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About the Author


Mary Sherlock, MB BCh BAO, PhD, FRCPC

Dr. Mary Sherlock is a pediatric gastroenterologist and Associate Professor at McMaster University, Hamilton. She obtained her medical degree from University College Dublin, Ireland. Her pediatric gastroenterology fellowship training was at The Hospital for Sick Children. She has a PhD in clinical epidemiology from the University of Toronto. Dr. Sherlock’s clinical and research interests are focused on pediatric eosinophilic esophagitis and pediatric inflammatory bowel disease. She is the clinical lead of the pediatric eosinophilic esophagitis clinic at McMaster Children’s Hospital.

The Medical Management of Eosinophilic Esophagitis


Eosinophilic esophagitis (EoE) was first recognised as a unique condition in the early 1990s. It was described by Alex Straumann1 who identified 10 children with resistant ‘gastro-esophageal reflux disease (GERD) symptoms’ with typical endoscopic features and esophageal eosinophilia who achieved resolution of symptoms and esophageal eosinophilia with an elemental formula. While once a rare condition, EoE is being increasingly diagnosed worldwide, with an incidence rate estimated to be 5 to 10 per 100,0002. While widely recognised as being a Th-2 inflammatory disorder, predominantly triggered by food allergens, there is a growing body of literature supporting the role of aeroallergens in the condition3,4. Management of the condition involves close collaboration amongst gastroenterology and allergy specialists. At least half of affected patients will have other allergic disorders including allergic rhinitis, asthma, eczema and some will also have IgE-mediated food allergies. Workup and management of aeroallergen sensitivities is important as swallowed aeroallergens may be a contributing factor to eosinophilic esophagitis, with many patients noting a seasonal exacerbation in their symptoms5. 


EoE is diagnosed when there are 15 eosinophils/high power field (hpf) in esophageal biopsies in a patient with symptoms of esophageal dysfunction, when other causes of esophageal eosinophilia have been ruled out. Other histologic features should also be present such as thickening of the basal cell layer, eosinophilic layering and possible eosinophilic micro-abscesses. Symptoms can be variable, depending on age of presentation and include nausea, vomiting, heartburn, abdominal pain, dysphagia and food impaction6,7. Vomiting and feeding aversion may be more common in very young children, with the more classic dysphagia and food impaction more common in older children, adolescents and adults8. Endoscopic features should be described using the EoE Endoscopic Reference Score (EREFS) which characterizes edema, esophageal rings, exudates, linear furrows and strictures9. 

Until relatively recently, it was recommended that diagnostic evaluation be performed following a trial of proton pump inhibitor (PPI) therapy, to remove potential GERD as a cause for the esophageal eosinophilia7. It is now recognised that a significant proportion of patients will have PPI-responsive EoE10. Therefore, the most recent diagnostic guidelines from the AGREE conference no longer include the requirement for patients to have a trial of PPI therapy prior to endoscopic evaluation, as this strategy will not distinguish between GERD and PPI-responsive EoE6. 


Treatments of EoE are aimed at improving symptoms, improving inflammation and preventing complications, mainly stricture development11.

There are 2 broad therapeutic approaches: 1) dietary-based (elimination diets) or 2) medications (proton-pump inhibitors and swallowed topical steroids). Dilations may be required to manage esophageal strictures. The American Gastroenterology Association Institute and the Joint Task Force on Allergy Immunology Practice Parameters (AGA-JTF) has proposed a guideline for management of EoE and looks at both dietary and medical strategies3,12.

Dietary Management – Elimination diets

Elimination diets are frequently used to treat EoE. The most effective elimination diet is an elemental diet, with remission rates of up to 90% described13. Despite the high efficacy, this is rarely used, except in the youngest children, due to the unpalatability of the amino acid-based formula and the usual need for a nasogastric tube. Therapy with an elemental formula is often prolonged with the need for multiple endoscopic procedures trying to identify the trigger food(s). A more popular approach is the use of empiric elimination diets based on the most common food allergens. 

