Eosinophilic Esophagitis in the Middle East: Insight From a Comprehensive Systematic Review.

Background: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease of the esophagus, defined by esophageal dysfunction and dense eosinophilic infiltration (≥ 15 eosinophils per HPF) in biopsies, after exclusion of other causes. While its global incidence is rising, data from the Middle East remain limited and fragmented. This systematic review aims to comprehensively synthesize available evidence on EoE in Middle Eastern populations, focusing on clinical presentations, allergic comorbidities, diagnostic practices, histological and endoscopic findings, and management strategies. Methods: A systematic search of PubMed, Scopus, Embase, and Web of Science was conducted through July 2025. Studies were included if they reported original data on EoE patients from Middle Eastern countries, describing demographics, clinical features, diagnosis, or management. Data extraction and quality appraisal were performed independently by two reviewers, using Joanna Briggs Institute (JBI) tools. Results: Sixty seven studies comprising 2870 EoE patients from 11 Middle Eastern countries were included. A pronounced male predominance was observed (male-to-female ratios: approximately 2:1 in adults, 2.5:1 in children). Clinical presentations mirrored global patterns, with dysphagia and food impaction as predominant symptoms. Allergic comorbidities were commonly reported. Diagnostic criteria were consistent, but underdiagnosis and misclassification were noted. Histological and endoscopic findings were broadly in line with international data, though mucosal remodeling and strictures were frequently observed, suggesting diagnostic delays. Management approaches included the use of PPIs, corticosteroids, dietary elimination, and, in selected cases, dupilumab. Conclusions: Middle Eastern EoE patients display clinical features, comorbidities, and management patterns like those seen globally. Unique regional aspects such as dietary exposures, allergic profiles, and diagnostic challenges highlight the need for improved clinician awareness and standardized diagnostic protocols.