Every diagnostic criterion and every drug in the EoE ladder is downstream of one mechanism: a Th2 allergic response to food allergen in a susceptible host that ends in fibrosis, rings, and impaction if untreated. Hold the cytokine story and the 15-eosinophil threshold, and the diagnosis, the EREFS score, and the treatment ladder follow. The case. A 32-year-old atopic man presents with a food bolus impaction. After it is cleared, what biopsies do you take, how many, and what threshold makes the diagnosis? Topics covered Th2 mechanism: IL-5 and IL-13 driving eosinophil recruitment and remodeling The diagnostic threshold: at least 15 eosinophils per high-power field Biopsy strategy: multiple levels, proximal and distal, even on normal-looking mucosa EREFS endoscopic score: edema, rings, exudates, furrows, strictures Demographics: atopic men in the third and fourth decades, food impaction as the presentation PPI as first-line therapy (PPI-responsive EoE folded into the disease) Topical swallowed steroids: budesonide and fluticasone formulations Dietary elimination: empiric six-food and step-up approaches Dupilumab for refractory or steroid-dependent disease Dilation for fibrostenotic strictures once inflammation is controlled Key decisions Any adult food bolus impaction gets esophageal biopsies at that endoscopy, even if the mucosa looks normal, because EoE is a histologic diagnosis Take biopsies at multiple levels (proximal and distal): EoE is patchy and a single-site sample misses it PPIs are now first-line EoE therapy, not a rule-out step: PPI-responsive eosinophilia is EoE, not a separate entity Treat the inflammation before dilating a stricture: dilation addresses fibrosis but does not treat the disease Refractory or steroid-dependent EoE escalates to dupilumab rather than open-ended steroid escalation For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected]. (00:00) - Opening: the Th2 mechanism drives everything (02:00) - The 15-eosinophil diagnostic threshold (04:30) - Biopsy strategy and the food impaction presentation (07:00) - EREFS endoscopic score (09:30) - The treatment ladder: PPI, steroids, diet (14:00) - Dupilumab for refractory disease (17:00) - Dilation for fibrostenotic strictures

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