The six-food elimination diet is the most effective of the empiric elimination diets, with remission rates being about 70% in adults and children14-16. The most common food allergens in children are milk, followed by wheat, egg, soy, and peanuts15, whereas in adults, the most common food allergens are wheat, followed by milk, egg, soy and peanut14.

The six-food elimination diet is quite restrictive. Some physicians will elect to start with a milk-elimination diet, as milk is the most commonly identified food allergen. An improvement in symptoms, endoscopic and histologic features (with eosinophil count < 15/hpf) was noted in just over 50% of children in one study17.

An interesting approach has been proposed by Molina-Infante et al with a step-up approach to dietary elimination. In their ‘2-4-6 prospective study’, participants including adults (n=105) and children (n=25) first eliminated 2 foods (milk and gluten-containing grains). Forty-three percent (56 patients) achieved clinical and histologic remission with this strategy. Patients not in remission moved to a 4-food elimination diet (also removing eggs and legumes, including soy, lentils, chickpeas, beans, peas and peanuts). Those who failed the 4-food group elimination diet stepped up to a six-food group elimination diet, which also included the removal of all seafood and fish, with remission rates of 60% and 79% described in the 4-food and 6-food groups, respectively. Milk was identified as one of the triggering antigens in 52% of participants, and gluten in 16%. Twenty-eight percent were sensitive to both gluten and milk. Milk was the sole food allergen in 33% of children and 18 % of adults18. 

With all elimination diets, it is preferable to re-evaluate endoscopically as new foods are introduced, as there is a poor correlation between symptoms and histologic disease activity19. Eliminating a specific food group should be undertaken for a minimum of 6 weeks20 with some experts suggesting a longer duration. The need for repeated endoscopies is a significant drawback to dietary elimination strategies, with the consequence of missed work for parents and adult patients, missed school days, need for general anaesthesia (in children) and general increased risk associated with repeated procedures. In my practice, I aim to scope after 8 weeks. In addition, early childhood is a critical period for oromotor development. Interruption to this process can result in significant feeding issues and food aversions21. In older children and teens, dietary elimination can have a significant impact on quality of life22.

Involvement of a registered dietician is very important for any child or adult following an elimination diet. The registered dietician can educate the patient on the elimination diet, while ensuring the diet does not cause micronutrient deficiencies. Nutritional status and growth should be monitored in all patients following dietary restriction.


Proton Pump Inhibitor Therapy

Many adult and pediatric patients will show a histologic response with PPI therapy. A meta-analysis and systematic review of 33 published studies (188 pediatric participants; 431 adult participants), found improvement 

in symptoms in 60.8% of patients (95% CI 48.3 – 72.2 %). Histologic remission was noted in 50.5% of participants (95% CI 42.4% – 58.7). The authors did note significant heterogeneity amongst the studies with a publication bias in studies reporting histologic response, indicating that some caution is needed when interpreting the meta-analysis findings23. There is no clear recommendation in the literature on PPI dosing, although a prospective study of adult patients, found that the majority of patients who achieved histologic remission on 40 mg omeprazole b.i.d. for 8 weeks, stayed in histologic remission when the dose was reduced to 40 mg daily24.

The potential mechanism of action of PPI therapy in esophageal eosinophilia (in addition to anti-secretory activity) has been explored. A multicentre study of the EoE transcriptome which included genes for eosinophil chemotaxis (CCL26 (eotaxin-2)), mast cells (CPA3) as well as barrier molecules (DSG1) and tissue remodelling genes (POSTN) showed that the inflammatory molecular signature was nearly completely reversible with PPI therapy25.

Given the relative safety profile and ease of use, some patients may prefer this therapy prior to trying swallowed topical steroids or elimination diets3.

Swallowed topical steroids

Swallowed budesonide (typically a nebule is used to make a viscous suspension) and swallowed fluticasone (from a metered-dose-inhaler) have been shown to be effective in the treatment of both pediatric and adult patients26-28. A double-blind, double-dummy trial comparing swallowed fluticasone with swallowed viscous budesonide found similar efficacy with both medications29. To increase contact time of the medication with the esophageal mucosa, patients should not eat or drink for 30 minutes after the dose but may want to rinse out their mouth to help prevent esophageal candidiasis.

