Insights into the natural history and disease course of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease marked by eosinophilic inflammation and esophageal dysfunction, with a significant impact on morbidity, quality of life, and health care utilization. Once considered rare, EoE has become increasingly prevalent, with global estimates exceeding 140 cases per 100,000 individuals. This rise highlights the need to better understand the natural history and disease course to inform diagnosis and management strategies. Evidence suggests that EoE is a progressive condition, such that untreated inflammation contributes to esophageal remodeling and fibrotic complications over years to decades. Patients can develop esophageal food impactions, leading to emergency department utilization and the need for emergent endoscopy. In addition, patients with fibrostenotic disease can require serial dilations. Long-term management, including dietary therapy, proton pump inhibitors, topical corticosteroids, and newer therapies such as dupilumab, demonstrate promise in altering the disease course. However, variability exists in the strength of evidence regarding each therapy's ability to halt or reverse fibrosis. Knowledge gaps persist, particularly in defining fibrosis, identifying phenotypes prone to progression, and tailoring therapies to individual patients. Addressing these gaps will require continued research into understanding fibrosis progression and how therapies alter this trajectory. These efforts are poised to significantly improve clinical care and enhance outcomes for patients with EoE.