Eosinophilic oesophagitis (EoE) is the most well-researched and well-understood of all eosinophilic gastrointestinal diseases (EGIDs). While this is good news for people with EoE, it also means that people with a non-EoE EGID often don’t have the same level of guidance and support when seeking diagnosis or treatment.

This lack of standardised guidance extends diagnostic delays and makes it harder to match the right management strategies to the right patients.

A 2025 review, published in Gastroenterology & Hepatology, explores our current understanding of non-EoE EGIDs, the state of existing guidance, and suggests a standardised approach to treating these conditions.

The current state of EGIDs nomeclature

The first step to fixing a problem is to name it. However, the review highlights that we haven't always had a clear disease definition or naming system for non-EoE EGIDs. This ambiguity made it difficult to diagnose certain EGIDs because the same name (e.g., eosinophilic gastroenteritis) could be used to refer to an EGID that affected one area of the gut in one patient but also to an EGID that affected a completely different area of the gut in another patient. This meant it wasn’t always clear what treatment a patient needed.

To combat this, the naming system we used to describe and diagnose EGIDs was changed in 2022. This new standardised nomenclature states that:

• EGIDs is an umbrella term for all gastrointestinal diseases with pathologic eosinophilic infiltration.
• EGIDs are named (and diagnosed) based on what parts of the gut they affect (e.g. eosinophilic gastritis, the stomach is affected)
• If more than one part of the gut is affected, it should be classified based on where the symptoms and endoscopic features are most predominant.
• Complications and the depth of involvement should be noted when known, to help make it easier to understand a patient’s condition at a glance.

The authors note that because this new system was only introduced in 2022, older diagnoses or research are unlikely to align with it. This can make treatment and future research (if drawing on old research) more challenging.

What do we know about non-EoE EGIDs?

The review emphasises that we’re increasingly recognising EoG, EoN, and EoC as distinct conditions as our understanding of them has grown.

Eosinophilic gastritis (EoG) and eosinophilic enteritis (EoN)

The authors noted that EoG and EoN were previously grouped under the term eosinophilic gastroenteritis. They share similar symptoms, such as nausea, vomiting, and abdominal pain, and are both more common in people with a family history of EoE.

Eosinophilic colitis (EoC)

EoC is the rarest EGID, and there is still no consensus on how high eosinophil levels need to be before EoC can be diagnosed. As a result, it can still only be diagnosed by first excluding other conditions.

The authors also stressed that there’s currently very little evidence of the strong type 2 allergic immune response normally associated with EGIDs, suggesting that EoC may be distinct from other EGIDs. More research will help us understand exactly what’s happening here.

Eosinophilic oesophagitis and non-EoE EGIDs

Most importantly, the review highlights that while EGIDs were previously thought to occur individually, we now know that it’s common for multiple areas of the digestive tract to be affected. This can show up in different ways:

• Many patients have a combination of multiple non-EoE EGIDs (e.g., EoG and EoN).
• Some patients with a non-EoE EGID will also have oesophageal symptoms (oesophageal involvement). These patients often wait longer for a diagnosis and have more severe symptoms.

How should we approach the diagnosis and treatment of non-EoE EGIDs?

Diagnosis

Historically, non-EoE EGIDs have been more difficult to diagnose than EoE because we lacked clear histologic diagnostic guidelines. The authors note that this is changing, with the first formalised paediatric guidelines published in 2024 by ESPGHAN/NASPGHAN.

Promisingly, the CEGIR’s multidisciplinary working group is currently developing and further refining these guidelines so that doctors can more confidently diagnose non-EoE EGIDs in the future.

Treatment

The review identified a range of treatments used to manage non-EoE EGIDs, including:

• Proton pump inhibitors (PPIs)
• Swallowed topical corticosteroids
• Systemic corticosteroids (often used to induce remission)
• Food elimination diets (e.g., SFED removing dairy, wheat, egg, soya, fish and nuts or 4FED)

However, the authors noted that whilst doctors may be familiar with using oral topical corticosteroids to treat EoE, they can’t use the same approach for non-EoE EGIDs. Instead, they need to understand which part of the gut to target and adapt their advice to patients accordingly. The authors suggest:

• To target the stomach, patients will need to open enteric-coated budesonide capsules, crush the granules inside, and solubilise them in liquid or applesauce.
• To target the proximal small intestine, patients should open enteric-coated budesonide capsules and swallow the granules inside.
• To target the distal small intestine, patients should swallow the capsules intact.

Due to the risks associated with long-term/repeated steroid use, the authors also highlighted several treatments that could be used as adjunctive or alternative therapies:

• Mast cell stabilisers (e.g., cromolyn sodium and ketotifen)
• Empiric elimination diets or elemental diets

Suggested treatment algorithm

To help doctors prescribe the right treatment to patients more quickly, the authors suggested a treatment algorithm based on current research and practices.

The authors suggested this treatment algorithm to help HCPs better treat and manage EGIDs.

Underpinning this algorithm is the idea that treatment choices should be based on which part(s) of the gut are affected, the disease severity, and patients’ goals for their own care.

Monitoring

All EGIDs are chronic conditions, which means they’ll need to be monitored throughout a patient’s life to ensure treatments are working and to catch any changes early.

The authors note that the most common approach is to perform routine endoscopies with biopsies, as peripheral eosinophilia is only present in some non-EoE EGID cases. In those patients who do present with raised peripheral eosinophilia, this may be used as an additional tool to help monitor the condition.

The review also emphasises that histologic remission and symptomatic remission don’t always occur together. Instead, patients may achieve one but not the other, underscoring the importance of monitoring both histologic signs and patient-reported symptoms.

Conclusion

Whilst knowledge gaps remain in our understanding of non-EoE EGIDs, we’re reaching a point where standardised nomenclature, diagnostic guidelines, and treatment algorithms are possible.

In particular, the review highlights that:

• Our understanding of non-EoE EGIDs has evolved, leading to a change in nomenclature.
• Disease presentation can look very different depending on which parts of the gut are affected and the depth of involvement. Making diagnoses and treatment recommendations as specific as possible is important for ensuring patients receive the right care.
• Paediatric diagnostic guidelines are now available, and guidelines for adults are in development, helping to streamline the diagnostic process.
• Effective treatment requires regular monitoring of disease activity to make sure treatments are working.
• Corticosteroids have long been an important part of treatment, but they should be administered differently depending on which EGID a patient has.
• Biologics will be the future of treatment, with several clinical trials already underway.

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References

Lam AY & Gonsalves N. Eosinophils Beyond the Esophagus: A Review of Non-EoE Eosinophilic Gastrointestinal Diseases. Gastroenterology & Hepatology (New York). 2025 Aug;21(8):511-519. PMID: 40894984; PMCID: PMC12397780.

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