Stanford School of Medicine
 use browser back button to return

Surgical Pathology Criteria

Eosinophilic Esophagitis


  • Marked eosinophil infiltration restricted to the esophagus

Alternate/Historical Names

  • Allergic esophagitis

Diagnostic Criteria

  • Intraepithelial eosinophils at least 15/HPF in any one field (Furuta)
    • 6-14/HPF is considered indeterminate
    • The specificity of such cutoffs has been challenged (Rodrigo)
  • Eosinophils may be diffuse or in clusters
    • Microabscess is defined as a cluster of 4 or more
  • Eosinophils often located in superficial layers of mucosa
    • Superficial epithelium containing sheets of eosinophils may slough
  • Eosinophilic infiltrates must not be present in rest of GI tract
    • Generalized GI infiltrates should suggest eosinophilic gastroenteritis
  • Peripheral eosinophilia may be present but usually <1500/ml
  • Report should contain the following
    • Number of eosinophils/HPF
    • Presence or absence of microabscesses
    • Distribution: diffuse or accentuated at surface
    • Presence or absence of squamous hyperplasia
      • Papillary or basal cell

Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting/updates : 11/11/09, 11/11/11

Differential Diagnosis

Gastroeophageal Reflux vs Eosinophilic Esophagitis
Intraepithelial Eosinophils Diagnosis
≥15-20/HPF Marked intraepithelial eosinophilia consistent with eosinophilic esophagitis if other causes are ruled out (see below)
5-14/HPF Indeterminate for eosinophilic esophagitis
<5/HPF Consistent with reflux
Eosinophils are assessed in the single most involved field


Eosinophilic GI disorders by location

Eosinophilic Esophagitis Eosinophilic Gastroenteritis Eosinophilic Proctocolitis
Confined to esophagus Involves stomach and/or small intestine Confined to rectum and colon
Good response to dietary manipulation Poor response to dietary manipulation Good response to dietary manipulation


Eosinophils may be numerous in other diseases

  • Food impaction must be ruled out clinically
  • Lodging of medicinal agents (pill esophagitis) must be ruled out clinically
  • Drug related must be ruled out clinically
  • Hypereosinophilic syndrome
    • Requires >1500 eosinophils / microliter
  • Parasitic disease must be ruled out by stool examination
  • Crohn disease
    • May contain many eosinophils in the infiltrate but they do not predominate
    • Very rare in esophagus
  • Milk protein enteropathy must be ruled out clinically especially in infants
  • Systemic diseases
    • Churg Strauss vasculitis
    • Pemphigoid
    • Polyarteritis nodosa
    • Scleroderma
    • Stevens-Johnson syndrome
  • Graft versus host disease


  • Peak age 20-40 years
    • Range 6 months to 89 years
    • Rare under 1 year of age
  • Frequently associated with allergy, asthma, atopy
  • Peripheral eosinophilia may be present but usually <1500/ml
  • May have dysphagia, focal strictures and food impaction
  • Endoscopic findings
    • Longitudinal furrows
    • Multiple rings (feline esophagus)
    • Fragile and inelastic (crepe paper esophagus)
    • White exudates
      • Rich in eosinophils
    • Focal strictures and long segment strictures
  • Failure to thrive in infants
  • Pediatric
    • May respond to elemental (amino acid) diet or dietary restrictions
    • May respond partially or not at all to anti-reflux therapy
    • May respond to oral steroids
  • Adult
    • Increasingly diagnosed in patients refractory to anti-reflux therapy with normal pH
    • May respond to antihistamines or topical steroids


  • Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
  • Mueller S. Classification of eosinophilic gastrointestinal diseases. Best Pract Res Clin Gastroenterol. 2008;22(3):425-40.
  • Rodrigo S, Abboud G, Oh D, DeMeester SR, Hagen J, Lipham J, DeMeester TR, Chandrasoma P. High intraepithelial eosinophil counts in esophageal squamous epithelium are not specific for eosinophilic esophagitis in adults. Am J Gastroenterol. 2008 Feb;103(2):435-42.
  • Chang F, Anderson S. Clinical and pathological features of eosinophilic oesophagitis: a review. Pathology. 2008 Jan;40(1):3-8.
  • Furuta GT, Liacouras CA, Collins MH, Gupta SK, Justinich C, Putnam PE, Bonis P, Hassall E, Straumann A, Rothenberg ME; First International Gastrointestinal Eosinophil Research Symposium (FIGERS) Subcommittees. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007 Oct;133(4):1342-63.
  • Prasad GA, Talley NJ. Eosinophilic esophagitis in adults. Gastroenterol Clin North Am. 2008 Jun;37(2):349-68.
  • Sgouros SN, Bergele C, Mantides A. Eosinophilic esophagitis in adults: a systematic review. Eur J Gastroenterol Hepatol. 2006 Feb;18(2):211-7.
  • Sant'Anna AM, Rolland S, Fournet JC, Yazbeck S, Drouin E. Eosinophilic esophagitis in children: symptoms, histology and pH probe results. J Pediatr Gastroenterol Nutr. 2004 Oct;39(4):373-7.
  • Teitelbaum JE, Fox VL, Twarog FJ, Nurko S, Antonioli D, Gleich G, Badizadegan K, Furuta GT. Eosinophilic esophagitis in children: immunopathological analysis and response to fluticasone propionate. Gastroenterology. 2002 May;122(5):1216-25.
  • Straumann A, Spichtin HP, Grize L, Bucher KA, Beglinger C, Simon HU. Natural history of primary eosinophilic esophagitis: a follow-up of 30 adult patients for up to 11.5 years. Gastroenterology. 2003 Dec;125(6):1660-9.
  • Parfitt JR, Gregor JC, Suskin NG, Jawa HA, Driman DK. Eosinophilic esophagitis in adults: distinguishing features from gastroesophageal reflux disease: a study of 41 patients. Mod Pathol. 2006 Jan;19(1):90-6.
  • Hurrell JM, Genta RM, Melton SD. Histopathologic diagnosis of eosinophilic conditions in the gastrointestinal tract. Adv Anat Pathol. 2011 Sep;18(5):335-48.
  • Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, Burks AW, Chehade M, Collins MH, Dellon ES, Dohil R, Falk GW, Gonsalves N, Gupta SK, Katzka DA, Lucendo AJ, Markowitz JE, Noel RJ, Odze RD, Putnam PE, Richter JE, Romero Y, Ruchelli E, Sampson HA, Schoepfer A, Shaheen NJ, Sicherer SH, Spechler S, Spergel JM, Straumann A, Wershil BK, Rothenberg ME, Aceves SS. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011 Jul;128(1):3-20.
Printed from Surgical Pathology Criteria:
© 2009  Stanford University School of Medicine