsiveness as a true EoE phenotype, not exclusion criterion.

2. Swallowed topical corticosteroid: The corticosteroid coats the oesophageal mucosa directly, reducing local eosinophilic inflammation, rather than being swallowed rapidly into the stomach.

Budesonide oral viscous slurry — 1 mg twice daily; compounded by a pharmacist (mixed with sucralose or honey-based thickener to increase oesophageal contact time). Swallow; do not gargle. Do not eat or drink for 30 minutes after.
Fluticasone MDI 220 mcg — four puffs swallowed (not inhaled) twice daily; PBS-listed as an inhaler for asthma (off-label use for EoE is common in Australian practice). Rinse mouth after to reduce oral candidiasis risk.
Budesonide orodispersible tablet (Jorveza) — TGA-approved for EoE; PBS evaluation in progress.
Histological remission in 60–80% of patients. Side effects: oral candidiasis in approximately 10% — counsel on rinsing mouth and not eating or drinking immediately after; rare adrenal suppression with long-term use.

3. Dupilumab (Dupixent): An anti-IL-4 receptor alpha monoclonal antibody that blocks Th2-pathway signalling. Subcutaneous injection 300 mg every two weeks. The Dellon NEJM 2022 trial demonstrated significant improvement in both histological and symptomatic outcomes compared with placebo. TGA-approved and PBS Section 100 listed since 2024 for adults and adolescents with severe EoE refractory to PPI and topical corticosteroid, or those with significant concurrent atopic comorbidity (severe asthma or atopic dermatitis) where a single biologic may address multiple conditions. Requires specialist gastroenterology or immunology initiation and Authority prescription.

Diet

Dietary therapy aims to identify and avoid the food triggers driving individual oesophageal inflammation. It requires commitment, dietitian support, and repeated endoscopy to confirm responses, but allows long-term management without medication.

Empiric elimination approaches (food removed regardless of allergy test results, since EoE triggers are largely non-IgE-mediated):

6-food elimination diet — removes cow’s milk, wheat, egg, soy, nuts and seeds, and fish and seafood simultaneously for 6–8 weeks, followed by gastroscopy. If in remission, foods are reintroduced one at a time every 6–8 weeks with repeat gastroscopy per reintroduction. Identifies specific triggers in approximately 70% of patients; time-intensive; requires dietitian support for nutritional adequacy.
4-food elimination — removes cow’s milk, wheat, egg, soy; more practical for most patients; effective for a substantial proportion.
2-food elimination — removes cow’s milk and wheat only; simplest approach; effective in approximately 40% of patients; reasonable first step for motivated patients in general practice.
Elemental (amino acid formula) diet — highly effective (approximately 95% histological remission) but extremely difficult to maintain in adults; rarely used outside paediatric specialist centres.

Dietitian referral via the GPCCMP (MBS 965/967) is appropriate for all patients pursuing dietary elimination.

Dilation

Endoscopic balloon or bougie dilation is used for fibrostenotic strictures causing significant dysphagia that has not fully resolved with medical or dietary therapy alone. Dilation is symptomatic relief — it does not address the underlying inflammation, so it is used as an adjunct to, not a substitute for, medical or dietary treatment. Post-dilation chest pain occurs in approximately 75% of patients (usually mild and self-resolving); oesophageal perforation risk is approximately 0.5%.

Maintenance therapy

EoE is a lifelong condition — relapse rates above 70% at one year are seen without ongoing treatment. Maintenance therapy is the standard of care. Options include:

Ongoing PPI at minimum effective dose.
Ongoing topical corticosteroid at minimum effective dose or frequency.
Long-term avoidance of identified trigger foods.
Dupilumab for severe or biologic-responsive patients.

Periodic surveillance gastroscopy (typically annually or more frequently if active disease) assesses histological control and monitors for fibrosis progression.

C. The allergy-EoE connection and atopic management

EoE is part of the atopic disease spectrum. Approximately 70% of patients have at least one concurrent atopic condition — allergic rhinitis, asthma, atopic dermatitis, or IgE-mediated food allergy. This has two implications.

First, ASCIA recommends allergy/immunology assessment for patients with concurrent IgE-mediated food allergy — these patients need a separate management plan including an ASCIA Action Plan and, if indicated, epinephrine autoinjector (EpiPen), which is distinct from the dietary elimination approach to EoE triggers.

