Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults.

doi:10.1177/2050640616689525

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Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults.

Journal Article•DOI•

Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults.

Alfredo J. Lucendo, Javier Molina-Infante, Ángel Arias, Ulrike von Arnim¹, Albert J. Bredenoord, Christian Bussmann, Jorge Amil Dias, Mogens Bove, Jesús González-Cervera, Helen Larsson, Stephan Miehlke, Alexandra Papadopoulou², Joaquín Rodríguez-Sánchez, Alberto Ravelli³, Jukka Ronkainen⁴, Cecilio Santander, Alain M. Schoepfer⁵, Martin Storr, Ingrid Terreehorst, Alex Straumann, Stephen Attwood⁶ - Show less +17 more•Institutions (6)

Otto-von-Guericke University Magdeburg¹, National and Kapodistrian University of Athens², Boston Children's Hospital³, University of Oulu⁴, University Hospital of Lausanne⁵, Durham University⁶

23 Jan 2017-United European gastroenterology journal (Sage Publications Ltd.)-Vol. 5, Iss: 3, pp 335-358

TL;DR: Evidence-based recommendations for EoE diagnosis, treatment modalities, and patients’ follow up are proposed in the guidelines, and expert opinion and best clinical practice are provided.

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Abstract: IntroductionEosinophilic esophagitis (EoE) is one of the most prevalent esophageal diseases and the leading cause of dysphagia and food impaction in children and young adults. This underlines the importance of optimizing diagnosys and treatment of the condition, especially after the increasing amount of knowledge on EoE recently published. Therefore, the UEG, EAACI ESPGHAN, and EUREOS deemed it necessary to update the current guidelines regarding conceptual and epidemiological aspects, diagnosis, and treatment of EoE.MethodsGeneral methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used in order to comply with current standards of evidence assessment in formulation of recommendations. An extensive literature search was conducted up to August 2015 and periodically updated. The working group consisted of gastroenterologists, allergists, pediatricians, otolaryngologists, path...

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Journal Article•DOI•

Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference.

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Evan S. Dellon¹, Chris A. Liacouras², Javier Molina-Infante, Glenn T. Furuta³, Jonathan M. Spergel², Noam Zevit⁴, Stuart J. Spechler⁵, Stephen Attwood⁶, Alex Straumann, Seema S. Aceves⁷, Jeffrey A. Alexander⁸, Dan Atkins³, Nicoleta C. Arva⁹, Carine Blanchard¹⁰, Peter A Bonis¹¹, Wendy Book, Kelley E. Capocelli¹², Mirna Chehade¹³, Edaire Cheng¹⁴, Margaret H. Collins¹⁵, Carla M. Davis¹⁶, Jorge Amil Dias, Carlo Di Lorenzo¹⁷, Ranjan Dohil⁷, Christophe Dupont¹⁸, Gary W. Falk², Cristina Targa Ferreira¹⁹, Adam T. Fox, Nirmala Gonsalves⁹, Sandeep K. Gupta²⁰, David A. Katzka⁸, Yoshikazu Kinoshita²¹, Calies Menard-Katcher³, Ellyn Kodroff, David C. Metz², Stephan Miehlke, Amanda B. Muir², Vincent A. Mukkada¹⁵, Simon Murch²², Samuel Nurko²³, Yoshikazu Ohtsuka²⁴, Rok Orel²⁵, Alexandra Papadopoulou²⁶, Kathryn A. Peterson²⁷, Hamish Philpott²⁸, Philip E. Putnam¹⁵, Joel E. Richter²⁹, Rachel Rosen²³, Marc E. Rothenberg¹⁵, Alain M. Schoepfer³⁰, Melissa Scott, Neil Shah³¹, Javed Sheikh³², Rhonda F. Souza⁵, Mary Jo Strobel, Nicholas J. Talley³³, Michael F. Vaezi³⁴, Yvan Vandenplas³⁵, Mario C. Vieira³⁶, Marjorie M. Walker³³, Joshua B. Wechsler³⁷, Barry K. Wershil³⁷, Ting Wen¹⁵, Guang Yu Yang⁹, Ikuo Hirano⁹, Albert J. Bredenoord³⁸ - Show less +62 more•Institutions (38)

