Endoscopic image of esophagus in a case of<unk> . Concentric rings are termed trachealization of the esophagus. The barium swallow of the esophagus on the left side shows multiple rings associated with<unk> . The diagnosis of<unk>  is typically made on the combination of symptoms and findings on diagnostic testing. To properly diagnose<unk> , various diseases such as GERD, esophageal cancer, achalasia, hypereosinophilic syndrome, infection, Crohn's disease, and drug allergies need to be ruled out. Prior to the development of the<unk>  Diagnostic Panel,<unk>  could only be diagnosed if gastroesophageal reflux did not respond to a six-week trial of twice-a-day high-dose proton-pump inhibitors (PPIs) or if a negative ambulatory pH study ruled out gastroesophageal reflux disease (GERD). Radiologically, the term "ringed esophagus" has been used for the appearance of<unk>  on barium swallow studies to contrast with the appearance of transient transverse folds sometimes seen with esophageal reflux (termed "feline esophagus"). Endoscopy Endoscopically, ridges, furrows, or rings may be seen in the esophageal wall. Sometimes, multiple rings may occur in the esophagus, leading to the term "corrugated esophagus" or "feline esophagus" due to similarity of the rings to the cat esophagus. Presence of white exudates in esophagus is also suggestive of the diagnosis. On biopsy taken at the time of endoscopy, numerous eosinophils can be seen in the superficial epithelium. A minimum of 15 eosinophils per high-power field are required to make the diagnosis. Eosinophilic inflammation is not limited to the esophagus alone, and does extend through the whole gastrointestinal tract. Profoundly degranulated eosinophils may also be present, as may micro-abscesses and an expansion of the basal layer. Patients found to have signs of<unk>  on endoscopy should undergo an empiric 8-week trial of high-dose proton pump inhibitor therapy (twice daily) before repeat endoscopy in order to rule out GERD. Although endoscopic findings are helpful in identifying patients with<unk> , they are not diagnostic of the disease if the patient has no clinical symptoms. Esophageal mucosal biopsy Currently, endoscopic mucosal biopsy remains the most important diagnostic test for<unk> , and is required to confirm the diagnosis. Biopsy specimens from both the proximal/mid and distal esophagus should be obtained regardless of the gross appearance of the mucosa. Specimens should also be obtained from areas revealing endoscopic abnormalities. At least four biopsies are required to obtain adequate sensitivity for the detection of<unk> . A definitive diagnosis of<unk>  is based on the presence of at least 15 eosinophils/HPF in the esophageal biopsies of patients despite treatment with high-dose PPI. GERD can increase eosinophilic infiltration in the distal esophagus, however, eosinophils associated with GERD generally occur at a lower density (i.e. < 15/HPF). Allergy assessment A thorough personal and family history of other atopic conditions is recommended in all patients with<unk> . Testing for allergic sensitization may be considered using skin prick testing or blood testing for allergen-specific IgE. This is particularly important for the 10–20% of<unk>  patients who also have symptoms of immediate IgE-mediated food allergy. Atopy patch testing has been used in some cases for the potential identification of delayed, non-IgE (cell-mediated) reactions. Diagnostic criteria The diagnosis of<unk>  requires all of the following: * Symptoms related to esophageal dysfunction. * Eosinophil-predominant inflammation on esophageal biopsy, characteristically consisting of a peak value of ≥15 eosinophils per high power field (HPF). * Exclusion of other causes that may be responsible for symptoms and esophageal eosinophilia.
Eosinophilic esophagitis
Gastroesophageal reflux disease
Herpes esophagitis
Coeliac disease
Lymphocytic esophagitis
Crohn's disease
Cytomegalovirus esophagitis
Eosinophilic granulomatosis with polyangiitis