Adult eosinophilic esophagitis patients diagnosed by food impaction are paucisymptomatic at index gastroscopy

Background: Eosinophilic esophagitis (EoE) frequently presents with dysphagia or food impaction (FI), although gastroesophageal reflux-like (GER-like) symptoms may also occur. Whether EoE patients diagnosed after an FI event may present esophageal symptoms before diagnosis that could raise clinical suspicion remains unclear. This study aimed to assess differences in symptoms occurrence before EoE diagnosis, endoscopic, and histological activity, and diagnostic delay, between patients diagnosed after an FI event and those diagnosed with no FI (NFI patients). Methods: A retrospective study was conducted, including consecutive adult EoE patients (May 2023–February 2025). EoE was defined by a peak eosinophil count (PEC) ≥ 15 eos/high-powered field. All patients were evaluated within 2 weeks of diagnosis, and symptoms occurrence before EoE diagnosis was assessed using a structured questionnaire. FI and NFI patients were compared in terms of symptoms occurrence, clinical, endoscopic, and histological features, and diagnostic delay. Results: 57 EoE patients (73.7% male; mean age 38.4 ± 15.0 years) were included. Among them, 19 (33.3%) were diagnosed after an FI event, and 38 (66.7%) in the absence of an FI event. No differences were observed in terms of gender, age, and allergic comorbidities. Prior proton pump inhibitor use was more frequently observed in NFI patients (65.8% vs. 36.8%, P = 0.0502). FI patients had a significantly longer diagnostic delay (14.4 ± 12.1 vs. 6.4 ± 7.3 years, P = 0.0030), and they more frequently reported the absence of esophageal symptoms before EoE diagnosis (47.4% vs. 2.6%, P = 0.0001). Before EoE diagnosis, dysphagia, heartburn, and reflux-like symptoms were significantly less frequent in FI patients (47.4% vs. 89.5%, P = 0.001; 15.8% vs. 63.2%, P = 0.0008; and 26.3% vs. 63.2%, P = 0.0119, respectively). The mean EoE Endoscopic Reference Score was higher in FI patients (5.5 ± 1.4 vs. 3.6 ± 2.1, P = 0.0008). EoE patients diagnosed after an FI event seem to be paucisymptomatic before EoE diagnosis, despite showing higher endoscopic activity, suggesting the need for greater awareness among clinicians of symptoms that may raise suspicion of EoE.