Three things to know
- Eosinophilic oesophagitis (EoE) is one of the causes of dysphagia (difficulty swallowing).
- Medication helps control inflammation. Dilatation can help widen a scarred narrowing from EoE.
- Feeling better does not always mean the inflammation has settled. Biopsies help check the response.
Watch: understanding EoE
English narration and captions. The written guide below contains the key information.
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Difficulty swallowing
People with eosinophilic oesophagitis, or EoE, often have difficulty swallowing, called dysphagia. Food getting stuck often means they need to chew more carefully, take smaller bites or change the texture of their food to make swallowing easier.
Inflammation in the lining
EoE is an immune-related condition affecting the oesophagus, the tube that carries food to the stomach. Inflammatory cells called eosinophils build up in its lining. The lining can become swollen, leaving less room for food to pass.
Rings and narrowing
Over time, ongoing inflammation can also lead to scarring. The oesophagus may become less flexible, and rings or a tighter narrowing can develop. These changes do not happen to everyone with EoE.
Why food can stick
A mouthful of solid food may move more slowly through a narrowed area, or become lodged there. This helps explain why swallowing can be difficult even when someone has learned to eat very carefully.
From biopsy to microscope
Sometimes the oesophagus looks relatively normal during gastroscopy. Small tissue samples, called biopsies, are therefore needed. The samples are examined under a microscope to look for eosinophils and other tissue changes that help establish the diagnosis.
Treat the inflammation
Treatment aims to settle the inflammation with medicines, dietary therapy, or a combination of both. As inflammation settles, swelling can reduce and the opening can widen. The choice of treatment depends on the findings, previous treatment and what is practical to maintain.
Widen a significant narrowing
If inflammation has caused scarring and narrowing, stretching, called dilatation, may be performed during the endoscopy to make swallowing easier. Treatment to control the inflammation is still needed to help prevent further scarring.
Check healing and know when to seek help
Follow-up may include another gastroscopy and biopsies to check how well treatment is working. If food becomes stuck and you cannot swallow saliva, seek urgent medical care. Call 111 for severe breathing difficulty.
Changes in swallowing
Food may feel slow to pass or become stuck after swallowing. This is called dysphagia. People often adapt by chewing for longer, taking smaller bites, avoiding meat or bread, or choosing softer textures. Tell me about these changes even if you feel you are managing.
I ask whether the problem affects solid food, liquids or both, whether it is getting worse, and whether food has ever needed to be removed at endoscopy. These details help distinguish narrowing from a problem with how the oesophagus moves. EoE is one possible cause, so new or worsening difficulty swallowing should be assessed.
How EoE is diagnosed
Gastroscopy allows me to look for rings, narrowing and other changes, and take small tissue samples from different parts of the oesophagus. The lining can look relatively normal, so biopsies are important even when the camera view is reassuring.
A pathologist examines the samples under a microscope for eosinophils and other changes. I interpret this alongside your symptoms, endoscopy findings and other possible causes of inflammation.
Medicines and diet before the examination
Acid-suppressing treatment, swallowed steroids and food elimination can affect the biopsy findings. Tell me what you are taking or avoiding. Follow the instructions for your examination; do not stop prescribed treatment or change your diet on your own.
Is this the same as an immediate food allergy?
EoE often occurs alongside asthma, eczema or hay fever, but its food triggers are different from an immediate allergic reaction. Skin-prick or blood allergy tests do not reliably identify which foods drive EoE. Separate immediate allergy symptoms still need their own assessment.
Does EoE predispose to cancer?
EoE is not considered a precancerous condition, and current evidence does not establish that EoE causes oesophageal cancer. It can cause difficulty swallowing or food sticking, symptoms that can also occur with other conditions, including cancer, so new, persistent or worsening symptoms still need appropriate assessment rather than being assumed to be EoE.
Treatment: drugs, diet and dilatation
Medicines and dietary therapy treat the inflammation. Dilatation stretches a scarred narrowing when needed. These treatments can be combined. I consider the biopsy findings, the degree of narrowing, previous treatment and what you can maintain in everyday life.
Watch: treating EoE
English narration and captions. The written guide below contains the key information.
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The three Ds
EoE treatment can be thought of as the three Ds: drugs, diet and dilatation. Medicines and dietary treatment address the inflammation. Dilatation helps when narrowing is making swallowing difficult. Some people need more than one approach.
Often starting with omeprazole
Treatment often starts with omeprazole, a proton pump inhibitor commonly used for reflux. It can also help people with EoE who do not have reflux. In a large review of proton pump inhibitors, about forty-five percent of patients reached remission, meaning the inflammatory cell count on biopsies fell below the diagnostic threshold.