University of North Carolina at Chapel Hill¹, University of Pennsylvania², University of Colorado Denver³, Tel Aviv University⁴, Baylor University Medical Center⁵, Durham University⁶, University of California, San Diego⁷, Mayo Clinic⁸, Northwestern University⁹, Nestlé¹⁰, Tufts University¹¹, Boston Children's Hospital¹², Icahn School of Medicine at Mount Sinai¹³, University of Texas Southwestern Medical Center¹⁴, Cincinnati Children's Hospital Medical Center¹⁵, Baylor College of Medicine¹⁶, Nationwide Children's Hospital¹⁷, University of Paris¹⁸, University of Health Sciences Antigua¹⁹, University of Illinois at Urbana–Champaign²⁰, Shimane University²¹, University Hospitals Coventry and Warwickshire NHS Trust²², Harvard University²³, Juntendo University²⁴, University of Ljubljana²⁵, National and Kapodistrian University of Athens²⁶, University of Utah²⁷, University of Adelaide²⁸, University of South Florida²⁹, University of Lausanne³⁰, University College London³¹, Kaiser Permanente³², University of Newcastle³³, Vanderbilt University³⁴, Vrije Universiteit Brussel³⁵, Federal University of Paraná³⁶, Children's Memorial Hospital³⁷, University of Amsterdam³⁸

01 Oct 2018-Gastroenterology

TL;DR: An updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement, and the evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EOE than as a diagnostic criterion.

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621 citations

Cites background or methods from "Guidelines on eosinophilic esophagi..."

...Anti-inflammatory effects of PPIs: PPIs may decrease esophageal eosinophilia in EoE....
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...%) confounds efforts to differentiate GERD and EoE.46 Adding PPI-REE to this discussion is a further complexity....
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...Hypereosinophilic syndrome, non-EoE eosinophilic gastrointestinal disorders, achalasia, Crohn’s disease, infections, connective tissue disorders, and drug hypersensitivity reactions (Table 3) have been associated with esophageal eosinophilia but are uncommon or present with clinical features that readily distinguish them from EoE.4,11 EoE is finally diagnosed after evaluation shows that there are no other causes substantially contributing to symptoms and esophageal eosinophilia....
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...In some patients, because it may be difficult to ascertain the precise contribution of GERD to esophageal eosinophilia, clinical evaluation for GERD could be undertaken in concordance with published GERD guidelines before a definitive diagnosis of EoE.51,52 Available studies examining the distinction between GERD and EoE (Supplementary Material 3) are limited by study design, absence of comprehensive testing modalities, and the lack of a criterion standard to define either condition....
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...It is beyond the scope of this article to provide comprehensive recommendations for the treatment of EoE.(29,31) To date, no prospective, double-blind, randomized trial has compared the efficacies of steroids to PPI or diet to PPI....
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Journal Article•DOI•

Systematic review with meta‐analysis: the incidence and prevalence of eosinophilic oesophagitis in children and adults in population‐based studies

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Ángel Arias, Isabel Pérez-Martínez¹, José María Tenías, Alfredo J. Lucendo•Institutions (1)

University of Oviedo¹

01 Jan 2016-Alimentary Pharmacology & Therapeutics

TL;DR: The recognition of eosinophilic oesophagitis (EoE) has risen sharply, but its current epidemiology is still under debate.

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Abstract: Summary Background The recognition of eosinophilic oesophagitis (EoE) has risen sharply, but its current epidemiology is still under debate. Aim To estimate accurately the prevalence and incidence rates of EoE, by a systematic review and meta-analysis. Methods MEDLINE, EMBASE and SCOPUS databases were searched for population-based studies on the epidemiology of EoE. Pooled incidence and prevalence rates, male:female and children:adult ratios, and geographical and temporal variations were calculated with random-effects models. Results The search yielded 1334 references; the final quantitative summary included 13 population-based studies from North America, Europe and Australia, with the results showing high heterogeneity. The pooled EoE incidence rate was 3.7/100 000 persons/year [95% confidence interval (CI): 1.7–6.5] and was higher for adults (7; 95% CI: 1–18.3) than for children (5.1; 95% CI: 1.5–10.9). The pooled prevalence of EoE was 22.7 cases/100 000 inhabitants (95% CI: 12.4–36), rising to 28.1 (95% CI: 13–49) when studies with a lower risk of bias were considered; prevalence was higher in adults than in children (43.4; 95% CI: 22.5–71.2 vs. 29.5; 95% CI: 17.5–44.7, respectively), and in American compared to European studies. A steady rise in EoE incidence and prevalence rates was observed upon comparison of studies conducted before and after 2008. No significant publication bias was found. Conclusions Eosinophilic oesophagitis is an increasingly common diagnosis in North America and Europe. The population-based incidence and prevalence of eosinophilic oesophagitis vary widely across individual studies, probably due to variations in diagnosis and risk of bias of research. More prospective, large-scale, multicenter studies are needed to evaluate reported data.

