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Eosinophilic oesophagitis (EO) is an increasingly recognised condition in adults presenting with dysphagia and chest pain. Although this condition is well recognised and described in paediatric patients, it is under recognised in adults. There appears to have been a general lack of desire among adult gastroenterologists to take biopsy specimens from the “normal” oesophagus. The established diagnostic criterion of EO is a dense infiltration of the epithelium with eosinophils (>15/high power field). Distal oesophageal biopsy alone may miss the diagnosis of EO as eosinophil infiltration is not uniform. Therefore, biopsies should be obtained from the distal and mid-oesophagus. Several endoscopic features such as small calibre oesophagus, white vesicles or papules, proximal stenosis, and rings have been associated with EO. Tearing or even perforation of the oesophagus can occur with simple passage of the endoscope even in the absence of overt rings. Endoscopic findings can be normal or very subtle in these patients, and the findings can easily be missed during endoscopy.

Therefore, in patients undergoing evaluation for dysphagia, caution should be exercised even in the macroscopically normal oesophagus. Careful inspection is required both on insertion and withdrawal of the endoscope.

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