What is the difference between eosinophilic esophagitis and eosinophilic gastroenteritis in patients with a history of atopic diseases or food allergies?

Distinguishing Eosinophilic Esophagitis from Eosinophilic Gastroenteritis

Eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE) are distinct entities differentiated primarily by anatomic location: EoE involves isolated esophageal eosinophilia (≥15 eos/hpf), while EGE involves eosinophilic infiltration of the stomach, small intestine, and/or colon, either alone or in combination. 1, 2

Anatomic Distribution

The fundamental distinction is anatomic localization:

• EoE: Eosinophilic inflammation is isolated to the esophagus with no involvement of other gastrointestinal segments 1
• EGE: Eosinophilic infiltration involves one or more parts of the gastrointestinal tract beyond the esophagus (stomach, small intestine, colon), and can be classified as eosinophilic gastritis (stomach only), eosinophilic enteritis (small bowel), eosinophilic colitis (colon only), or combinations thereof 2, 3

Critical caveat: Eosinophilic gastroenteritis or colitis can coexist with eosinophilic esophagitis, and when this occurs, the patient has both conditions simultaneously 1

Clinical Presentation Differences

Eosinophilic Esophagitis

• Adolescents/adults: Dysphagia and food impaction are predominant symptoms 1, 4
• Children: Feeding problems, food refusal, vomiting, failure to thrive, heartburn, and abdominal pain 1, 4
• Symptoms are specifically related to esophageal dysfunction 1

Eosinophilic Gastroenteritis

• Non-specific gastrointestinal symptoms: Abdominal pain, vomiting, and diarrhea each present in approximately 50% of patients 5
• Symptoms vary based on location and depth of eosinophilic infiltration (mucosal, muscular, or serosal subtypes) 5, 3
• Can present with protein-losing enteropathy or bowel obstruction requiring surgery 3

Endoscopic and Histologic Features

Eosinophilic Esophagitis

Characteristic endoscopic findings include: 1, 4

• Rings (corrugated/trachealized esophagus)
• Linear furrows
• White plaques or exudates
• Edema or decreased vascularity
• Strictures or luminal narrowing
• Crepe-paper mucosa (fragile, easily torn)

Histologic threshold: ≥15 eosinophils per high-power field (0.3 mm²) in esophageal biopsies, with at least four specimens obtained from different esophageal levels 1, 6

Eosinophilic Gastroenteritis

• Endoscopic findings are variable and non-specific 5
• Diagnosis requires prominent tissue eosinophilia on gastric, small bowel, or colonic biopsies 5
• Important pitfall: The disease is patchy, and muscular/serosal subtypes may require full-thickness biopsies for definitive diagnosis 5

Peripheral Eosinophilia

• EoE: Present in only 10-50% of adults and 20-100% of children, typically modest (2-fold elevation) 4
• EGE: Present in approximately two-thirds of patients 5
• Critical distinction: Peripheral eosinophilia >1,500 cells/μL suggests hypereosinophilic syndrome rather than isolated EoE or EGE 4

Atopic Associations

Both conditions share strong atopic associations, particularly in patients with food allergies or atopic diseases: 1

• EoE: 50-80% have concurrent atopic conditions (allergic rhinitis, asthma, eczema, food allergies) 4
• EGE: Approximately 70% have concomitant atopic diseases or family history of allergies, with strong association to food allergies 5
• Both are driven by Th2-mediated inflammation triggered by food and/or environmental allergens 2, 7, 6

However, transcriptome analysis reveals EGE is more of a systemic disease with a different gene signature than EoE 2

Diagnostic Approach

For EoE:

1. Obtain at least four esophageal biopsies from different levels 1
2. Confirm ≥15 eos/hpf as peak value 1
3. Exclude other causes of esophageal eosinophilia (GERD, infections, drug hypersensitivity, hypereosinophilic syndrome, connective tissue diseases) 1, 4
4. PPI response should NOT exclude EoE diagnosis—PPI-responsive esophageal eosinophilia is now considered part of the EoE spectrum 1

For EGE:

1. Perform esophagogastroduodenoscopy (EGD) and/or colonoscopy with biopsies 2, 5
2. Demonstrate eosinophilic infiltration in stomach, small bowel, or colon 2, 5
3. EGE is a diagnosis of exclusion—must rule out parasitic infections, inflammatory bowel disease, connective tissue diseases, malignancies, and drug effects 2, 5
4. Consider full-thickness biopsies if muscular or serosal involvement is suspected 5

Treatment Differences

Eosinophilic Esophagitis

Established first-line therapies include: 1

• Topical swallowed corticosteroids
• Dietary elimination (elemental, 2-food, 4-food, or 6-food elimination diets)
• PPI therapy (now considered therapeutic, not diagnostic)
• Esophageal dilation for strictures

Treatment goal: Control inflammation to prevent fibrostenotic complications (strictures, food impaction), not just symptom relief 1

Eosinophilic Gastroenteritis

• Systemic corticosteroids remain most effective but cause substantial toxicity with prolonged use 5, 3
• Elimination diets can be successful 5
• EGE is often poorly responsive to therapy with no commonly accepted long-term treatment 2
• Leukotriene inhibitors show encouraging results in some reports 5

Natural History and Prognosis

• EoE: Chronic disease with risk of progressive fibrostenotic complications if untreated; diagnostic delay >2 years associated with 52% rate of fibrostenotic disease 1
• EGE: Relapsing nature often mandates prolonged treatment; long-term prognosis remains poorly defined 5, 3

Both conditions require long-term management and monitoring, but EoE has more established treatment algorithms and better-defined outcomes 1, 2