10 Common Symptoms of Eosinophilic Esophagitis You Should Know

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory condition that affects the esophagus, the tube connecting your mouth to your stomach. This disease occurs when white blood cells called eosinophils accumulate in the lining of the esophagus, causing inflammation and various uncomfortable symptoms. EoE has become increasingly recognized over the past two decades and can affect both children and adults, though symptoms may differ between age groups.

Understanding the symptoms of eosinophilic esophagitis is crucial for early diagnosis and proper management of this condition. Many people live with EoE symptoms for years before receiving a correct diagnosis, often adapting their eating habits without realizing they have a medical condition. In this comprehensive guide, we’ll explore the ten most common symptoms of eosinophilic esophagitis to help you recognize when it’s time to seek medical attention.

1. Difficulty Swallowing (Dysphagia)

Difficulty swallowing, medically known as dysphagia, is the most common and characteristic symptom of eosinophilic esophagitis in adults. This occurs because the inflammation caused by eosinophils makes the esophagus narrow and less flexible, creating a physical barrier to food passage.

Patients with EoE often describe a sensation that food is “getting stuck” in the chest or throat area. This difficulty is typically more pronounced with solid foods, particularly dense proteins like meat, bread, and rice. Many people unconsciously adapt by:

• Chewing food more thoroughly and for longer periods
• Taking smaller bites
• Drinking large amounts of liquid with meals to help wash food down
• Avoiding certain textures or types of food altogether

The severity of dysphagia can vary from mild discomfort to complete inability to swallow certain foods. This symptom tends to be progressive, worsening over time if the underlying inflammation is not addressed.

2. Food Impaction

Food impaction is a serious and distressing symptom where food becomes completely lodged in the esophagus and cannot pass into the stomach. This is considered a medical emergency and is one of the most common reasons adults with undiagnosed EoE seek emergency care.

During a food impaction episode, patients experience:

• Complete inability to swallow anything, including saliva
• Intense chest discomfort or pain
• Excessive salivation that cannot be swallowed
• Panic and anxiety due to the inability to clear the obstruction

Food impaction typically requires immediate medical intervention, often involving endoscopy to remove the stuck food. Recurrent episodes of food impaction are a strong indicator of EoE disease and should prompt thorough evaluation. Many patients report having experienced multiple episodes before receiving a proper EoE diagnosis.

3. Chest Pain or Heartburn-Like Symptoms

Many individuals with eosinophilic esophagitis experience chest pain that can closely mimic heartburn or even cardiac-related chest pain. This symptom occurs due to inflammation and muscle spasms in the esophageal wall triggered by the accumulation of eosinophils.

The chest pain associated with EoE has several distinctive features:

• Located behind the breastbone (retrosternal area)
• May occur during or after eating
• Often does not respond well to typical heartburn medications like antacids or proton pump inhibitors
• Can be constant or intermittent
• May be accompanied by a burning sensation similar to acid reflux

Because these symptoms overlap significantly with gastroesophageal reflux disease (GERD), many EoE patients are initially misdiagnosed with GERD. The key difference is that EoE-related chest pain typically persists despite acid-suppression therapy, which should raise suspicion for alternative diagnoses like eosinophilic esophagitis.

4. Regurgitation of Undigested Food

Regurgitation involves the backward flow of undigested food from the esophagus back into the mouth or throat. This differs from vomiting, as it occurs without the forceful abdominal contractions and nausea typically associated with vomiting.

In eosinophilic esophagitis, regurgitation happens because:

• The inflamed esophagus cannot properly propel food downward
• Narrowing (strictures) in the esophagus prevents normal food passage
• Food accumulates in the esophagus rather than moving efficiently to the stomach

Patients may notice this symptom particularly when lying down or bending over after eating. The regurgitated material typically tastes like the recently consumed food rather than having the bitter, acidic taste associated with stomach acid reflux. This symptom can be socially embarrassing and may lead to anxiety around eating, particularly in public settings.

5. Nausea and Vomiting

Nausea and vomiting are common symptoms of EoE, particularly in children and adolescents, though adults can experience them as well. These symptoms result from the esophageal inflammation and dysfunction that characterize the disease.

The nausea associated with eosinophilic esophagitis typically:

• Occurs in relation to meals, either during or shortly after eating
• May be triggered by specific foods
• Can lead to decreased appetite and food avoidance
• May be accompanied by abdominal discomfort

Vomiting in EoE patients can vary in frequency and severity. Some individuals experience occasional episodes, while others may have chronic, recurrent vomiting. In children with EoE, persistent vomiting may lead to concerns about growth and nutritional status. Parents often report that their children seem to have a “sensitive stomach” or are “picky eaters” before an EoE diagnosis is established.