Suggested doses for swallowed topical steroids have been proposed in the 2011 consensus recommendation for adult and pediatric patients7:

Technique: Puff a single puff directly (without use of a spacer-device) into the mouth and swallow. Do not breathe in until the dose is swallowed. After 15 seconds a second puff is administered. A typical dosing regimen is 2 puffs (250 μg per puff) swallowed twice per day. The patient should not eat or drink for 30 minutes after the dose.

Duration of therapy: There is no clear guideline on treatment duration or dosing for the use of swallowed topical steroids in the long-term. The literature shows that when treatment is stopped, symptoms and histologic activity are likely to recur.

More recently trials of an orodispersible form of budesonide have been performed in adult patients, for both induction and maintenance therapy30,31. The maintenance trial showed that rates of remission at 48 weeks 

were 73.5% and 75%, for the 

0.5 mg twice daily and 1 mg twice daily dosing, respectively. The rate of clinic-histologic remission was almost 60%, and the rate of histologic remission was just over 90% in patients treated with orodispersible budesonide, 1mg b.i.d. for 6 weeks, in comparison with placebo32. Approximately 16% of patients developed oral candidiasis. This medication has become the first approved treatment for EoE and is now available for adult patients in Canada. 

Maintenance therapies

Eosinophilic esophagitis is a chronic condition which recurs when treatment is discontinued. Given the concern that untreated esophageal inflammation may lead to fibrostenotic disease, maintenance therapy may be considered4. For patients in whom triggering foods are identified, it is preferable to continue avoiding these foods. This is particularly helpful as it avoids the need for swallowed topical steroids, but can be difficult to adhere to, particularly in adult patients33. A few studies have explored ongoing use of swallowed topical steroids, showing higher remission rates in those continuing with therapy versus those who use placebo/no medication34,35. The AGA-JTF guideline recommends that patients who achieve remission with topical steroid therapy continue with this treatment as maintenance3. Further guidance on dosing and use in children will be helpful in future publications.

Use of steroid therapy raises concern about the risk of adrenal suppression. Symptoms of adrenal suppression are non-specific and include nausea, lethargy, reduced responsiveness (i.e. altered level of consciousness) and can be life-threatening in an adrenal crisis.

While there are guidelines for screening for adrenal insufficiency for asthmatic patients on long-term corticosteroids36, no such guideline exits for patients with EoE receiving steroid therapy. For patients who continue on daily topical steroid therapy, clinicians may consider screening for adrenal suppression with an 8:00 am cortisol level, on an annual basis. Screening for adrenal suppression amongst EoE patients is not done consistently by treating physicians37. Several studies, often small, have shown reduced early morning cortisol and reduced ACTH stimulation tests in patients treated with prolonged use of topical corticosteroid38,39. Despite the potential risk of adrenal suppression, a larger study of 106 patients identified true adrenal insufficiency (post ACTH stimulation test) in just 5 patients, all of whom were on additional steroids for other atopic conditions. A larger number in the group had abnormal early morning cortisol levels at one point during follow up40. Nonetheless, given that corticosteroids are often used for prolonged periods or for repeated courses and considering that many patients will have other forms of steroid therapy for coexistent atopic conditions, it is important to be aware of this potential adverse effect, particularly as the consequences of a true adrenal crisis can be devastating.

Endoscopic Dilation

For patients with a fibrotic stricture, dilations may be required. Dilations can be done via therapeutic endoscopy or with an interventional radiologist. A retrospective review of 509 patients at a single centre, found that 164 (32%) patients required a dilation over a 12-year follow-up period. More than one dilation was required in almost 60% of patients41.

