Paediatric-onset versus adult-onset eosinophilic oesophagitis: distinct atopic endotypes and clinical manifestations

Background and aim Eosinophilic oesophagitis (EoE) is an emerging type 2 inflammatory disorder. We aimed to compare clinical and atopic profiles of paediatric-onset and adult-onset EoE. Methods We performed a retrospective cohort study using a database encompassing over five million individuals. Patients diagnosed with EoE between 2000 and 2025 were stratified by age at diagnosis: paediatric (<18 years) and adult (≥18 years). Demographic, laboratory, comorbidity and treatment data were extracted. Matched analyses were performed. Results Among 2496 patients with EoE, 1609 (64.5%) had paediatric-onset and 887 (35.5%) adult-onset. Compared with adult-onset, paediatric-onset patients exhibited higher rates of asthma (34.4% vs 28%, p<0.001), atopic dermatitis (41.2% vs 16.3%, p<0.001) and food allergy (34.4% vs 5.9%, p<0.001), along with greater peripheral eosinophilia (median 0.49 vs 0.30 K/µL, p<0.001). Adult-onset patients more frequently had allergic rhinitis (38.9% vs 30.1%<0.001) and nasal polyps (4.7% vs 0.6%, p<0.001). Findings persisted in matched analyses, with paediatric-onset patients showing significantly more asthma, food allergies and higher eosinophil counts. Conclusions Paediatric-onset and adult-onset EoE represent clinically distinct endotypes. Paediatric disease aligns with food-triggered, systemic atopy, while adult disease is more strongly linked to aeroallergen sensitisation and nasal polyposis. Recognising these divergent pathways is essential for tailored diagnostic and therapeutic strategies.