This nationwide survey represents the first investigation of how suspected or known EoE is managed by Austrian endoscopists and demonstrates a substantial heterogeneity in management. The following main findings emerge: (1) most endoscopists, even though surgeons less often, obtain biopsies even in a normal appearing esophagus in patients with dysphagia; (2) the approved budesonide orodispersible tablet is the most preferred first-line medication in a new diagnosis of EoE; (3) there exists a hesitancy against a maintenance therapy and follow-up rates with endoscopy and histology are low.

Diagnostic delay in EoE has not changed in the last decades and is around 4 years [8]. As patient-dependent delay is difficult to address, it is even more important that the physician-dependent delay is as short as possible. An endoscopist encounters a patient with an unknown EoE either at the emergency department with an EFI or in the case of an upper endoscopy due to esophageal symptoms. Therefore, it is of utmost importance that all patients with esophageal symptoms, especially dysphagia, and patients with an EFI should undergo biopsies following an adequate protocol (at least 6 biopsies) regardless of the endoscopic appearance of the esophagus [4, 9]. In comparison to a survey conducted in Germany some years ago, a higher rate of respondents in Austria (85%) obtains biopsies in patients with dysphagia and an endoscopically normal appearing esophagus. However, although guidelines recommend taking at least 5–6 biopsies of different locations [4], only 50% of endoscopists indicate to obtain more than 4 biopsies. On the one hand, it is affirmative to see that there is increased awareness regarding EoE resulting in a high number of patients that will be biopsied, but on the other hand it would be desirable if sufficient biopsies were taken in these patients in order not to miss EoE due to the patchy character of the disease.

Similar to a survey conducted in Europe and the USA [3], many non-EoE experts are unaware of the importance of taking biopsies at the time of esophageal food impaction (EFI). Nearly 50% of endoscopists in Austria indicate not to take biopsies during the emergency endoscopy in case of EFI, but to start a PPI and postpone the biopsies to a follow-up endoscopy. Although this approach may be justified because of real-life obstacles (patient often not fasting and no endoscopy nurse available), it goes along with problems that should be avoided. Patients without having had biopsies at the index endoscopy will be lost to follow-up in up to 80% of cases [10] and most of these patients are likely to be left with an undiagnosed EoE [11]. Furthermore, if PPI are not stopped before the follow-up endoscopy, it will mask EoE [12] resulting in patients with a missed diagnosis.

Nowadays, a budesonide orodispersible tablet is the only approved drug for the treatment of EoE in Europe. Nevertheless, PPI are by far the most prescribed drug in patients with EoE in many countries in Europe [13]. It is hypothesized that the orodispersible tablet is favored by the large majority as first-line therapy in Austria due to the fact that the data for induction therapy are very convincing [14, 15] and reimbursement, at least for the first months, is covered by the health insurance in Austria.

After 12 weeks of induction therapy, guidelines recommend an endoscopy with biopsies to assess mucosal healing or at least histologic response [4]. Due to the discordance between symptoms and inflammation, a symptom-based follow-up is not appropriate [16]. However, in contrast to Germany [2], where 84.6% of gastroenterologists monitor patients with endoscopy and histology after initiation of therapy, only 65% of respondents in Austria follow these guidelines.

As EoE is a chronic disease with a progressive disease course in the majority of patients and has a 90% relapse rate after cessation of therapy [17], a long-term treatment is highly important and follow up is needed on a regular basis. Not in line with recommendations, barely 40% percent of responders would continue the initiated therapy as maintenance therapy. Interestingly, there was a significant difference between gastroenterologists and surgeons (44% vs. 19%) pointing out that surgeons have a greater reluctance to prescribe a maintenance treatment. The reason of this hesitancy against a long-term therapy in a known chronic inflammatory gastrointestinal disease is ambiguous. Whether a lack of knowledge of the chronic nature of disease, the scepticism towards Swallowed topical corticosteroids (STC) or missed insurance coverage for maintenance treatment of the approved medication in EoE is responsible for this finding, cannot be answered. It must be emphasized that in patients treated with the approved orodispersible tablet there is no safety signal and sustained efficacy up to 96 weeks of maintenance treatment [18]. Furthermore, real-life data with other STC (mostly fluticasone) from Switzerland confirms efficacy and safety over many years [19].

Although scientific data demonstrate the importance of a follow-up every 12–24 months [20, 21], the literature regarding the adequate time interval for performing EGD in patients with stable disease is unknown. Although a regular and close follow-up (at least every 2 years) is advocated by most experts [9, 22], only half of respondents indicate to schedule regular check every 1–2 years.

Our study has several strengths and also some limitations. This is the first survey to investigate the clinical practice pattern of Austrian endoscopists regarding suspected and known EoE. We were not able to determine the exact response rate because the survey was not sent directly to the participants but distributed by the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and members were allowed to forward the link to participate. The ÖGGH has 1230 members including not only endoscopists, but also physicians not certified in endoscopy, retired physicians and physicians in training. The survey was sent out to all 1230 ÖGGH members originally. As only certified endoscopists were allowed to participate in the survey, our response rate may be similar to the survey conducted in Germany with 413 respondents [2].

In conclusion, our survey demonstrates that endoscopists in Austria have a high awareness of EoE in patients with dysphagia, but there is a wide heterogeneity of clinical practice pattern in terms of biopsy protocol, long-term treatment and follow-up management in patients with EoE. Our results may help to indicate where there is room for improvement to ameliorate adherence to the guidelines and ultimately improve the management of patients with EoE.