Prevalence of Eosinophilic Esophagitis in Patients with Upper GI Symptoms in a Tertiary Care Center in North India

Keywords

eosinophilic esophagitis - esophageal biopsy - gastroesophageal reflux

Introduction

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disorder of the esophagus characterized by esophageal dysfunction and histopathological evidence of eosinophil-predominant infiltration of the esophageal mucosa, defined by the presence of ≥ 15 eosinophils per high-power field (HPF) in the absence of other identifiable causes of esophageal eosinophilia.[1] First described by Landres et al[2] in 1978, EoE was only recognized as a distinct clinicopathological entity in the early 1990s. Since then, it has emerged as an increasingly prevalent cause of esophageal symptoms in both pediatric and adult populations worldwide.[3]

The clinical presentation of EoE varies with age. Infants and young children commonly exhibit feeding difficulties, failure to thrive, vomiting, and food aversion, whereas adolescents and adults frequently present with retrosternal discomfort, persistent heartburn, dysphagia, food bolus impaction, and refractory dyspepsia. Importantly, EoE shares significant symptomatic overlap with gastroesophageal reflux disease (GERD), making differentiation between these conditions challenging. It is now recognized that EoE may account for approximately 1 to 9% of cases initially presenting with GERD-like symptoms. Moreover, patients with EoE often demonstrate a suboptimal or inconsistent response to proton-pump inhibitor (PPI) therapy, further complicating the diagnostic process.[4] [5] [6] [7]

The global prevalence of EoE has been extensively documented, with most epidemiological data originating from North America, Europe, and Australia, where similar rates of disease have been reported. In contrast, studies from Asia, South America, and the Middle East suggest a comparatively lower prevalence. In India, data regarding the epidemiology of EoE remain limited. A non-Indian study by Prasad et al[8] reported a prevalence of 10 to 15% among patients presenting with dysphagia, while Veerappan et al[9] identified EoE in 6.5% of 400 consecutive patients undergoing esophagogastroduodenoscopy (EGD) for various indications. These findings, although not from Indian cohorts, provide valuable international context and highlight the global relevance of EoE prevalence patterns. More recently, Baruah et al[10] documented a 3.2% prevalence in adults with GERD-like symptoms, and Samanta et al[11] reported a prevalence of 3.5% among pediatric patients. Other prospective studies have shown prevalence rates ranging from 2.4 to 6.6%, supporting the notion that EoE may be an underdiagnosed contributor to esophageal symptoms in this region.[12] [13]

GERD remains a highly prevalent gastrointestinal (GI) disorder in India, affecting approximately 7 to 15% of the population in both urban and rural settings. However, a subset of these patients fails to respond adequately to PPI therapy, raising the possibility of misdiagnosed or undiagnosed EoE. Despite its clinical significance, there is a paucity of comprehensive data regarding the burden of EoE among Indian patients with esophageal complaints.[14]

In view of this knowledge gap, the present study was conducted to determine the prevalence of EoE among patients presenting with esophageal symptoms and to identify clinical or demographic predictors associated with EoE in this population. This effort is intended to enhance the recognition of EoE in routine clinical practice and contribute to the growing body of literature on its epidemiology in India.

Materials and Methods

Study Design and Setting

This prospective, observational study was conducted in the gastroenterology outpatient department of our institution over a 20-month period, from April 2023 to December 2024. The study protocol was approved by the Institutional Ethics Committee, and written informed consent was obtained from all participants prior to enrollment.

Study Population

Adult patients presenting with esophageal symptoms such as retrosternal discomfort, heartburn, dysphagia to solids, or a history of food bolus impaction persisting for at least 4 weeks were screened for eligibility. Inclusion criteria required that all participants consent to undergo EGD with esophageal biopsies.

Exclusion Criteria Comprised

• Prior or current diagnosis of infectious esophagitis

• Recent use of PPIs within the preceding 4 weeks

• Diagnosed Crohn's disease, esophageal malignancy, or hematological disorders such as coagulopathy, thrombocytopenia, or esophageal varices

• Previous diagnosis of EoE

• Current systemic corticosteroid therapy

• History of antireflux surgery

Endoscopic and Biopsy Procedures

All eligible subjects underwent EGD, during which six to eight esophageal biopsy specimens were systematically obtained. Biopsies were taken from:

• The upper esophagus (5 cm distal to the upper esophageal sphincter; minimum of three samples)

• The lower esophagus (5 cm proximal to the gastroesophageal [GE] junction; at least three samples)

In addition, any endoscopically visible abnormal mucosa was biopsied. Other procedures such as dilatation, polypectomy, or additional biopsies were performed at the discretion of the endoscopist.