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259 citations

Journal Article•DOI•

Pathophysiology of Eosinophilic Esophagitis.

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Kelly M. O’Shea¹, Seema S. Aceves², Evan S. Dellon³, Sandeep K. Gupta⁴, Jonathan M. Spergel⁵, Glenn T. Furuta⁶, Marc E. Rothenberg¹ - Show less +3 more•Institutions (6)

Cincinnati Children's Hospital Medical Center¹, University of California, San Diego², University of North Carolina at Chapel Hill³, University of Illinois at Chicago⁴, University of Pennsylvania⁵, University of Colorado Denver⁶

01 Jan 2018-Gastroenterology

TL;DR: Understanding these processes is opening the way to better treatment based on disrupting allergic inflammatory and type 2 cytokine-mediated responses, including anti-cytokine therapeutics and dietary therapy.

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257 citations

Journal Article•DOI•

Efficacy of Budesonide Orodispersible Tablets as Induction Therapy for Eosinophilic Esophagitis in a Randomized Placebo-Controlled Trial

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Alfredo J. Lucendo, Stephan Miehlke¹, Christoph Schlag², Michael Vieth, Ulrike von Arnim³, Javier Molina-Infante, Dirk Hartmann, Albert J. Bredenoord, Constanza Ciriza de los Ríos, Stefan Schubert, Stefan Brückner⁴, Ahmed Madisch, J Hayat⁵, Jan Tack⁶, Stephen Attwood⁷, Ralph Mueller, Roland Greinwald, Alain M. Schoepfer⁸, Alex Straumann, Tim Vanuytsel, Hubert Louis, Carmen Musala, Dorothea Frederking, Monther Bajbouj, Simon Nennstiel, Renate Schmelz, Schmelz Heimerl, Anna Magdalena Stephan, Christiane Fibbe, Niels Liedtke, Jutta Keller, Ulrich Rosien, Sebastian Haag, Arne Schneider, Christoph Schmöcker, Hendrik Buchholz, Frank Lammert, Markus Casper, Matthias C. Reichert, Dirk Sommer, Hubert Mönnikes, Miriam Stengel, Marco Schmidtmann, Michaela Müller, Alexander J. Eckardt, Till Wehrmann, Peter Armerding, Wolf Peter Hofmann, Thomas Liceni, Arne Kandulski, Jochen Weigt, Norbert Börner, Anne Lutz-Vorderbrügge, Jörg Albert, Stefan Zeuzem, Irina Blumenstein, Kathrin Sprinzl, Johannes Hausmann, Arjan Bredenoord, Marijn J. Warners, Alfredo Lucendo Villarin, Ángel Arias, Maria Ángeles Tejero Bustos, María Jesús Carrillo Ramos, José María Olalla Gallardo, Rocío Juárez Tosina, José Luis Zamorano, Cecilio Santander Vaquero, Sergio Casabona Francés, Teresa Pérez, Teresa Rodriguez, Fernando Canga Rodríguez-Valcárcel, Isabel Castel de Lucas, Antonia Perelló Juan, Merce Barenys, Carlos Pons, Isabel Perez Martinez, M. Eugenia Lauret, Andrés Castaño García, Esmeralda Rubio, Petr Hruz, Simon Brunner, Andrew Poullis - Show less +79 more•Institutions (8)

Eppendorf (Germany)¹, Technische Universität München², Otto-von-Guericke University Magdeburg³, Dresden University of Technology⁴, National Health Service⁵, Katholieke Universiteit Leuven⁶, Durham University⁷, University Hospital of Lausanne⁸

01 Jul 2019-Gastroenterology

TL;DR: In a randomized trial of adults with active EoE, budesonide oral tablets were significantly more effective than placebo in inducing clinical and histologic remission.