Monitoring Treatment Response

Treatment response is determined with endoscopic and histologic re-evaluation. In children, this usually requires general anaesthesia. Repeated endoscopies are inconvenient for the patient and families and utilise hospital resources. Less invasive testing is being explored, and transnasal endoscopy, which does not require sedation, is being used at some centres in the United States for both pediatric and adult patients42,43. The scope is thin, measuring 6 mm, and adult patients have reported that a non-sedated transnasal endoscopy is more tolerable than a non-sedated standard endoscopy44. In children, the use of virtual reality goggles helps with tolerability of the procedure45.

Other less invasive tests of disease activity include the esophageal string test and swallowed cytosponge. A multicenter study looked at a one-hour esophageal string test in adult (n=60) and pediatric (n=74) patients. Levels of various eosinophil-derived proteins obtained with the string were comparable with values obtained from mucosal biopsies. There was also good correlation with endoscopic mucosal appearance. The results obtained with the string test were able to distinguish ‘active’ versus ‘inactive’ eosinophilic esophagitis. Over 90% of parents and adult patients reported that they preferred the string test over the stand endoscopic procedure46. The cytosponge test is less invasive than a standard endoscopy and involves swallowing a gelatin capsule containing a mesh sponge. The test can be performed at the bedside. An adult study found that there was good correlation between eosinophil counts obtained from the sponge and from mucosal biopsies47.


Therapeutic approaches may change in the future. Biologic agents targeting cytokines involved in the EoE inflammatory pathway are currently being studied, as are novel formulations of existing therapies. Less-invasive monitoring methods, though not yet available in Canada outside of a clinical trial, are desirable. When choosing therapies, close collaboration with the patient and their family is important to facilitate joint decision-making and to increase the chance of adherence to the treatment plan.


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2. Arias A, Lucendo AJ. Epidemiology and risk factors for eosinophilic esophagitis: lessons for clinicians. Expert Rev Gastroenterol Hepatol. 2020;14(11):1069-82.

3. Hirano I, Chan ES, Rank MA, Sharaf RN, Stollman NH, Stukus DR, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis. Gastroenterology. 2020;158(6):1776-86.

4. Dellon ES, Hirano I. Epidemiology and Natural History of Eosinophilic Esophagitis. Gastroenterology. 2018;154(2):319-32 e3.

5. Ram G, Lee J, Ott M, Brown-Whitehorn TF, Cianferoni A, Shuker M, et al. Seasonal exacerbation of esophageal eosinophilia in children with eosinophilic esophagitis and allergic rhinitis. Ann Allergy Asthma Immunol. 2015;115(3):224-8 e1.

6. Dellon ES, Liacouras CA, Molina-Infante J, Furuta GT, Spergel JM, Zevit N, et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018;155(4):1022-33 e10.

7. Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128(1):3-20 e6; quiz 1-2.

8. Furuta GT, Katzka DA. Eosinophilic Esophagitis. N Engl J Med. 2015;373(17):1640-8.

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10. Molina-Infante J, Ferrando-Lamana L, Ripoll C, Hernandez-Alonso M, Mateos JM, Fernandez-Bermejo M, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol. 2011;9(2):110-7.

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12. Rank MA, Sharaf RN, Furuta GT, Aceves SS, Greenhawt M, Spergel JM, et al. Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters. Gastroenterology. 2020;158(6):1789-810 e15.

13. Arias A, Gonzalez-Cervera J, Tenias JM, Lucendo AJ. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis. Gastroenterology. 2014;146(7):1639-48.

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16. Lucendo AJ, Arias A, Gonzalez-Cervera J, Yague-Compadre JL, Guagnozzi D, Angueira T, et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol. 2013;131(3):797-804.

17. Wechsler JB, Schwartz S, Arva NC, Kim KA, Chen L, Makhija M, et al. A Single Food Milk Elimination Diet Is Effective for Treatment of Eosinophilic Esophagitis in Children. Clin Gastroenterol Hepatol. 2021.

18. Molina-Infante J, Arias A, Alcedo J, Garcia-Romero R, Casabona-Frances S, Prieto-Garcia A, et al. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study. J Allergy Clin Immunol. 2018;141(4):1365-72.