Histopathological Evaluation

Biopsy specimens were immediately fixed in 10% neutral-buffered formalin and processed in the department of pathology. After fixation (5–6 hours), tissues were paraffin-embedded, sectioned serially, and stained with hematoxylin and eosin.

Microscopic Evaluation Included

• Assessment for features of reflux esophagitis

• Enumeration of intraepithelial eosinophils (mean eosinophil count per HPF across all fragments)

• Evaluation of eosinophil degranulation, parasitic or fungal elements, subepithelial stromal changes, epithelial dysplasia, or malignancy

In cases showing marked eosinophilic infiltration, Warthin–Starry silver staining was performed to rule out Helicobacter pylori organisms.

Clinical and Laboratory Data Collection

Comprehensive demographic and clinical data were recorded, including:

• Endoscopic findings

• Peripheral blood eosinophil counts

• Anti-nuclear antibody titers

• Coagulation parameters (prothrombin time and international normalized ratio)

• History of comorbid conditions (asthma, atopic dermatitis)

• Duration and response to PPI therapy

In our study, patients' symptom severity was recorded using a 10-point Visual Analog Scale (VAS), where “0” indicated no symptoms and “10” represented the most severe symptoms imaginable. A positive response to PPI therapy was defined as a ≥ 50% reduction in the baseline VAS score after 8 weeks of treatment, consistent with prior clinical studies that have used similar cutoffs to define treatment response in EoE and GERD cohorts.

Endoscopic Diagnostic Criteria for EoE

Characteristic endoscopic features considered suggestive of EoE included:

• Mucosal edema (reduced vascularity, pallor)

• Exudative changes (superficial white speckled plaques)

• Linear furrowing (longitudinal esophageal striations)

• Concentric rings (trachealization)

• Luminal strictures

Statistical Analysis

All data were analyzed using SPSS version 25.0 (IBM Corp., Chicago, Illinois, United States). Quantitative variables were expressed as mean ± standard deviation and compared using the independent samples t-test. Categorical variables were presented as frequencies and percentages, with comparisons performed using the chi-square test. Univariate analysis was employed to identify potential independent predictors of EoE in symptomatic patients. But due to the very small number of EoE cases (n = 4), multivariate analysis was not feasible. Associations identified on univariate testing should therefore be interpreted with caution. A p-value of < 0.05 was considered statistically significant.

Results

Patient Characteristics

A total of 350 consecutive patients presenting with esophageal symptoms were enrolled and underwent esophageal biopsy. The mean age of the study cohort was 43.6 ± 7.3 years, with a male predominance (n = 192; 54.8%). The median duration of reflux-related symptoms was 9.6 months (range: 1–36 months). A personal history of allergic disorders (such as asthma, atopic dermatitis, or food allergies) was documented in 21 patients (6%) ([Fig.1]).

Peripheral Eosinophil Counts

The overall median absolute eosinophil count (AEC) among all patients was 242 cells/mm³ (range: 5–1530). Peripheral eosinophilia (defined as AEC > 500 cells/mm³) was identified in 26 patients (7.4%) with GE symptoms.

Presenting Symptoms

Among the presenting symptoms, abdominal pain was reported by 210 patients (60.0%) overall, occurring in 208 non-EoE patients (60.1%) and in 2 of the 4 patients with EoE (50%). Heartburn or chest pain was the most common complaint, observed in 306 patients (87.4%), and was nearly universal across both groups, including all 4 EoE cases (100%). Dysphagia to solids was noted in 16 patients (4.6%) overall, being relatively uncommon in the non-EoE group (13 cases, 3.8%) but present in 3 of the 4 patients with EoE (75%), suggesting a strong association with the condition. Food bolus impaction was reported in 4 patients (1.1%) overall, including 3 non-EoE patients (0.9%) and 1 patient with EoE (25%), indicating that although infrequent in the general cohort, this symptom was disproportionately more common in those with EoE.

Endoscopic Findings

Endoscopic examination revealed normal findings in 257 patients (73.4%). Hiatal hernia was observed in 44 patients (12.4%), and features of reflux esophagitis were present in 46 patients (13.1%), distributed as Los Angeles grade A in 18 patients (5.1%), grade B in 22 patients (6.3%), and grade C in 6 patients (1.7%). Other isolated findings included gastritis in 3 patients, esophageal stricture in 1 patient, mucosal nodularity in 1 patient, and trachealization with esophageal rings in 1 patient—the latter subsequently confirmed as EoE on histopathological examination ([Table 1]).

