Beyond Endoscopy, Toward Innovative Diagnosis and Monitoring of Eosinophilic Gastrointestinal Diseases

Currently, esophagogastroduodenoscopy with biopsy is essential to the diagnosis and management of eosinophilic gastrointestinal diseases to visually evaluate the gastrointestinal mucosa, obtain mucosal biopsies, and assess treatment response because symptoms do not necessarily correlate with histology. To assess mucosal inflammation after initiating or modifying treatment, multiple repeat esophagogastroduodenoscopies are commonly needed and are burdensome due to postprocedure recovery, costs, and impact on quality of life. For these reasons, there is increasing interest in novel, less-invasive modalities in the management of eosinophilic gastrointestinal diseases, particularly eosinophilic esophagitis. Herein, we review innovative modalities that may be used in lieu of esophagogastroduodenoscopy for eosinophilic esophagitis including unsedated transnasal endoscopy, esophageal string test, and sponge-based devices, innovative modalities complementary to endoscopy such as impedance planimetry. We discuss the role of pH impendence monitoring and radiologic imaging in eosinophilic esophagitis and explore the future of noninvasive modalities including biomarkers and the microbiome.