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147 citations

Journal Article•DOI•

The natural course of eosinophilic esophagitis and long-term consequences of undiagnosed disease in a large cohort.

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Marijn J. Warners, Renske A B Oude Nijhuis, Laetitia R H de Wijkerslooth, Andreas J. Smout, Albert J. Bredenoord - Show less +1 more

27 Apr 2018-The American Journal of Gastroenterology

TL;DR: The natural course of EoE is investigated and the association between undiagnosed disease and the occurrence of complications over two decades in a large cohort is evaluated to assess the risk of stricture presence and progression from an inflammatory to fibrostenotic phenotype.

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111 citations

Cites background from "Guidelines on eosinophilic esophagi..."

...Nevertheless, current guidelines encourage chronic maintenance therapy in order to reduce the risk for these long-term complications [9]....
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References

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Open Access

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Journal Article•DOI•

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

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Gordon H. Guyatt¹, Andrew D Oxman, Gunn Elisabeth Vist, Regina Kunz², Yngve Falck-Ytter³, Pablo Alonso-Coello⁴, Holger J. Schünemann - Show less +3 more•Institutions (4)

McMaster University¹, University Hospital of Basel², Case Western Reserve University³, Autonomous University of Barcelona⁴

24 Apr 2008-BMJ

TL;DR: The advantages of the GRADE system are explored, which is increasingly being adopted by organisations worldwide and which is often praised for its high level of consistency.

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Abstract: Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide

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13,324 citations

"Guidelines on eosinophilic esophagi..." refers methods in this paper

...The use of GRADE (Grading of Recommendations Assessment, Development, and Evaluation) technology has been recommended in recent years as a standard tool for the development of clinical practice guides.(8) The present guide is the first one developed in EoE using this methodology....
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Book•

Group Techniques for Program Planning - A Guide to Nominal Group and Delphi Processes

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Andre L. Delbecq, Andrew H. Van de Ven, David H. Gustafson

01 Jan 1975

2,586 citations

"Guidelines on eosinophilic esophagi..." refers methods in this paper

...A full-day consensus meeting was held in Vienna, Austria, on 16 October 2016 in order to vote the statements and recommendations based on the nominal group technique.(10) The participants decided whether they considered the statement/recommendation to be adequate, based on a six-point Likert scale (1: strongly disagree; 2: quite disagree; 3: somewhat disagree; 4: somewhat agree; 5: quite agree; 6: strongly agree), and suggested changes or new ones....
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Journal Article•DOI•

Eosinophilic esophagitis: Updated consensus recommendations for children and adults

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Chris A. Liacouras¹, Glenn T. Furuta, Ikuo Hirano, Dan Atkins, Stephen Attwood, Peter A Bonis, A. Wesley Burks, Mirna Chehade, Margaret H. Collins, Evan S. Dellon, Ranjan Dohil, Gary W. Falk, Nirmala Gonsalves, Sandeep K. Gupta, David A. Katzka, Alfredo J. Lucendo, Jonathan E. Markowitz, Richard J. Noel, Robert D. Odze, Philip E. Putnam, Joel E. Richter, Yvonne Romero, Eduardo Ruchelli, Hugh A. Sampson, Alain M. Schoepfer, Nicholas J. Shaheen, Scott H. Sicherer, Stuart J. Spechler, Jonathan M. Spergel, Alex Straumann, Barry K. Wershil, Marc E. Rothenberg, Seema S. Aceves - Show less +29 more•Institutions (1)

University of Pennsylvania¹

01 Jul 2011-The Journal of Allergy and Clinical Immunology

TL;DR: A new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation.