6. Abdominal Pain

Abdominal pain is another frequently reported symptom of eosinophilic esophagitis, especially in younger patients. While EoE primarily affects the esophagus, the resulting dysfunction in swallowing and food passage can create discomfort that extends to the abdominal region.

Characteristics of EoE-related abdominal pain include:

• Location in the upper abdomen or lower chest region
• Cramping or aching quality
• Association with meals, particularly certain foods
• Variable intensity from mild discomfort to severe pain

The exact mechanism of abdominal pain in EoE is not completely understood but may relate to esophageal distension when food cannot pass properly, referred pain from esophageal inflammation, or co-existing gastrointestinal inflammation. Children with EoE may have difficulty localizing their pain and may simply indicate that their “tummy hurts,” which can make diagnosis more challenging.

7. Feeding Difficulties and Food Refusal (Primarily in Children)

In infants and young children, eosinophilic esophagitis often manifests as feeding difficulties and food refusal rather than the swallowing problems seen in adults. These symptoms can be particularly concerning for parents and may be mistaken for behavioral issues or picky eating.

Common feeding-related symptoms in pediatric EoE include:

• Prolonged feeding times (meals taking 30 minutes or longer)
• Refusal to advance to age-appropriate food textures
• Preference for liquid or soft foods
• Gagging or choking during meals
• Limited diet variety, with strong food preferences or aversions
• Irritability or crying during or after feeding

Infants with EoE may refuse bottles or breast, arch their backs during feeding, or show signs of discomfort. Toddlers and older children might develop elaborate rituals around eating, require constant liquid intake during meals, or simply refuse entire food groups. These behaviors are often the child’s adaptive response to the discomfort caused by esophageal inflammation, though they may not be able to verbalize that swallowing is painful or difficult.

8. Poor Weight Gain or Growth Failure (in Children)

Children with eosinophilic esophagitis may experience poor weight gain or failure to thrive, which occurs when nutritional intake is insufficient to support normal growth and development. This symptom is particularly concerning and often prompts medical evaluation.

Growth problems in pediatric EoE result from several factors:

• Reduced caloric intake due to feeding difficulties and food refusal
• Limited diet variety leading to nutritional deficiencies
• Chronic inflammation increasing metabolic demands
• Malabsorption if inflammation extends beyond the esophagus

Healthcare providers typically track children’s growth using standardized growth charts. Red flags for EoE include crossing downward across growth percentiles, significant deviation from expected growth trajectory, or failure to gain weight appropriately over several months. Parents may notice that their child’s clothes continue to fit for extended periods, or that the child appears smaller than peers of the same age. Addressing the underlying esophageal inflammation is crucial for restoring normal growth patterns in affected children.

9. Chronic Cough or Throat Clearing

Some individuals with eosinophilic esophagitis experience a persistent cough or frequent need to clear their throat. These respiratory-type symptoms occur even though EoE primarily affects the digestive system, and they can sometimes lead to initial evaluation by ear, nose, and throat specialists or pulmonologists before the correct diagnosis is made.

The chronic cough in EoE has several potential explanations:

• Irritation of the upper esophagus triggering a cough reflex
• Microaspiration of esophageal contents into the airway
• Inflammation extending to the throat area
• Associated allergic conditions affecting both the airways and esophagus

This cough is typically dry and non-productive, meaning it doesn’t bring up mucus or phlegm. It may be worse after eating or when lying down. The constant throat clearing can be socially disruptive and may lead to throat irritation or hoarseness. Unlike coughs caused by respiratory infections, the cough associated with EoE persists for weeks or months without improvement and doesn’t respond to typical cough medications.

10. Sleep Disturbances

Sleep disturbances are an often-overlooked symptom of eosinophilic esophagitis that can significantly impact quality of life. The esophageal discomfort, regurgitation, and other symptoms of EoE can interfere with normal sleep patterns.

Sleep problems in EoE patients may include:

• Difficulty falling asleep due to chest discomfort or heartburn-like symptoms
• Frequent nighttime awakenings caused by regurgitation or coughing
• Need to sleep in elevated positions to minimize symptoms
• Choking sensations during sleep
• General restlessness and poor sleep quality

The impact of disrupted sleep extends beyond nighttime hours, leading to daytime fatigue, difficulty concentrating, mood changes, and reduced productivity. In children, poor sleep can affect behavior, school performance, and overall development. Parents may report that their child is a restless sleeper, frequently changes positions during the night, or wakes up complaining of discomfort. Addressing the underlying inflammation in the esophagus often leads to improvements in sleep quality, which in turn enhances overall well-being and daily functioning.