Table 1 Baseline characteristics of study population

Characteristics	All patients with esophageal symptoms (n = 350)	Without EoE (n = 346)	With EoE (n = 4)
Mean age (y) ± SD	43.6 ± 7.3	41.3 ± 13.7	39.6 ± 4.2
Gender, n (%)
Male	192 (54.8%)	189 (54.6%)	3 (75%)
Female	158 (45.2%)	157 (45.4%)	1 (25%)
Median duration of symptoms (mo)	9.6	7.2	11.5
Symptoms, n (%)
Abdominal pain	210 (60.0%)	208 (60.1%)	2 (50.0%)
Heartburn/Chest pain	306 (87.4%)	302 (87.3%)	4 (100%)
Dysphagia to solids	16 (4.6%)	13 (3.8%)	3 (75.0%)
Food bolus impaction	4 (1.1%)	3 (0.9%)	1 (25.0%)
Response to PPI, n (%)	217 (62.0%)	217 (62.7%)	0 (0%)
History of allergy, n (%)	21 (6.0%)	18 (5.2%)	3 (75.0%)
Median absolute eosinophil count (cells/mm3)	206 (5–1530)	162 (6.5–1530)	410 (210–1530)
Endoscopic findings, n (%)
Normal	257 (73.4%)	256 (73.9%)	1 (25.0%)
Hiatal hernia	44 (12.5%)	44 (12.7%)	0 (0%)
Esophagitis LA Grade A	18 (5.1%)	18 (5.2%)	0 (0%)
Esophagitis LA Grade B	22 (6.3%)	22 (6.4%)	0 (0%)
Esophagitis LA Grade C	6 (1.7%)	6 (1.7%)	0 (0%)
Esophagitis LA Grade D	0 (0%)	0 (0%)	0 (0%)
Others (stricture, nodularity, trachealization)	3 (0.9%)	0 (0%)	3 (75.0%)

Abbreviations: EoE, eosinophilic esophagitis; LA, Los Angeles; PPI, proton-pump inhibitor; SD, standard deviation.

Prevalence and Characteristics of Eosinophilic Esophagitis

Histopathological evaluation of esophageal biopsies revealed significant eosinophilic infiltration (> 15 eosinophils per HPF) in 4 out of 350 patients, corresponding to a hospital-based prevalence of 1.14% for EoE among patients presenting with esophageal symptoms.

The demographic and clinical characteristics of patients with EoE compared with those without EoE are summarized in [Table 1]. Patients diagnosed with EoE were predominantly male (n = 3; 75%) with a mean age of 39.6 ± 4.2 years. The median symptom duration in the EoE subgroup was 11.5 months, longer than in the non-EoE group (7.2 months). Notably, 3 out of the 4 EoE patients (75%) reported a history of allergic disorders, compared with 5.2% in the non-EoE group.

Dysphagia for solids and food bolus impaction were more frequently reported among EoE patients compared with those without EoE (75% vs. 3.7% and 25% vs. 0.8%, respectively). None of the EoE patients demonstrated symptom improvement with PPI therapy, in contrast to the high PPI response rate observed in the non-EoE cohort.

The median peripheral AEC in the EoE group was 410 cells/mm³ (range: 210–1530), significantly higher than in the non-EoE group (median: 162 cells/mm³).

Endoscopic and Histopathological Features of EoE Patients

Among the 4 EoE patients, endoscopic abnormalities were noted in three cases:

• Trachealization with esophageal rings (n = 1)

• Linear furrows (n = 2)

• White exudates and erosion (n = 1)

One patient had a normal EGD despite significant eosinophilic infiltration on biopsy ([Table 2]).

Table 2 Detailed clinical, endoscopic, and histopathological characteristics of patients with eosinophilic esophagitis (EoE)

