European Guidelines on Eosinophilic Esophagitis: Evidence‐Based Statements and Recommendations for Diagnosis and Management in Children and Adults. Part 1: Diagnosis, Epidemiology and Natural History
Alfredo J. Lucendo, Javier Molina‐Infante, Ángel Arias, Ulrike von Arnim, Henrik Bergquist, Luc Biedermann, Albert J. Bredenoord, Marie Carlson, Javier Chahuan, Jorge Amil Dias, Thomas Eiwegger, Sara Feo‐Ortega, Sandra L. Garcia‐Dionisio, Matteo Ghisa, Jesús González‐Cervera, Thomas Greuter, Danila Guagnozzi, Carolina Gutiérrez‐Junquera, Lucía Gutiérrez‐Ramírez, Cord Langner, Helen Larsson, Anne Lund Krarup, Salvatore Oliva, Alexandra Papadopoulou, Francesca Racca, Cecilio Santander, Edoardo Vincenzo Savarino, Christoph Schlag, Alain M. Schoepfer, Martin A. Storr, Antonio Tejera‐Muñoz, Noam Zevit, Stephen E. Attwood, Alex StraumannABSTRACT
Introduction
Eosinophilic esophagitis (EoE) has evolved from a rare condition to the leading cause of dysphagia and food impaction. This document (Part 1) provides an updated evidence‐based framework for the definition, epidemiology, natural history, and diagnosis of EoE in children and adults, updating the 2017 European evidence‐based guidelines.
Methods
A panel of 32 experts from EUREOS, EAACI, ESPGHAN, and ESP developed these guidelines. Comprehensive literature searches were conducted (PubMed, Scopus, Embase, and Google Scholar) using the PICO framework. The GRADE methodology was applied to assess the certainty of evidence and strength of recommendations, while consensus was established via the Delphi method, requiring a minimum agreement threshold of 80%.
Results
These guidelines characterize EoE as a heterogeneous condition driven by type 2 inflammation, with natural history influenced by diverse phenotypes and progression risks. EoE burden has risen sharply, with an annual incidence exceeding 10/100,000 and a pooled prevalence over 60/100,000, surpassing 160/100,000 in some regions. Diagnosis requires both symptoms of esophageal dysfunction and ≥ 15 eosinophils/hpf in esophageal mucosa, following the exclusion of alternative causes. EoE is clearly distinguished from asymptomatic esophageal eosinophilia. Key diagnostic recommendations include obtaining at least six biopsies from at least two esophageal levels, as endoscopic appearance alone lacks sufficient sensitivity. Gastric or duodenal biopsies are no longer mandatory unless driven by specific symptoms or endoscopic abnormalities at any point.
Conclusions
These guidelines provide a robust clinical framework that reflects the increasing global prevalence of EoE and standardizes diagnostic criteria across all age groups to improve patient management.