19. Safroneeva E, Straumann A, Coslovsky M, Zwahlen M, Kuehni CE, Panczak R, et al. Symptoms Have Modest Accuracy in Detecting Endoscopic and Histologic Remission in Adults With Eosinophilic Esophagitis. Gastroenterology. 2016;150(3):581-90 e4.

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21. Mukkada VA, Haas A, Maune NC, Capocelli KE, Henry M, Gilman N, et al. Feeding dysfunction in children with eosinophilic gastrointestinal diseases. Pediatrics. 2010;126(3):e672-7.

22. Klinnert MD, Silveira L, Harris R, Moore W, Atkins D, Fleischer DM, et al. Health-related quality of life over time in children with eosinophilic esophagitis and their families. J Pediatr Gastroenterol Nutr. 2014;59(3):308-16.

23. Lucendo AJ, Arias A, Molina-Infante J. Efficacy of Proton Pump Inhibitor Drugs for Inducing Clinical and Histologic Remission in Patients With Symptomatic Esophageal Eosinophilia: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol. 2016;14(1):13-22 e1.

24. Gomez-Torrijos E, Garcia-Rodriguez R, Castro-Jimenez A, Rodriguez-Sanchez J, Mendez Diaz Y, Molina-Infante J. The efficacy of step-down therapy in adult patients with proton pump inhibitor-responsive oesophageal eosinophilia. Aliment Pharmacol Ther. 2016;43(4):534-40.

25. Wen T, Dellon ES, Moawad FJ, Furuta GT, Aceves SS, Rothenberg ME. Transcriptome analysis of proton pump inhibitor-responsive esophageal eosinophilia reveals proton pump inhibitor-reversible allergic inflammation. J Allergy Clin Immunol. 2015;135(1):187-97.

26. Gupta SK, Vitanza JM, Collins MH. Efficacy and safety of oral budesonide suspension in pediatric patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2015;13(1):66-76 e3.

27. Konikoff MR, Noel RJ, Blanchard C, Kirby C, Jameson SC, Buckmeier BK, et al. A randomized, double-blind, placebo-controlled trial of fluticasone propionate for pediatric eosinophilic esophagitis. Gastroenterology. 2006;131(5):1381-91.

28. Murali AR, Gupta A, Attar BM, Ravi V, Koduru P. Topical steroids in eosinophilic esophagitis: Systematic review and meta-analysis of placebo-controlled randomized clinical trials. J Gastroenterol Hepatol. 2016;31(6):1111-9.

29. Dellon ES, Woosley JT, Arrington A, McGee SJ, Covington J, Moist SE, et al. Efficacy of Budesonide vs Fluticasone for Initial Treatment of Eosinophilic Esophagitis in a Randomized Controlled Trial. Gastroenterology. 2019;157(1):65-73 e5.

30. Lucendo AJ, Miehlke S, Schlag C, Vieth M, von Arnim U, Molina-Infante J, et al. Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial. Gastroenterology. 2019;157(1):74-86 e15.

31. Straumann A, Lucendo AJ, Miehlke S, Vieth M, Schlag C, Biedermann L, et al. Budesonide Orodispersible Tablets Maintain Remission in a Randomized, Placebo-Controlled Trial of Patients With Eosinophilic Esophagitis. Gastroenterology. 2020;159(5):1672-85 e5.

32. Lucendo AJ, Miehlke S, Schlag C, Vieth M, von Arnim U, Molina-Infante J, et al. Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial. Gastroenterology. 2019;157(1):74-86 e15.

33. Wang R, Hirano I, Doerfler B, Zalewski A, Gonsalves N, Taft T. Assessing Adherence and Barriers to Long-Term Elimination Diet Therapy in Adults with Eosinophilic Esophagitis. Dig Dis Sci. 2018;63(7):1756-62.

34. Andreae DA, Hanna MG, Magid MS, Malerba S, Andreae MH, Bagiella E, et al. Swallowed Fluticasone Propionate Is an Effective Long-Term Maintenance Therapy for Children With Eosinophilic Esophagitis. Am J Gastroenterol. 2016;111(8):1187-97.

