Missed Diagnoses of Eosinophilic Esophagitis in the ED: A Call to Action

The Missed Opportunity for EoE Diagnosis in the ED

Eosinophilic esophagitis (EoE) is a chronic inflammatory condition of the esophagus that often goes undiagnosed, especially in emergency departments (ED) when patients present with esophageal food impaction (EFI). Recent research underscores this significant issue, revealing that the opportunity for timely diagnosis through necessary biopsies is frequently overlooked by clinicians. According to a study presented at the American College of Gastroenterology (ACG) 2025 Annual Scientific Meeting, only 19% of patients undergoing esophagogastroduodenoscopy (EGD) had biopsies taken at the time of their food impaction event, despite recommendations to do so.

Understanding EoE and Its Delays

EoE is a progressive type 2 inflammatory disease that, on average, sees a diagnostic delay of four years, and in some cases, up to ten years. This delay increases the risk of complications, emphasizing the need for rapid identification and treatment. Patients presenting with EFI could provide a key diagnostic window—one that healthcare providers are currently missing. Dr. Walker D. Redd, the lead author of the study, highlighted that “clinicians should remember to perform esophageal biopsies during endoscopy for esophageal food impaction” to avoid these delays.

Diagnostic Protocols: What We Know

The current guidelines from the ACG recommend obtaining at least two to four biopsies from distinct esophageal areas, especially from regions exhibiting visual inflammation, during EGD. This method not only assists in confirming the presence of EoE but also serves to mitigate future complications stemming from unaddressed inflammation. Despite these guidelines, prior evidence suggests that many patients are still not receiving adequate biopsies when symptoms arise.

The Statistics Tell a Story

In a detailed look involving 2,566 patients treated for esophageal food or foreign body removal, only 1,434 underwent EGD evaluations between 2018 and 2024. Alarmingly, nearly 60% of these patients were over the age of 60, a demographic that may require closer monitoring for EoE symptoms. Among patients who received a biopsy during EGD, about 47% were ultimately diagnosed with EoE. However, the majority of those not biopsied—93%—lacked documented follow-up care within a year, raising concerns about long-term management and health outcomes.

Barriers to Follow-Up Care

Further scrutiny reveals troubling patterns in patient follow-up care. Only 10% of patients underwent follow-up endoscopy for biopsy within a year, with a significant portion lost to follow-up altogether. This inadequacy points to a gap in the healthcare delivery process that needs to be addressed. Experts like Dr. Danny Issa have called for strengthened quality improvement initiatives to ensure that patients who exhibit symptoms of EoE receive appropriate follow-up care and management.

Taking Action: What Can Be Done?

Healthcare professionals must recognize the critical need to conduct thorough follow-ups and advocate for diagnostic protocols that include biopsies for suspected cases of EoE. Awareness and adherence to guidelines could transform patient outcomes by ensuring timely treatment and reducing the risk of disease progression. Moreover, understanding the barriers to follow-up care—including patient mobility and healthcare access—can lead to targeted solutions that enhance the overall quality of care.

Looking Toward the Future

In conclusion, the research highlights a vital opportunity to address the gaps in diagnosing eosinophilic esophagitis in emergency settings. As our understanding of EoE continues to evolve, it is crucial for healthcare professionals to implement necessary protocols to mitigate delays and improve patient outcomes. By prioritizing these practices, we can foster a healthcare environment that values proactive diagnostics and comprehensive patient care.