Eosinophilic Esophagitis (EoE) in Northern Virginia

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Eosinophilic esophagitis, often shortened to EoE, is a chronic condition in which a type of white blood cell builds up in the lining of the esophagus and causes inflammation. It is one of the more common reasons adults have ongoing trouble swallowing, and it is frequently the explanation when a piece of food gets stuck badly enough to require a trip to the emergency room. It was rarely diagnosed a generation ago and is recognized far more often today. This guide explains what eosinophilic esophagitis is, who tends to develop it, why a biopsy is the only way to confirm it, and how it is managed over the long term.

This article is general education, not medical advice. Swallowing symptoms should be evaluated by a physician who can consider your full history.

What eosinophilic esophagitis is

Eosinophils are a type of white blood cell involved in allergic and immune responses. They are not normally present in the esophagus, the muscular tube that carries food from the throat to the stomach. In eosinophilic esophagitis, they collect in the esophageal lining and drive inflammation that, over time, can make the esophagus stiffer, narrower, and less able to move food along smoothly.

The American College of Gastroenterology, in its 2025 clinical guideline on the condition, defines the diagnosis as the presence of symptoms of esophageal dysfunction together with at least 15 eosinophils per high-power field on an esophageal biopsy, once other causes of esophageal eosinophilia have been evaluated and ruled out. Those other causes include acid reflux, pill-related injury of the esophagus, drug reactions, and inflammatory bowel disease, which is part of why the diagnosis belongs with a gastroenterologist rather than with a self-assessment.

It is a chronic condition rather than an infection or a passing irritation. It does not resolve on its own, and current guidelines treat it as something to manage continuously rather than to treat once.

Symptoms of eosinophilic esophagitis in adults

Symptoms differ by age, and this is one of the clearer patterns in the condition. The ACG guideline notes that dysphagia, meaning difficulty swallowing, and food impaction, meaning food that becomes lodged in the esophagus, are the most common presentations in adults, while failure to thrive and poor growth are the most common presentations in children.

In adults, the picture often includes:

• Solid food, especially bread, rice, or meat, that feels like it sticks partway down
• An episode of food becoming genuinely stuck, sometimes requiring urgent care to remove
• Chest discomfort or pain with swallowing
• Heartburn that does not improve the way ordinary reflux does on acid-reducing medication
• Food that comes back up undigested

Because the condition develops slowly, many people adapt to it without realizing they have. The ACG guideline describes a set of coping behaviors worth recognizing, grouped under the word IMPACT: imbibing fluids with every bite, modifying foods by cutting them very small or avoiding certain textures, prolonging meal times, avoiding hard-textured foods, chewing excessively, and turning away tablets and pills. People who have quietly built these habits over years often describe their swallowing as normal, because it has been their normal for a long time. If you recognize several of these in yourself, that is worth mentioning to a physician even if you would not have called it a symptom. Our guide to difficulty swallowing in Northern Virginia covers the broader range of causes.

Who develops eosinophilic esophagitis

Eosinophilic esophagitis is closely tied to allergic conditions. The ACG guideline advises that the presence of other atopic diseases, specifically food allergies, asthma, and eczema, should raise suspicion for the condition. A personal or family history of these is a meaningful part of the clinical picture, and physicians ask about it for that reason.

It is diagnosed across the age range, but adults presenting with dysphagia and food impaction represent a large share of new diagnoses, and it is recognized more often in younger and middle-aged adults than in older ones. That age pattern is part of why it is sometimes missed: swallowing difficulty in a healthy person in their thirties is easy to attribute to eating too quickly.

How eosinophilic esophagitis is diagnosed

The diagnosis cannot be made from symptoms alone, and it cannot be made from what the esophagus looks like. It requires tissue. An upper endoscopy, also called an EGD, is the procedure involved: a thin flexible camera is passed gently through the mouth under sedation so the physician can see the esophageal lining directly and take small tissue samples. You can read more in our guide to upper endoscopy (EGD) in Northern Virginia.

Two details of that exam matter more than patients usually realize. The ACG guideline recommends obtaining at least six biopsies from two levels of the esophagus, the proximal or mid portion and the distal portion, because the inflammation is patchy and a single sample from one spot can miss it. It also recommends that a systematic endoscopic scoring system be used at every endoscopy, assessing five features of the esophageal lining: edema, rings, exudates, furrows, and strictures. Scoring these consistently is what makes it possible to compare one exam to the next and tell whether treatment is working.

Why the esophagus can look normal and the biopsy still matters

The visible changes of eosinophilic esophagitis can be subtle, and in some people the esophagus looks close to normal to the eye while the biopsy shows significant inflammation. This is the single most important practical point about the diagnosis. If someone has persistent swallowing symptoms and had an endoscopy years ago that was described as normal, it is fair to ask whether biopsies were taken. An endoscopy without esophageal biopsies cannot rule the condition out.

