Beyond Eosinophil Depletion: Toward Multidimensional Remission in Eosinophilic Gastritis and Duodenitis

Eosinophilic gastritis (EoG) and eosinophilic duodenitis (EoD) are chronic, immune-mediated gastrointestinal disorders in which tissue eosinophil density is both an accessible biomarker and a common trial endpoint. Recent targeted studies have shown trial-level divergence between objective endpoints and patient-reported outcomes. This narrative review examines mechanisms, measurement tools, conventional treatment, and biologic studies published or registered through October 2026. In a 26-patient benralizumab trial, histologic remission occurred in 77% of treated patients and 8% of placebo recipients, yet symptom and endoscopic changes were not statistically different. In the DEGAS trial, dupilumab improved histology and endoscopy at 12 weeks, while the symptom change did not differ significantly from placebo. Two Phase 3 lirentelimab trials with registry-posted results met histologic endpoints without significant symptom benefit. Paired individual data are needed to establish within-person discordance. These findings do not make eosinophils unimportant. They show that target engagement, biological disease control, patient status, treatment success, and durability answer different questions. We propose a provisional framework that separates biological disease activity, structural damage, and patient status; treats burden and safety as modifiers of treatment success; and applies duration as a temporal qualifier. The framework favors domain-specific reporting and named discordance states over a single remission score. Patchy disease, variable microscopic field geometry, shallow mucosal sampling, nonspecific symptoms, and limited EoD-specific validation remain important constraints. Patient-informed international consensus and prospective longitudinal testing are needed before the proposed states can guide routine care.