Food allergy and eosinophilic esophagitis: what do we do?

Eosinophilic esophagitis (EoE) is an inflammatory disease of the esophagus triggered by foods and possibly environmental allergens. Common conditions that mimic EoE include gastroesophageal reflux disease and proton pump inhibitor-responsive esophageal eosinophilia. These need to be excluded before confirming the diagnosis of EoE. Identification of food triggers for EoE using standard allergy tests remains challenging. Dietary therapy for EoE so far consists of test-directed elimination of foods, empiric elimination of common food allergens, or exclusive feeding of amino acid-based formulas, with variable success. No FDA-approved medications yet exist for EoE. Topical corticosteroids to the esophagus are being used. EoE is a chronic disease; therefore, long-term therapy seems to be necessary to avoid potential long-term complications such as esophageal remodeling and strictures. Optimal long-term therapies and follow-ups are still not established; therefore, discussion with patients and families regarding the choice of therapy is important to ensure the best possible outcomes from a medical and social standpoint. In this article, we discuss all the above issues in detail by using a hypothetical case; highlighting in a stepwise manner what is known with respect to diagnosis, work-up, and management of EoE; and discussing gaps in knowledge that need to be addressed in the future.