Second, dupilumab may be particularly valuable for patients with both severe EoE and significant atopic comorbidity — a single biologic addressing multiple conditions simultaneously. This is one of the Authority criteria for PBS-listed dupilumab.

Aeroallergen sensitivity — grass pollen, house dust mite — is common in EoE and may contribute to symptom seasonality. This does not directly change EoE treatment but is relevant when optimising allergic rhinitis and asthma management.

D. Australian operations

Specialist referral pathway:

Suspected EoE: refer to gastroenterology for endoscopy and biopsy.
Concurrent significant atopic disease: refer to allergy/immunology via ASCIA-accredited specialists.
Dietary elimination: dietitian referral — via GPCCMP enables Medicare-rebated visits.
Multidisciplinary EoE clinics: Royal Melbourne Hospital, Royal Prince Alfred Sydney, Royal Brisbane and Women’s Hospital, and Sir Charles Gairdner Perth have established or developing multidisciplinary services.
Food impaction: emergency department for urgent gastroscopy.

MBS items:

GP consultation: items 23/36/44
GP Chronic Condition Management Plan (GPCCMP): items 965/967 (replaced 721/723 from 1 July 2025) — enables dietitian, psychologist (chronic disease coping and dietary adherence), and other allied health referral
Gastroscopy (specialist): items 32072/32084/32090
Bloods: item 73807 range
Allergy immunology consultation: item 110/116 range

PBS medicines:

PPIs (omeprazole, pantoprazole, lansoprazole, esomeprazole) — PBS General Schedule.
Fluticasone MDI (Flixotide) — PBS for asthma; off-label use as swallowed therapy for EoE is standard practice at Australian specialist centres.
Budesonide orodispersible tablet (Jorveza) — TGA-approved for EoE; PBS evaluation in progress at time of writing.
Compounded budesonide oral viscous slurry — pharmacist-compounded; cost varies by pharmacy.
Dupilumab (Dupixent) — PBS Section 100 Highly Specialised Drug since 2024; Authority Required; specialist (gastroenterologist or immunologist) initiation.

Emergency and safety: Any complete food impaction — inability to swallow saliva, copious secretions, respiratory distress — is a medical emergency. Attend the nearest emergency department immediately. Glucagon 1 mg IV can be used to relax the oesophagus while awaiting endoscopy, but definitive management is endoscopic removal. Do not push the impacted bolus.

E. Special populations

Children and adolescents: Paediatric EoE has a different clinical phenotype — vomiting, food refusal, growth failure — and requires paediatric gastroenterology input. Elemental formula is more commonly used in younger children. Dietary elimination is guided by a paediatric dietitian experienced in the field. Dupilumab is PBS-listed for adolescents aged 12 and above meeting criteria.

Patients with concurrent severe asthma or atopic dermatitis: These patients are the prime candidates for dupilumab therapy via the PBS Section 100 pathway, as it addresses multiple Th2-pathway conditions simultaneously. Refer to both gastroenterology and allergy/immunology for joint assessment.

Older adults: EoE is increasingly recognised in adults over 60. The fibrostenotic phenotype (established scarring and stricture) is more common in older patients with longer disease duration before diagnosis. Dilation is frequently needed alongside medical therapy. Allergy testing is less reliable in older adults.

Indigenous Australians: Specific EoE epidemiology in Aboriginal and Torres Strait Islander communities is limited. Cultural and linguistic sensitivity around dietary changes is essential — engage Aboriginal Health Workers and culturally appropriate dietitians. Standard referral pathways apply.

Pregnancy: Topical corticosteroids (budesonide slurry) are generally preferred over systemic agents in pregnancy; PPI use in pregnancy requires individual risk-benefit discussion. Dupilumab — limited pregnancy safety data; specialist endocrinology and obstetric input.

When to escalate

Refer or escalate urgently when:

Complete food impaction — inability to swallow saliva: attend emergency department immediately for urgent endoscopy (within 12 hours).
Suspected oesophageal perforation — severe chest pain after impaction or dilation: emergency department.
Failure of two adequate treatment trials (PPI for 8–12 weeks plus topical corticosteroid for 8–12 weeks): refer for consideration of dupilumab or dietitian-supervised elimination diet in a specialist centre.
Severe or rapidly progressive dysphagia — concern about malignancy or tight stricture requiring dilation: urgent gastroenterology.
Paediatric failure to thrive attributable to EoE — paediatric gastroenterology.
Significant concurrent atopic comorbidity requiring biologic assessment — allergy/immunology plus gastroenterology joint review.