35. Dellon ES, Collins MH, Katzka DA, Mukkada VA, Falk GW, Morey R, et al. Long-Term Treatment of Eosinophilic Esophagitis With Budesonide Oral Suspension. Clin Gastroenterol Hepatol. 2021.

36. Issa-El-Khoury K, Kim H, Chan ES, Vander Leek T, Noya F. CSACI position statement: systemic effect of inhaled corticosteroids on adrenal suppression in the management of pediatric asthma. Allergy Asthma Clin Immunol. 2015;11(1):9.

37. Bose P, Kumar S, Nebesio TD, Li C, Hon EC, Atkins D, et al. Adrenal Insufficiency in Children With Eosinophilic Esophagitis Treated With Topical Corticosteroids. J Pediatr Gastroenterol Nutr. 2020;70(3):324-9.

38. Ahmet A, Benchimol EI, Goldbloom EB, Barkey JL. Adrenal suppression in children treated with swallowed fluticasone and oral viscous budesonide for eosinophilic esophagitis. Allergy Asthma Clin Immunol. 2016;12:49.

39. Golekoh MC, Hornung LN, Mukkada VA, Khoury JC, Putnam PE, Backeljauw PF. Adrenal Insufficiency after Chronic Swallowed Glucocorticoid Therapy for Eosinophilic Esophagitis. J Pediatr. 2016;170:240-5.

40. Hsu S, Wood C, Pan Z, Rahat H, Zeitler P, Fleischer D, et al. Adrenal Insufficiency in Pediatric Eosinophilic Esophagitis Patients Treated with Swallowed Topical Steroids. Pediatr Allergy Immunol Pulmonol. 2017;30(3):135-40.

41. Runge TM, Eluri S, Cotton CC, Burk CM, Woosley JT, Shaheen NJ, et al. Outcomes of Esophageal Dilation in Eosinophilic Esophagitis: Safety, Efficacy, and Persistence of the Fibrostenotic Phenotype. Am J Gastroenterol. 2016;111(2):206-13.

42. Friedlander JA, DeBoer EM, Soden JS, Furuta GT, Menard-Katcher CD, Atkins D, et al. Unsedated transnasal esophagoscopy for monitoring therapy in pediatric eosinophilic esophagitis. Gastrointest Endosc. 2016;83(2):299-306 e1.

43. Nguyen N, Lavery WJ, Capocelli KE, Smith C, DeBoer EM, Deterding R, et al. Transnasal Endoscopy in Unsedated Children With Eosinophilic Esophagitis Using Virtual Reality Video Goggles. Clin Gastroenterol Hepatol. 2019;17(12):2455-62.

44. Kadayifci A, Atar M, Parlar S, Balkan A, Koruk I, Koruk M. Transnasal endoscopy is preferred by transoral endoscopy experienced patients. J Gastrointestin Liver Dis. 2014;23(1):27-31.

45. Scherer C, Sosensky P, Schulman-Green D, Levy M, Smith C, Friedlander J, et al. Pediatric Patients’ and Parents’ Perspectives of Unsedated Transnasal Endoscopy in Eosinophilic Esophagitis: A Qualitative Descriptive Study. J Pediatr Gastroenterol Nutr. 2021;72(4):558-62.

46. Ackerman SJ, Kagalwalla AF, Hirano I, Gonsalves N, Katcher PM, Gupta S, et al. One-Hour Esophageal String Test: A Nonendoscopic Minimally Invasive Test That Accurately Detects Disease Activity in Eosinophilic Esophagitis. Am J Gastroenterol. 2019;114(10):1614-25.

47. Katzka DA, Smyrk TC, Alexander JA, Geno DM, Beitia RA, Chang AO, et al. Accuracy and Safety of the Cytosponge for Assessing Histologic Activity in Eosinophilic Esophagitis: A Two-Center Study. Am J Gastroenterol. 2017;112(10):1538-44.