Eosinophilic Esophagitis in India: A Rare or Underdiagnosed Entity?

Dear editor,

Eosinophilic esophagitis (EoE) has been well established as a distinct clinicopathological entity in North America and Europe, with prevalence estimates ranging from 0.1 to 6% based on endoscopic and histopathological studies. However, data from India remain limited. A study from North India by Baruah et al identified only 6 cases among 190 patients with esophageal symptoms highlighting a possible diagnostic gap.[1] Nagarajan et al reported a much higher prevalence (23%) among 73 patients in Tamil Nadu, indicating possible regional variability. Another study by Prasad et al noted a 3.9% prevalence in a pediatric cohort, with many diagnoses made retrospectively after being initially labeled as gastroesophageal reflux disease (GERD).[2] [3]

This prospective cross-sectional study was conducted between April 2024 and January 2025 at a tertiary care center in Karnataka, India. Consecutive patients presenting with esophageal symptoms such as dysphagia, chest pain, or food impaction were included to undergo upper gastrointestinal endoscopy. Exclusion criteria included known GERD with confirmed response to acid suppression, infectious esophagitis, and prior esophageal surgery. Each patient underwent upper gastrointestinal endoscopy with systematic four-quadrant esophageal biopsies at 4 and 14 cm above the esophagogastric junction. Biopsy samples were evaluated for eosinophilic infiltration. EoE was defined as ≥ 15 eosinophils per high-power field (HPF) in at least one biopsy site. More than 15 eosinophils/HPF were considered as significant for diagnosing EoE. A total of 105 patients were included. The mean age was 44.5  ±  12.2 years, with 56.2% males. Presenting symptoms included dysphagia (69.5%), odynophagia (16.2%), and non-cardiac chest pain (14.3%) ([Table 1]). The median eosinophil count was 2.7 eosinophils/HPF (range: 0.1–22.3). Esophagitis present in 27.6% of cases (but no EoE pattern).

Table 1 Symptoms of suspected EoE patients

Symptom	Number of cases (n)	Percentage (%)
Dysphagia	73	69.5
Odynophagia	17	16.2
Chest Pain	15	14.3

Abbreviation: EoE, eosinophilic esophagitis.

Prevalence was calculated as the proportion of patients diagnosed with EoE. A 95% confidence interval (CI) was estimated using Wilson's score method to account for small sample size. No patient met histological criteria for EoE (0/105). The estimated prevalence of EoE was 0% (95% CI: 0.0%–3.7%) using Wilson's score method.

This finding raises important questions regarding the true epidemiological burden of EoE in India and warrants further discussion.

Our findings add to this growing body of evidence by suggesting that EoE may be truly rare in South India. While no patients in our cohort met the histopathological criteria for EoE (≥ 15 eosinophils/HPF), 27.6% had some degree of esophagitis, raising the possibility that some cases may have been misclassified. This aligns with global literature, where up to 40% of EoE cases are initially treated as refractory GERD before biopsy confirmation.[3]

Several factors may contribute to the observed regional differences in EoE prevalence:

1. Dietary and environmental influences: Western studies link EoE to allergen exposure, especially wheat and dairy.[4] Indian dietary patterns, particularly in South India, may confer a different risk profile.

2. Genetic predisposition: Studies suggest racial and ethnic differences in EoE susceptibility, with lower prevalence in Asian populations.[5] However, no genetic studies have been conducted on EoE in Indian patients.

3. Diagnostic and awareness gaps: Routine biopsies from the esophagus are still not standard practice in India unless endoscopic abnormalities are present, possibly leading to missed cases.

Given the paucity of Indian data, we believe our findings reinforce the need for multicenter prospective studies incorporating systematic biopsy protocols to accurately assess the true burden of EoE in the Indian population. We also advocate for continued education among gastroenterologists on considering EoE in patients with chronic reflux, particularly those unresponsive to proton-pump inhibitor therapy.

We appreciate the opportunity to share our observations and hope this discussion stimulates further research into EoE epidemiology in India.

 

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Conflict of Interest

None declared.

Data Availability Statement

Data is made available from G.B. upon reasonable request.

Authors' Contributions

A.K.R., B.M., and G.B. contributed to study design and data collection. S.R., A.K.R., and P.K. were involved in analysis and manuscript writing. G.P.C. and S.S. were involved in critical inputs. All authors approved the final version.

Patients' Consent

Patient consent has been obtained from all the patients.

• References

• 1 Baruah B, Kumar T, Das P. et al. Prevalence of eosinophilic esophagitis in patients with gastroesophageal reflux symptoms: a cross-sectional study from a tertiary care hospital in North India. Indian J Gastroenterol 2017; 36 (05) 353-360
• 2 Prasad KK, Thapa BR, Lal S, Nain CK, Sharma AK, Singh K. Prevalence of eosinophilic esophagitis in a pediatric population: single-center experience in northwestern India. Am J Clin Pathol 2012; 138 (Suppl. 01) A350
• 3 Nagarajan KV, Krishnamurthy AN, Yelsangikar A. et al. Does eosinophilic esophagitis exist in India?. Indian J Gastroenterol 2023; 42 (02) 286-291
• 4 Straumann A, Katzka DA. Diagnosis and treatment of eosinophilic esophagitis. Gastroenterology 2018; 154 (02) 346-359
• 5 Wilson JM, Li RC, McGowan EC. The role of food allergy in eosinophilic esophagitis. J Asthma Allergy 2020; 13: 679-688

Publication History

Article published online:
22 August 2025