Advancing the understanding of eosinophilic esophagitis: From pathogenesis to novel therapies

Table 1 Consolidated comparison of major international guidelines for the diagnosis and management of eosinophilic esophagitis

Guideline body and year	Population	Key recommendations
American College of Gastroenterology, 2025[2]	Children and adults	Diagnosis: Symptoms of esophageal dysfunction and ≥ 15 eosinophils/HPF on biopsy, after excluding other causes. Treatment: First-line options include PPIs, swallowed topical corticosteroids and empiric step-up elimination diets (2 foods or 4 foods preferred over elemental). Monitoring: Regular clinical, endoscopic and histologic assessment. Long term: Maintenance therapy and multidisciplinary care recommended
European Society for Paediatric Gastroenterology, Hepatology and Nutrition, 2024[53]	Children	Diagnosis: Updated protocol with multiple biopsies, exclusion of other causes. Treatment: Topical corticosteroids, simplified empiric steps up elimination diets (start with single food), biologics for refractory cases and systemic steroids only for severe strictures. Monitoring: Emphasis on quality of life, transition to adult care, regular endoscopic/histologic follow up
EoETALY, 2024; Italian Society of Gastroenterology; Italian Society of Neurogastroenterology and Motility; Italian Society of Allergology, Asthma, and Clinical Immunology[54]	Children and adults	Diagnosis: ≥ 15 eosinophils/HPF, exclude other causes. Treatment: PPIs, topical corticosteroids, step-up empiric elimination diets, biologics for refractory cases and systemic steroids not for routine use. Monitoring: SCOPE (Symptoms, Control, Observation, Pathological Evaluation) scheme for comprehensive assessment. Emphasis on early diagnosis, multidisciplinary and lifelong management
American Society for Gastrointestinal Endoscopy, 2022[55]	Children and adults	Diagnosis: Endoscopy is essential for diagnosis, assessment of response and monitoring. Tissue sampling: Multiple biopsies from different esophageal sites recommended. Therapy: Endoscopic dilation for strictures; dilation is safe and effective for fibrostenotic disease. Monitoring: Endoscopy remains the gold standard for disease activity and remission; fewer invasive tests not yet established
British Society of Gastroenterology, British Society of Paediatric Gastroenterology, Hepatology and Nutrition, 2022[56]	Children and adults	Diagnosis: ≥ 15 eosinophils/HPF, exclude other causes. Treatment: PPIs, topical corticosteroids, empiric step up elimination diets and esophageal dilation for strictures. Monitoring: Regular clinical, endoscopic and histologic review. Long-term: Maintenance therapy and multidisciplinary team involvement
American Gastroenterological Association institute and the joint task force, 2020[57]	Children and adults	Diagnosis: Symptoms plus ≥ 15 eosinophils/HPF, after excluding other causes. Treatment: Topical corticosteroids (moderate certainty for induction), PPIs (very low certainty for induction), multiple dietary strategies (elemental, empiric 2 foods, 4 foods, 6 foods elimination; moderate to low certainty), allergy-based testing diets not recommended. Dilation: Safe for strictures but does not reduce eosinophil counts. Maintenance: Very low certainty for long term steroid use
United European Gastroenterology, European Society of Pediatric Gastroenterology, Hepatology and Nutrition, European Academy of Allergy and Clinical Immunology, European Society of Eosinophilic Oesophagitis, 2017[10]	Children and adults	Diagnosis: Symptoms of esophageal dysfunction and ≥ 15 eosinophils/HPF on biopsy, after excluding other causes. Treatment: First-line options include PPIs, swallowed topical corticosteroids, empiric step-up elimination diets (2 foods or 4 foods preferred over elemental). Monitoring: Regular clinical, endoscopic and histologic assessment. Long-term: Maintenance therapy and multidisciplinary care recommended

HPF: High-power field; PPI: Proton pump inhibitor.