Clinical heterogeneity and endotype stratification in eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease marked by esophageal dysfunction and eosinophilic inflammation, with significant variability in presentation, course, and treatment response. Although patients are diagnosed using the same criteria, they exhibit a range of characteristics with varying age at onset, symptoms, endoscopic appearance, treatment response, and progression to fibrostenotic complications. Clinical phenotyping offers a framework for describing observable disease features, including age-related symptom patterns, inflammatory and fibrostenotic traits, atopic comorbidities, and treatment responses. Complementing this approach, molecular endotyping aims to identify biologically distinct subgroups on the basis of shared underlying mechanisms, informed by transcriptomic, single-cell, and genetic analyses. In EoE, both bulk and single-cell transcriptomic studies have uncovered conserved disease signatures along with specific molecular endotypes linked to inflammatory load, epithelial dysfunction, and tissue remodeling. Genetic studies further reveal both polygenic risk factors and rare variants that influence disease susceptibility, progression, and response to treatment. This review synthesizes current knowledge on clinical phenotypes and molecular endotypes in EoE, highlighting how integrating these frameworks can improve risk stratification, inform treatment selection, and advance precision medicine.