One change in the current guideline is worth knowing about, because it affects people who were evaluated under the older approach. Earlier guidance required demonstrating that symptoms failed to respond to a proton pump inhibitor before eosinophilic esophagitis could be diagnosed. The 2025 ACG guideline eliminated that requirement. Acid-reducing medication is now understood as one of the treatments for the condition rather than as a test that has to be failed first.

Treatment options for eosinophilic esophagitis

There are several effective approaches, and the guideline supports more than one starting point, which means treatment is genuinely a shared decision between a patient and a gastroenterologist rather than a single protocol.

The ACG guideline recommends the following:

• Proton pump inhibitors. Acid-reducing medication helps a meaningful proportion of people with the condition, and it is now recommended as a treatment in its own right.
• Swallowed topical steroids. Budesonide or fluticasone, taken in a swallowed form that coats the esophagus rather than an inhaled form that goes to the lungs, reduce the inflammation directly.
• Empiric food elimination diets. Removing common trigger foods, then reintroducing them in a structured way to identify which ones matter.
• A biologic medication. Dupilumab is recommended for people, including children, whose condition does not respond to a proton pump inhibitor.
• Endoscopic dilation. Gently widening a narrowed esophagus, used alongside anti-inflammatory treatment rather than instead of it.

It is equally useful to know what the guideline advises against. Omalizumab, cromolyn, and montelukast are specifically not recommended for treating this condition, so if you have encountered them in reading, that is why a gastroenterologist is unlikely to suggest them.

Response is assessed with a follow-up endoscopy, generally 8 to 12 weeks after starting a food elimination diet or a proton pump inhibitor, and between 12 and 24 weeks for dupilumab. Symptoms, the endoscopic appearance, and a repeat biopsy are all reviewed together, because symptoms can improve while inflammation persists.

Food elimination diets, and what allergy testing can and cannot do

Diet is a real treatment option, not a fringe one, and the foods involved are well defined. The empiric approach targets six common triggers: cow's milk, wheat, soy, egg, seafood, and nuts. It can be done all at once or as a step-up, beginning with two foods, expanding to four, then to six, depending on what a person is able to sustain. Foods are then reintroduced individually to find the specific triggers, so the long-term diet is usually far less restrictive than the starting one.

One point here often surprises people. The ACG guideline recommends against using allergy testing to direct these elimination diets. Standard allergy tests do not reliably predict which foods drive eosinophilic esophagitis, which is why the approach is empiric, meaning based on the common triggers and a structured trial, rather than based on a test result. If a food-related digestive problem is your concern more broadly, our guide to celiac disease in Northern Virginia covers a different condition that is diagnosed very differently.

Narrowing, food impaction, and dilation

Left untreated over years, inflammation can lead to scarring that narrows the esophagus. This is the pathway that produces food impaction, and it is the main reason the condition is worth identifying before it has been going on for a long time.

When narrowing is causing swallowing difficulty, the guideline supports endoscopic dilation as an adjunct to medical therapy, with a goal diameter of at least 16 millimeters, achieved over one or more sessions depending on how narrow the esophagus is at the start. The word adjunct carries weight: dilation addresses the mechanical narrowing but does nothing about the underlying inflammation, so anti-inflammatory treatment is still needed even when dilation is performed.

Food that becomes completely lodged, to the point where you cannot swallow your own saliva, is an emergency and warrants immediate care rather than waiting it out.

Living with eosinophilic esophagitis over the long term

The condition is chronic, and the guideline is direct about what follows from that: continuing effective dietary or medication treatment is recommended to prevent symptoms, inflammation, and endoscopic changes from returning. Stopping treatment once swallowing feels normal is the common way people end up back where they started, often with more narrowing than before.

That said, long-term management is usually not burdensome once the right approach is found. Many people settle into a stable routine with a medication or a modest set of food restrictions and eat normally. The goal is a quiet esophagus over decades, which is achievable for most people with consistent care. If ongoing reflux is part of your picture as well, our guides to GERD and acid reflux and Barrett's esophagus cover conditions that are often considered alongside it. General patient information is also available from the National Institute of Diabetes and Digestive and Kidney Diseases, and the American College of Gastroenterology publishes a summary of its updated guideline.

Care for eosinophilic esophagitis in Northern Virginia with GC of NoVA

Gastroenterology Center of Northern Virginia cares for patients across Arlington, Annandale, and the surrounding communities who are dealing with swallowing difficulty, food that sticks, or reflux that has not responded the way it should. Our physicians can review your history and your allergy background, perform an upper endoscopy with the biopsies the diagnosis requires when it is appropriate, and work with you on a management plan you can sustain. We see patients at our Arlington office, next to VHC Health, and our Annandale office, in the Woodburn Medical complex. If this would be your first visit with a gastroenterologist, our guide to what to expect at a first appointment may be helpful.

To schedule an evaluation, contact our Arlington office at (703) 522-7476 or our Annandale office at (703) 560-6106, or learn more at gcofnova.com.

This article is for general education and is not medical advice. Talk with a qualified gastroenterologist about your symptoms, diagnosis, and treatment options.