Main Causes of Eosinophilic Esophagitis

Eosinophilic esophagitis is caused by an abnormal immune response, though the exact mechanisms are still being researched. The disease involves a complex interaction between genetic predisposition, environmental factors, and immune system dysfunction. Understanding these causes can help patients and healthcare providers better manage the condition.

Food Allergens

Food allergens are the primary trigger for eosinophilic esophagitis in most patients. Unlike typical food allergies that cause immediate reactions like hives or anaphylaxis, EoE involves a delayed immune response mediated by T-cells rather than IgE antibodies. The most common food triggers include:

• Milk and dairy products
• Wheat and gluten-containing grains
• Eggs
• Soy and soy products
• Nuts, particularly peanuts and tree nuts
• Fish and shellfish

When susceptible individuals consume these trigger foods, their immune system mistakenly identifies food proteins as threats, leading to the accumulation of eosinophils in the esophageal tissue and subsequent inflammation.

Aeroallergens and Environmental Factors

Environmental allergens that are inhaled can also contribute to eosinophilic esophagitis. Many EoE patients have concurrent allergic conditions such as asthma, allergic rhinitis (hay fever), or eczema. Common aeroallergens associated with EoE include:

• Pollen from trees, grasses, and weeds
• Dust mites
• Mold spores
• Animal dander

Some patients notice that their EoE symptoms worsen during specific seasons when their particular allergens are prevalent, suggesting a connection between inhaled allergens and esophageal inflammation.

Genetic Predisposition

Research has identified a genetic component to eosinophilic esophagitis. The disease tends to run in families, and specific genetic variations have been associated with increased EoE risk. The gene CAPN14 has been particularly implicated in EoE susceptibility. Additionally, individuals with EoE often have a family history of allergic diseases, suggesting shared genetic factors that predispose to allergic and immune-mediated conditions.

Immune System Dysfunction

EoE is fundamentally an immune-mediated disease involving dysfunction in the normal regulatory mechanisms that prevent excessive inflammation. In affected individuals, certain immune cells (particularly Th2 helper cells) become overactive and produce chemical messengers (cytokines) that recruit eosinophils to the esophagus. These eosinophils then release toxic proteins that damage the esophageal tissue and cause the characteristic symptoms of the disease.

Impaired Esophageal Barrier Function

Recent research suggests that individuals with EoE may have an impaired esophageal barrier, meaning the protective lining of the esophagus is more permeable than normal. This allows allergens and other triggers to penetrate more deeply into the esophageal tissue, where they can interact with immune cells and trigger inflammation. This barrier dysfunction may be both a cause and a consequence of the ongoing inflammation in EoE.

Prevention of Eosinophilic Esophagitis

Because eosinophilic esophagitis involves complex genetic and immunological factors, there is no guaranteed way to prevent the disease from developing. However, certain strategies may help reduce the risk of EoE or minimize symptom severity in susceptible individuals.

Early Introduction of Allergenic Foods in Infants

Some research suggests that introducing common allergenic foods to infants at appropriate ages (typically around 4-6 months, after consultation with a pediatrician) may help promote immune tolerance and potentially reduce the risk of developing food-related immune conditions like EoE. This approach contrasts with older recommendations to delay introduction of allergenic foods and is based on emerging evidence about immune system development.

Breastfeeding

Breastfeeding during infancy may provide some protective benefits against allergic diseases, though the specific impact on EoE risk is still being studied. Breast milk contains immune factors and promotes healthy gut microbiome development, which may influence overall immune function and potentially reduce susceptibility to immune-mediated conditions.

Environmental Allergen Management

For individuals with known allergies or strong family history of allergic conditions, reducing exposure to environmental allergens may be beneficial:

• Using dust mite-proof covers on mattresses and pillows
• Maintaining clean indoor environments with regular vacuuming and dusting
• Using air purifiers with HEPA filters
• Managing indoor humidity to prevent mold growth
• Keeping pets out of bedrooms if animal allergies are present

Early Recognition and Intervention

While not prevention in the traditional sense, early recognition of EoE symptoms and prompt medical evaluation can prevent disease progression and complications. Parents should be aware of feeding difficulties, food refusal, and poor growth in children, while adults should pay attention to recurring swallowing difficulties or food impaction episodes. Early diagnosis allows for timely intervention, which may prevent the development of esophageal strictures and other complications that occur with chronic, untreated inflammation.

Frequently Asked Questions

What is the difference between EoE and GERD?

