Management of refractory eosinophilic oesophagitis in adults

When dysphagia, food impaction or chest pain persists despite treatment, the response should be to reassess the diagnosis rather than automatically escalate therapy. Ongoing inflammation, fixed narrowing, reflux and medication injury can look similar.

Specialist care works best when it combines endoscopy, biopsy review, nutrition assessment and a clear treatment plan. In Australia, care usually begins with a GP referral; Medicare supports specialist consultations, but public endoscopy waits may be long, while private procedures can involve gaps or out-of-pocket costs.

Confirm the diagnosis before escalating care

Current diagnostic criteria generally require oesophageal eosinophilia of at least 15 eosinophils per high-power field on biopsy, together with exclusion of other causes. Endoscopy may appear nearly normal, so symptoms alone cannot establish or exclude the disease. Previous reports should be reviewed for adequate sampling at several levels of the oesophagus.

A gastroenterologist should assess the pattern of symptoms, previous impactions, weight loss and the effect on eating. Achalasia, coeliac disease, Crohn disease, candida infection and other inflammatory disorders may need exclusion. Reflux testing or oesophageal manometry is useful when the result will change management, rather than as a routine test for everyone.

Nutritional status also requires attention. Reduced food intake, insufficient fluid and increasingly modified textures can worsen quality of life without showing clearly on the scale. Inability to swallow saliva, significant bleeding or suspected perforation warrants emergency assessment at a public hospital emergency department rather than another routine appointment.

Reassess reflux, medicines and treatment resistance

Contemporary guidance does not require a proton pump inhibitor trial before diagnosing eosinophilic oesophagitis. However, persistent disease should not be considered refractory until appropriate treatment has been tried and factors such as adherence and incorrect dosing have been addressed.

Medication history deserves particular scrutiny. NSAIDs, doxycycline, bisphosphonates, some antidepressants and calcium-channel blockers can cause pill-induced oesophageal injury. These medicines should not be stopped without advice from the prescriber, but swallowing techniques, timing and formulation may be adjusted. Taking medicines with more water and remaining upright can reduce local injury.

Once the baseline diagnosis is secure, an eight-to-twelve-week trial of high-dose proton pump inhibitor treatment is reasonable, often twice daily and 30–60 minutes before meals. Doses should be taken consistently and reviewed with a pharmacist. Improvement with acid suppression does not exclude eosinophilic oesophagitis, and prolonged symptom relief may depend on maintaining the full therapeutic regimen.

Use swallowed topical corticosteroids effectively

Swallowed topical corticosteroids are appropriate when inflammation persists despite optimised acid suppression. Budesonide or fluticasone preparations can reduce eosinophilic inflammation, with treatment selection guided by availability, formulation, previous response and adverse effects.

Technique influences outcomes. Fluticasone intended for swallowing must not be used as an asthma inhaler, and tablets or capsules should be swallowed according to the prescribed method. After budesonide, patients should rinse their mouth and spit it out to reduce oral candidiasis risk. Eating and drinking immediately may reduce contact with the oesophagus.

Topical treatment should be reassessed for both symptoms and histology because symptom improvement can be incomplete. Persistent discomfort may reflect ongoing inflammation, a fixed stricture, reflux or another diagnosis. Antifungal treatment can usually address candidiasis while the underlying management plan continues.

Consider elimination diets with structured support

Empiric dietary elimination may reduce both inflammation and symptoms. A two- or four-food approach is usually more manageable than eliminating six foods, while broader regimens may be appropriate when symptoms and endoscopic findings are severe. Food reintroductions are essential for identifying which restrictions provide sustained benefit.

Food allergy testing is not a reliable way to select an elimination diet, because foods that provoke eosinophilic oesophagitis are not necessarily IgE-mediated allergens. A dietitian should guide the process, monitor nutritional adequacy and adjust restrictions according to the clinical response.

Common Australian dietary patterns often include wheat, dairy, eggs, seafood and nuts, making simultaneous restriction difficult and potentially expensive. Plans should accommodate budget, cooking habits and culturally appropriate foods while maintaining adequate protein, energy and fibre. Dietetic support is particularly important when dysphagia already limits food choices.

Dilate only when narrowing is the dominant problem

Oesophageal dilation may be useful for a fixed stricture that continues to impair swallowing despite control of inflammation. It can also help selected patients with severe symptomatic rings. Careful endoscopic assessment is needed to distinguish a permanent narrowing from oedema or spasm.

Dilation does not treat the underlying eosinophilic inflammation and therefore does not prevent recurrence. Excessive force increases the risk of perforation, while repeated procedures may be needed for complex strictures. It is generally a targeted intervention within a broader treatment plan, not a substitute for controlling mucosal disease.

Escalate selectively and monitor objectively

Failure of properly used topical therapy, or ongoing disease that compromises nutrition and swallowing, may justify specialist-directed advanced treatment. Dupilumab is an option for selected adults with severe eosinophilic oesophagitis, subject to current approval, PBS eligibility criteria and individual circumstances. PBS subsidy can reduce costs for eligible prescriptions, although private scripts, specialist fees and changing criteria may still affect access.

Other agents remain off-label or investigational, and systemic corticosteroids are generally avoided for routine long-term control because of toxicity. Clinical trials may provide access to emerging therapies. Major specialist services are concentrated in cities such as Melbourne, Sydney and Brisbane; telehealth can support interstate discussion and biopsy-slide review, although endoscopy usually requires travel.

Response should be measured objectively. Symptoms and endoscopic appearances can improve while residual eosinophilia remains, so repeat endoscopy and biopsies are often needed after a defined trial. Histological remission is generally defined by fewer than 15 eosinophils per high-power field, alongside improved swallowing and nutrition. Recurrence after treatment is common, making long-term surveillance necessary.

Sustain control with a multidisciplinary plan

Care should be coordinated between the gastroenterologist, dietitian, pharmacist and, when needed, speech pathologist or allergy specialist. A written plan should document medication technique, permitted foods, nutritional targets, warning symptoms and when repeat endoscopy is required. Periodic review is essential because swallowing difficulty and inflammation can change independently.

The essential point to remember is that treatment success means restored swallowing and nutrition alongside microscopic healing, not simply fewer symptoms. A sustained plan that addresses inflammation, food triggers and fixed narrowing is more reliable than repeated short-lived medication trials.