What this article is and is not

This is general health information drawn from Australian and international clinical guidelines — Therapeutic Guidelines, GESA, ASCIA, ACG 2022 EoE Guideline, AGREE 2018 Diagnostic Consensus, and the Dellon NEJM 2022 dupilumab trial. It is not personal medical advice and does not create a doctor–patient relationship. EoE diagnosis requires endoscopy — it cannot be made clinically or on blood tests alone. All treatment decisions are made in partnership with the treating gastroenterologist, and where applicable, allergy/immunology and dietitian.

For Australian patient resources: HealthDirect — Swallowing difficulty, GESA patient information, ASCIA patient information, Better Health Channel.

Sources cited

Frequently asked questions

What is eosinophilic oesophagitis and what causes it?

Eosinophilic oesophagitis (EoE) is a chronic condition where the lining of the oesophagus (the food pipe) becomes chronically inflamed by a type of allergy-related white blood cell called an eosinophil. The inflammation is triggered by food proteins — most commonly cow's milk and wheat — and sometimes environmental allergens like pollens. It is part of the same atopic (allergic) family as asthma, hayfever, and eczema, and often co-exists with these conditions. The inflammation makes swallowing increasingly difficult over time and, if untreated, can cause scarring and narrowing of the oesophagus.
How do I know if my swallowing difficulty could be EoE?

The typical adult pattern is difficulty swallowing solid food — particularly meat, bread, and dry foods — while liquids go down easily. Many people adapt unconsciously: eating very slowly, chewing 30 or more times, always drinking water with meals, cutting food into tiny pieces, or avoiding steaks and crusty bread. Food getting stuck partway down (food impaction, sometimes requiring emergency endoscopy) affects about half of adults with EoE and is often the event that leads to diagnosis. If you have heartburn that does not respond well to standard reflux treatment, that is another reason EoE is worth investigating. Discuss these symptoms with your GP.
What tests are needed to diagnose EoE?

Diagnosis requires a gastroscopy (endoscopy) with biopsies — there is no blood test or breath test that can diagnose EoE. The gastroscopist looks for characteristic appearances including circular rings, white spots (exudates), linear furrows, and narrowings in the oesophagus. Biopsies are taken from both the upper and lower oesophagus — at least six samples in total. The pathologist counts eosinophils under the microscope; 15 or more eosinophils per high-power field in at least one sample confirms EoE. A proton pump inhibitor (acid tablet) trial before or alongside endoscopy is often used, since some patients respond to PPI alone.
What are the treatment options for EoE in Australia?

Three approaches are used, often in combination. First, medications: a proton pump inhibitor (PPI, such as omeprazole at double the usual dose) achieves histological remission in about 40% of patients. Swallowed topical corticosteroids — budesonide in an oral viscous slurry or fluticasone from an inhaler swallowed (not inhaled) — work in 60–80%. Dupilumab (Dupixent), a biologic injection approved by the TGA and listed on the PBS Section 100 since 2024, is available for adults and adolescents with severe EoE. Second, dietary elimination — removing common trigger foods (typically starting with cow's milk and wheat) and re-challenging with biopsies to identify individual triggers. Third, endoscopic dilation for established strictures causing significant dysphagia.
Is EoE curable, and do I need treatment forever?

EoE is a chronic lifelong condition rather than a curable one, but it is very manageable. Without ongoing treatment, inflammation and symptoms relapse in over 70% of patients within a year of stopping therapy. With appropriate treatment — whether medication, dietary elimination of identified triggers, or a combination — symptoms can be very well controlled and progression to irreversible scarring and strictures can be prevented. If dietary triggers are identified through an elimination and re-challenge process, long-term avoidance of those specific foods (rather than all eliminated foods) is the maintenance approach. Regular review with your gastroenterologist — including periodic repeat endoscopy — guides ongoing management.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.

T1 AU primary 8 sources
T2 International primary 2 sources
- Hirano I et al. ACG 2022 EoE Guideline. Gastroenterology 2022
- Hirano I et al. AGREE 2018 Diagnostic Consensus. Gastroenterology 2018
T3 Named-author reconstruction 2 sources
- Dellon ES et al. Dupilumab in EoE. NEJM 2022
- Lucendo AJ et al. PPI-responsive EoE. Lancet 2017