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Abstract: Eosinophilic esophagitis (EoE) is a clinicopathologic condition of increasing recognition and prevalence. In 2007, a consensus recommendation provided clinical and histopathologic guidance for the diagnosis and treatment of EoE; however, only a minority of physicians use the 2007 guidelines, which require fulfillment of both histologic and clinical features. Since 2007, the number of EoE publications has doubled, providing new disease insight. Accordingly, a panel of 33 physicians with expertise in pediatric and adult allergy/immunology, gastroenterology, and pathology conducted a systematic review of the EoE literature (since September 2006) using electronic databases. Based on the literature review and expertise of the panel, information and recommendations were provided in each of the following areas of EoE: diagnostics, genetics, allergy testing, therapeutics, and disease complications. Because accumulating animal and human data have provided evidence that EoE appears to be an antigen-driven immunologic process that involves multiple pathogenic pathways, a new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The diagnostic guidelines continue to define EoE as an isolated chronic disorder of the esophagus diagnosed by the need of both clinical and pathologic features. Patients commonly have high rates of concurrent allergic diatheses, especially food sensitization, compared with the general population. Proved therapeutic options include chronic dietary elimination, topical corticosteroids, and esophageal dilation. Important additions since 2007 include genetic underpinnings that implicate EoE susceptibility caused by polymorphisms in the thymic stromal lymphopoietin protein gene and the description of a new potential disease phenotype, proton pump inhibitor-responsive esophageal eosinophila. Further advances and controversies regarding diagnostic methods, surrogate disease markers, allergy testing, and treatment approaches are discussed.

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1,675 citations

"Guidelines on eosinophilic esophagi..." refers background or methods in this paper

...The description of a new potential disease phenotype in 2011, termed PPIREE, was acknowledged as one of the major additions to previous knowledge.(4) It refers to patients with clinic, endoscopic and histologic features of EoE which completely remit on PPI therapy, albeit not necessarily associated to GERD....
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...Summary of evidence: When pharmacological treatment for EoE is stopped, symptoms and/or esophageal eosinophilia typically recur over a 3–6 month period.(4) However, the long-term therapeutic strategy and best maintenance doses for pharmacologic therapies are yet to be defined....
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...The efficacy of any pharmacological/dietary therapy should be checked by means of a follow-up endoscopy after a 6- to 12-week initial course.(4) In addition, all patients with fibrostenotic abnormalities (including narrow caliber esophagus <13 mm and strictures) should be offered endoscopic dilation, preferably after a trial of medical/pharmacological therapy....
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...Guidelines for the disease, which were originally written in 2007,(3) were updated in 2011 when a first formal definition of the disease was provided.(4) EoE was defined as a chronic immune/antigen-mediated disease, isolated to the esophagus, and characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation on esophageal biopsy....
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Journal Article•DOI•

Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment.

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Glenn T. Furuta¹, Chris A. Liacouras², Margaret H. Collins³, Sandeep K. Gupta⁴, Chris Justinich⁵, Phil E. Putnam³, Peter A Bonis⁶, Eric Hassall⁷, Alex Straumann⁸, Marc E. Rothenberg³ - Show less +6 more•Institutions (8)

University of Colorado Denver¹, University of Pennsylvania², Cincinnati Children's Hospital Medical Center³, Indiana University⁴, Queen's University⁵, Tufts University⁶, University of British Columbia⁷, University Hospital of Basel⁸

01 Oct 2007-Gastroenterology

TL;DR: A multidisciplinary task force of 31 physicians assembled with the goal of determining diagnostic criteria and making recommendations for evaluation and treatment of children and adults with suspected eosinophilic esophagitis (EE) provided current recommendations for care of affected patients.

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1,513 citations

Journal Article•DOI•

ACG Clinical Guideline: Evidenced Based Approach to the Diagnosis and Management of Esophageal Eosinophilia and Eosinophilic Esophagitis (EoE)

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Evan S. Dellon¹, Nirmala Gonsalves², Ikuo Hirano², Glenn T. Furuta³, Chris A. Liacouras⁴, David A. Katzka⁵ - Show less +2 more•Institutions (5)

University of North Carolina at Chapel Hill¹, Northwestern University², University of Colorado Denver³, University of Pennsylvania⁴, Mayo Clinic⁵

01 May 2013-The American Journal of Gastroenterology

TL;DR: Recommendations developed by adult and pediatric gastroenterologists are provided for the evaluation and management of patients with eosinophilic–esophageal disorders.

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944 citations