Characteristics	Case 1	Case 2	Case 3	Case 4
Age/Gender	36/M	42/M	17/M	26/F
Symptoms
Dysphagia	Yes	Yes	No	No
Chest pain/Heartburn	Yes	Yes	Yes	Yes
Regurgitation	No	Yes	No	No
Abdominal pain	No	Yes	No	Yes
Food impaction	No	Yes	No	No
History of atopy
Asthma	Yes	Yes	No	No
Food allergy	No	No	No	No
Atopic dermatitis	No	No	Yes	No
Family history of atopy	No	No	No	No
Absolute eosinophil count (cells/mm3)	1,530	210	350	470
Endoscopic features
Erosion	Yes	Yes	No	Yes
Linear furrows	Yes	No	No	Yes
White exudates	Yes	No	No	No
Plaque	No	No	No	No
Trachealization	No	Yes	No	No
Stricture	No	Yes	No	No
Treatment administered	PPI × 12 weeks + systemic steroids	Systemic steroid + PPI × 12 weeks + dilatation	PPI × 12 weeks + elimination diet	PPI × 12 weeks
Response to treatment
Symptomatic	Yes	Yes	Yes	Yes
Absolute eosinophil count on follow-up (cells/mm3)	180	N/A	N/A	N/A
Endoscopic improvement	Yes	Yes	N/A	Yes
Histopathological improvement	Yes	Yes	Yes	Yes

Abbreviations: F, female; M, male; N/A, not available; PPI, proton-pump inhibitor.

Histopathology confirmed mucosal eosinophilia (> 20 eosinophils per HPF) in the lower esophageal biopsies of all EoE patients. Only one case demonstrated similar eosinophilic infiltration in the upper esophageal biopsies. No parasitic infestation or fungal elements were identified on special staining. Stool microscopy in all EoE patients was unremarkable.

Treatment and Response

All EoE patients received therapy comprising PPI, systemic corticosteroids, or dietary modifications. Three patients achieved symptomatic relief following treatment; one required esophageal dilatation in addition to pharmacotherapy. Histopathological and endoscopic improvement was documented on follow-up in these cases ([Table 2]).

On univariate analysis, several clinical variables showed significant associations with EoE. Dysphagia to solids was the strongest predictor, with an odds ratio (OR) of 76.8 (95% confidence interval [CI]: 10.5–∞, p = 0.0003). A history of allergy was also highly predictive of EoE (OR 54.7, 95% CI: 7.2–∞, p = 0.0007). Food bolus impaction emerged as an important risk factor (OR 38.1, 95% CI: 2.9–∞, p = 0.02). Nonresponse to PPI therapy was significantly associated with EoE (p = 0.020). In contrast, abdominal pain (OR 0.66, 95% CI: 0.1–6.4, p = 1.0), heartburn/chest pain (OR ∞, p = 1.0), and male gender (OR 2.52, 95% CI: 0.26–24.1, p = 0.63) did not show statistically significant associations. Importantly, abnormal endoscopic findings were strongly associated with EoE (p < 0.001) ([Table 3]).

Table 3 Univariate analysis of clinical predictors of eosinophilic esophagitis (EoE)

Variable	Univariate OR (95% CI)	p-Value
Dysphagia to solids	76.8 (10.5–∞)	0.0003
History of allergy	54.7 (7.2–∞)	0.0007
Response to PPI	0.0 (not estimable)	0.020
Abdominal pain	0.66 (0.1–6.4)	1.0
Heartburn/Chest pain	∞ (not estimable)	1.0
Food bolus impaction	38.1 (2.9–∞)	0.02
Gender (male)	2.52 (0.26–24.1)	0.63
Endoscopic findings (other vs. normal)	—	< 0.001

Abbreviations: CI, confidence interval; OR, odds ratio; PPI, proton-pump inhibitor.

Discussion

In the present study, the prevalence of EoE among patients presenting with GE symptoms was 1.14%, which is comparable to the prevalence of 1.8% reported by Sharma et al in a similar patient cohort.[15] Conversely, Baruah et al[10] evaluated EoE prevalence specifically among GERD patients, while Joo et al reported a higher prevalence of 6.6% in individuals presenting with upper GI or esophageal symptoms.[16] Similarly, Veerappan et al[9] observed an EoE prevalence of 6.5% in a study of 400 consecutive patients undergoing EGD for various indications. Sealock et al[17] reported a prevalence of 2.4% in 1,357 American adults undergoing elective upper GI endoscopy, while Syed et al found a prevalence of 7.4% in a cohort of 94 Pakistani adults undergoing elective upper GI endoscopy.[18] These variations suggest that EoE remains a relatively uncommon diagnosis in the Northwestern region of India, as reflected by our study population.

