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The authors thank Dr El-Matary for his interest in our paper and for bringing several important questions to our attention.1Schoepfer A.M. et al.Gastroenterology. 2013; 145: 1230-1236Abstract Full Text Full Text PDF PubMed Scopus (476) Google Scholar Dr El-Matary reports on a subset of pediatric patients who, upon esophagogastroduodenoscopy, present with endoscopic and histologic findings compatible with eosinophilic esophagitis (EoE) but are asymptomatic. According to the current definition, these patients would not fulfil the diagnostic criteria for EoE, because the disease is defined as clinicopathologic entity.2Liacouras C.A. et al.J Allergy Clin Immunol. 2011; 128: 3-20.e6Abstract Full Text Full Text PDF PubMed Scopus (1590) Google Scholar As such, the presence of EoE-related symptoms is mandatory for establishment of the diagnosis. Thus, all patients included in the Swiss EoE database had EoE-related symptoms at the time of diagnosis. We can think of 3 possible diagnostic scenarios, when examining these asymptomatic patients with endoscopic and histologic features reminiscent of EoE, as described by Dr El-Matary. The first is that these patients have EoE, but that their symptoms are mild and perhaps not captured by a routine evaluation. The severity of dysphagia, the leading EoE symptom of adolescent and adult patients, strongly depends on the consistency of the ingested food. As such, the consistency of the ingested food should be taken into account when assessing EoE-related symptoms. Furthermore, behavioral adaptations to dysphagia, such as drinking fluids to help the food go down, avoidance of certain food consistencies (eg, meat), food modification (eg, cutting food into small pieces), or an increased time required to eat certain foods, are strategies that are frequently used by the patients to effectively “disguise” dysphagia.3Schoepfer AM, et al. Gastroenterol Clin North Am, In Press.Google Scholar Typically, a considerable proportion of patients who report being asymptomatic, when the physician enquires about presence of EoE-related symptoms in general, report problems when being specifically asked about behavioral adaptations to dysphagia or issues occurring while ingesting high-consistency foods. The second scenario is that these patients are indeed asymptomatic. In this case, it is possible that we are dealing with a cohort of “latent” EoE patients that could become symptomatic later in life. The third scenario is that these patients represent a distinct, new phenotype of EoE. It would be interesting to learn more about procedures with which gastroesophageal reflux disease was excluded in these patients, the type of endoscopic and histologic features these patients present with, and whether these patients have allergies or else are affected by concomitant allergic diseases. The chronic nature of inflammation and persistent symptoms are key features of EoE.4Straumann A. et al.Gastroenterology. 2003; 125: 1660-1669Abstract Full Text Full Text PDF PubMed Scopus (647) Google Scholar It is well-documented that an unbridled eosinophilic inflammation of the esophagus leads to remodeling and stricture formation.1Schoepfer A.M. et al.Gastroenterology. 2013; 145: 1230-1236Abstract Full Text Full Text PDF PubMed Scopus (476) Google Scholar, 4Straumann A. et al.Gastroenterology. 2003; 125: 1660-1669Abstract Full Text Full Text PDF PubMed Scopus (647) Google Scholar, 5Dellon E.S. et al.Gastrointest Endosc. 2014; 79: 577-585Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar, 6Kagalwalla A.F. et al.J Allergy Clin Immunol. 2012; 129: 1387-1396Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar, 7Mishra A. et al.Gastroenterology. 2008; 134: 204-214Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar Indeed, if the eosinophilic inflammation persists over time in the subset of patients described by Dr El-Matary, then these patients are at risk of developing strictures. At present, we would not recommend treating asymptomatic patients with either diet or anti-eosinophil medication.8Dellon E.S. et al.Am J Gastroenterol. 2013; 108: 679-692Crossref PubMed Scopus (808) Google Scholar However, we would advocate long-term endoscopic follow-up to monitor for occurrence of strictures that might lead to food bolus impactions.8Dellon E.S. et al.Am J Gastroenterol. 2013; 108: 679-692Crossref PubMed Scopus (808) Google Scholar In addition, we think that the findings observed by Dr El-Matary are clinically important, and we would like to encourage him to publish on this distinct patient subset. Natural History of Eosinophilic Esophagitis in Asymptomatic PatientsGastroenterologyVol. 146Issue 5PreviewI read with great interest the article by Schoepfer et al.1 In their cohort, a median delay of 6 years in the diagnosis of eosinophilic esophagitis (EoE) was associated with increased prevalence of fibrotic strictures. More than 85% of patients with a delay in the diagnosis of EoE had fibrotic esophageal strictures on endoscopy.1 This paper is very important because it does help our understanding of the natural history and long-term complications of untreated EoE. However, it seems that all patients recruited in the study were symptomatic. Full-Text PDF