Eosinophilic esophagitis (EoE) and gastroesophageal reflux disease (GERD) both affect the esophagus and can cause similar symptoms like heartburn and chest pain, but they are distinct conditions. GERD occurs when stomach acid frequently flows back into the esophagus, causing irritation. EoE is an immune-mediated condition where white blood cells called eosinophils accumulate in the esophagus in response to allergens. A key difference is that EoE symptoms typically don’t improve with acid-suppression medications that work well for GERD. Definitive diagnosis requires endoscopy with biopsies showing elevated eosinophil counts in the esophageal tissue.

How is eosinophilic esophagitis diagnosed?

EoE diagnosis requires an upper endoscopy (also called esophagogastroduodenoscopy or EGD) with biopsies of the esophageal tissue. During this procedure, a physician uses a thin, flexible tube with a camera to examine the esophagus and collect small tissue samples. The diagnosis is confirmed when the biopsy shows 15 or more eosinophils per high-power field in the esophageal tissue, along with characteristic symptoms and after ruling out other conditions that can cause esophageal eosinophilia. Blood tests and allergy testing may also be performed to identify potential triggers.

Can eosinophilic esophagitis go away on its own?

Eosinophilic esophagitis is generally considered a chronic condition that does not resolve spontaneously without intervention. The inflammation and symptoms typically persist or worsen over time if left untreated. However, with appropriate management—which may include dietary modifications, medication, or other approaches recommended by healthcare providers—many patients experience significant symptom improvement and reduction in esophageal inflammation. The condition requires ongoing monitoring and management rather than being a self-limited disease.

Is EoE a serious condition?

While eosinophilic esophagitis is a chronic condition that requires ongoing management, most patients can live normal, healthy lives with appropriate care. However, if left untreated, EoE can lead to serious complications including esophageal strictures (narrowing), food impaction requiring emergency intervention, and potentially perforation (tearing) of the esophagus in severe cases. The chronic inflammation can cause permanent remodeling and scarring of the esophageal tissue. Early diagnosis and proper management are important to prevent these complications and maintain quality of life.

What foods should be avoided with eosinophilic esophagitis?

The specific foods that trigger EoE vary from person to person, so dietary recommendations should be individualized based on testing and food trials under medical supervision. However, the most common food triggers include milk/dairy, wheat, eggs, soy, nuts, and fish/shellfish—often referred to as the “big six” allergens. Some patients may need to eliminate multiple foods, while others may have fewer triggers. Identifying and avoiding personal trigger foods can significantly reduce symptoms and inflammation. Any dietary changes for EoE should be made in consultation with healthcare providers and ideally with guidance from a dietitian to ensure nutritional adequacy.

Can adults develop EoE, or is it only a childhood disease?

Eosinophilic esophagitis can develop at any age, affecting both children and adults. While increased awareness has led to more pediatric diagnoses, many adults are also diagnosed with EoE, including individuals in their 30s, 40s, or even later. Some adults may have had unrecognized symptoms since childhood, while others develop the condition later in life. The symptom presentation differs somewhat between age groups, with adults more commonly experiencing dysphagia and food impaction, while children often have feeding difficulties, vomiting, and growth problems.

Is EoE related to other allergic conditions?

Yes, eosinophilic esophagitis is strongly associated with other allergic conditions. Many EoE patients have concurrent diagnoses of asthma, allergic rhinitis (hay fever), eczema (atopic dermatitis), or food allergies. This clustering of allergic diseases suggests shared immune system dysfunction and genetic predisposition. Approximately 50-80% of individuals with EoE have at least one other allergic condition. This connection is why allergists and immunologists are often involved in the diagnosis and management of EoE.

Will I need to have repeat endoscopies?

Most patients with eosinophilic esophagitis will require repeat endoscopies to monitor disease activity and response to management strategies. An initial follow-up endoscopy is typically performed after starting dietary changes or other interventions to assess whether esophageal eosinophil counts have decreased and inflammation has improved. Subsequent endoscopy frequency depends on individual factors such as symptom severity, treatment response, and risk of complications. While symptoms can be helpful indicators, they don’t always correlate perfectly with esophageal inflammation, so periodic endoscopic evaluation provides important objective information about disease status.

References:

• Mayo Clinic – Eosinophilic Esophagitis
• Johns Hopkins Medicine – Eosinophilic Esophagitis
• American Academy of Allergy, Asthma & Immunology – Eosinophilic Esophagitis
• Cincinnati Children’s Hospital – Eosinophilic Esophagitis
• American Partnership for Eosinophilic Disorders