On univariate analysis, dysphagia to solids (p < 0.001), a personal history of allergy (p = 0.0007), and lack of symptomatic response to PPIs (p = 0.02) were identified as significant predictors of EoE. Abdominal pain and heartburn, although common in both groups, were not discriminatory. AEC was descriptively higher in EoE patients but formal statistical testing was not feasible due to the very small sample size. These findings are consistent with those of Baruah et al who also reported these factors as important predictors of EoE.[10] A history of atopic disorders, particularly bronchial asthma, is reported in 30 to 50% of pediatric EoE patients, consistent with the presence of atopic comorbidities in our cohort. Additionally, peripheral eosinophilia was detected in 7.4% of our study population, a figure that falls within the previously reported range of 8.6 to 33%.[4] [19] [20]

Fig. 1 CONSORT flow diagram.

In our study, all EoE patients (100%) reported either retrosternal pain or heartburn, 50% experienced dysphagia to solids, and 25% reported food bolus impaction. These findings are comparable to observations by Sharma et al[14] and Joo et al.[16] Consistent with the results of Veerappan et al,[9] this study also demonstrated a male predominance among EoE patients. The mean age of EoE patients was 39.6 ± 4.2 years, which aligns with previous reports from Zink et al[21] and Baruah et al.[10]

Endoscopically, classic features of EoE such as esophageal rings (trachealization), longitudinal furrows, white plaques, and strictures have been well-documented. In Veerappan et al[9] prospective study, 72% of EoE patients exhibited at least one of these features, while Joo et al[16] reported such findings in 75% of cases. In our cohort, one patient with EoE demonstrated typical endoscopic findings of trachealization with rings and linear furrows, confirming the diagnostic importance of these features.

All patients in this study were evaluated using a symptom-based questionnaire designed to assess upper GI symptoms.[22] The severity of each symptom was scored as follows: 0 = no symptoms, 1 = mild (spontaneous remission without interference), 2 = moderate (slow remission with mild interference), and 3 = severe (persistent symptoms with marked interference). Symptom frequency was similarly graded: 1 = < 2 times/week, 2 = 2 to 4 times/week, and 3 = > 4 times/week, with a score of zero for absence of symptoms. The final symptom score for each symptom (heartburn, regurgitation) was obtained by multiplying the severity and frequency scores, and the total symptom score ranged from 0 to 18. Based on this score, GERD severity was classified as mild (4–8), moderate (9–13), and severe (14–18). Additional data included demographic information, comorbidities (asthma, atopic dermatitis, etc.), PPI therapy duration, and response to PPI (defined as at least 50% symptom improvement after 2 weeks of therapy).

In the subgroup analysis, 82 patients (44.3%) had mild, 66 (35.6%) had moderate, and 37 (19.4%) had severe GERD symptoms. Among the cohort, 152 patients (82.2%) were on PPI therapy, of whom 123 (81.6%) reported symptomatic relief, while the remaining had persistent symptoms despite PPI use.

Comparing patients with and without EoE, the EoE group showed a significantly higher history of allergy (16.6% vs. 0.11%, p = 0.003), greater incidence of PPI nonresponse (p = 0.001), and a higher median AEC (416.5 vs. 140 cells/mm³, p = 0.02). However, there was no significant difference in GERD symptom severity (p = 0.86) between the two groups.

Among the 29 patients with endoscopic evidence of esophagitis, 4 were diagnosed with EoE. Importantly, EoE was significantly more prevalent in patients exhibiting both endoscopic esophagitis and a history of allergy compared with those with esophagitis but no allergic history (3 vs. 1; p = 0.03), underscoring the potential synergistic role of these risk factors.

This study has certain limitations. Routine gastric and duodenal biopsies were not performed in all cases to exclude eosinophilic gastroenteritis, although targeted biopsies identified eosinophilic duodenitis in two patients without esophageal involvement. Ambulatory pH monitoring of the distal esophagus was not available, which limits our ability to definitively distinguish between PPI-nonresponsive GERD and EoE. Nevertheless, all patients diagnosed with EoE fulfilled the histological threshold of ≥ 15 eosinophils per HPF and demonstrated poor response to PPI therapy, supporting the diagnosis. As this was a hospital-based, single-center study, referral bias cannot be excluded, and the reported prevalence of 1.14% should be interpreted as a hospital-based prevalence rather than a population-based estimate. Prior PPI use before enrollment may also have influenced disease expression. Finally, the small number of EoE cases limits the generalizability of our findings, highlighting the need for larger, multicenter studies to validate these results.

Conclusion

The prevalence of EoE among Indian adults with esophageal symptoms is low (1.14%). However, a personal history of allergy, elevated peripheral eosinophil count, and poor response to PPI therapy are significant predictors of EoE. Early recognition of these factors can facilitate targeted biopsy and accurate diagnosis of EoE in clinical practice.

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