Swallowed steroid treatment
Another option is a swallowed steroid, which acts directly on the lining. Fluticasone from a metered-dose inhaler, such as Flixotide, can be prescribed to swallow rather than breathe in. This is an off-label use. Budesonide tablets, called Jorveza, dissolve in the mouth and are swallowed with saliva. Jorveza is not currently publicly funded in New Zealand for EoE.
Targeted treatment
Dupilumab is a targeted treatment that blocks specific signals involved in inflammation. It can help some people whose EoE remains active despite other treatment. It is not currently available as a routine EoE treatment in New Zealand.
Diet: often begin with milk
Dietary treatment aims to identify foods that trigger the inflammation. Often, the starting point is removing animal milk and dairy products. In one adult trial, thirty-four percent achieved remission on biopsies after six weeks of milk elimination alone. This means avoiding milk protein, not simply choosing lactose-free milk.
A broader diet when needed
A six-food elimination diet removes milk, wheat, egg, soy, nuts and seafood. It is more restrictive, so it is not always the first step. A dietitian can help with suitable replacements and nutrition. Foods are reintroduced in a planned way, with biopsies used to check which changes have helped.
Dilatation when narrowing persists
If a scarred narrowing is affecting swallowing, dilatation may be needed as well. A balloon gently stretches the narrowed area. Some people need more than one session, and medicines or dietary treatment continue to address the inflammation.
The goals of treatment
The goals are to control inflammation, relieve swallowing symptoms, reduce further scarring and long-term damage, and restore quality of life. Because symptoms can improve before the inflammation has settled, follow-up biopsies help guide ongoing treatment.
Medicines to treat inflammation
Omeprazole and other proton pump inhibitors
Treatment often starts with omeprazole, a common reflux medicine. It can also help EoE in people without reflux. A large review found that about 45% reached remission on biopsies with a proton pump inhibitor. This is a class estimate, not a result for omeprazole alone. Take the prescribed dose consistently; I review the response before changing treatment.
Swallowed steroids: fluticasone and Jorveza
These medicines act on the oesophageal lining. Fluticasone from a metered-dose inhaler, such as Flixotide, may be prescribed to swallow rather than breathe in. This is an off-label use and needs specific instructions. Jorveza contains budesonide in a tablet that dissolves in the mouth and is swallowed with saliva. Use the instructions for the particular preparation. Thrush in the mouth or oesophagus is a possible side effect; report a sore mouth, white patches or new pain when swallowing.
Targeted treatment: dupilumab
Dupilumab blocks specific inflammatory signals and is used overseas for some people with EoE. It is not currently available as a routine EoE treatment in New Zealand.
Dietary treatment without unnecessary restriction
The aim is to identify foods that trigger inflammation while keeping your diet nutritious and practical. Often we start with animal milk and dairy elimination rather than removing many food groups at once.
Starting with milk elimination
In one adult trial, 34% reached remission on biopsies after six weeks of milk elimination alone. This means avoiding milk protein, not just lactose. Lactose-free milk still contains milk protein. A dietitian can help with food labels, suitable replacements and calcium and protein intake.
When a broader diet is needed
A six-food elimination diet removes milk, wheat, egg, soy, nuts and seafood. It is more restrictive and is not always the first step. If inflammation persists, I discuss whether to broaden the diet or change medicine. Foods are reintroduced in a planned sequence, with biopsies used to assess the response rather than symptoms alone.
Extra help with eating
Dietitian assessment is particularly helpful if you are losing weight, avoiding several food groups or finding it hard to meet nutritional needs. Speech-language therapy may help when there is a separate difficulty starting a swallow, coughing with meals or a persistent swallowing habit that needs assessment.
When a narrowing needs stretching
If inflammation has caused scarring and a tight area, dilatation may be performed during endoscopy to improve swallowing. I usually use a balloon. A wire-guided Savary dilator may suit selected very tight or longer oesophageal narrowings.
Widening may need to be gradual, with more than one session. Medicines or dietary treatment remain important because dilatation does not treat the underlying inflammation. The potential benefits and risks are discussed before the procedure.
Checking healing and keeping it controlled
Follow-up looks at swallowing, the endoscopy appearance and biopsies. Symptoms can improve because you have changed how you eat, even when inflammation remains. A repeat gastroscopy with biopsies helps decide whether to continue, adjust or change treatment.
EoE commonly needs ongoing treatment. Once inflammation is controlled, we agree a maintenance approach and follow-up suited to your findings. The goals are comfortable swallowing, fewer episodes of food sticking, less further scarring and a normal quality of life.
If food becomes stuck
If food remains stuck, seek urgent medical assessment. If you cannot swallow saliva, go to an emergency department promptly. Do not try to force it down with more food or drink.
Call 111 for severe breathing difficulty. After an episode has resolved, follow-up is still needed to assess the cause and treatment.
The treatment and follow-up recommended for you are recorded in your clinical letters and endoscopy or biopsy reports.