Eosinophilic Oesophagitis Endoscopic Reference Score (EREFS)
Validated endoscopic scoring system for eosinophilic oesophagitis (EoE). Assesses 5 endoscopic features: Exudates, Rings, Oedema, Furrows, and Strictures. Score 0-9. Higher score = more active EoE. Used to monitor treatment response (dietary elimination, proton pump inhibitors, topical steroids, dupilumab). Developed by Hirano et al. 2013.
Score interpretation
EREFS 0-2 -- endoscopic remission; low activity EoE
→ Confirm histological remission on biopsy (less than 15 eosinophils per high power field is the standard histological remission threshold); if histological remission confirmed: continue current treatment (PPI, topical steroid such as swallowed fluticasone or budesonide oral dispersion, or dietary elimination therapy); monitor symptoms with PRO (patient-reported outcomes) instruments; endoscopic and histological assessment every 1-2 years on maintenance therapy; if symptoms recur: repeat endoscopy; do not discontinue treatment abruptly (high relapse rate).
EREFS 3-5 -- active EoE endoscopically; treatment review required
→ Review treatment compliance and adequacy; if on PPI: check dosing (omeprazole 40 mg BD or equivalent) and ensure given before meals; if on dietary elimination: review adherence, consider 6-food elimination diet (milk, wheat, egg, nuts, seafood, soy); topical steroids: swallowed budesonide oral dispersion 2 mg OD (Jorveza) or fluticasone 440-880 mcg swallowed (not inhaled); assess for new allergen exposure; consider escalation to dupilumab (biologic IL-4/IL-13 inhibitor, NICE TA850) if refractory to PPI and topical steroids; dilation of symptomatic strictures by experienced endoscopist; allergy testing/referral; gastroenterology or specialist EoE clinic review.
EREFS 6-9 -- severe active EoE; significant inflammation and remodelling
→ Urgent EoE specialist review; aggressive treatment intensification; if not on biologic therapy: assess eligibility for dupilumab (NICE TA850 -- indicated for relapsed/refractory moderate-severe EoE in adults aged 12 or above); if stricture causing food impaction: oesophageal dilation under fluoroscopic guidance or endoscopically by experienced team (risk of perforation -- informed consent); combination therapy: dietary elimination plus topical steroids; consider short course of systemic steroids if severe symptoms (prednisolone 1 mg/kg/day for 4-6 weeks -- bridges to maintenance); food impaction management: emergency endoscopy with gentle push technique; MDT with allergologist, dietitian, and gastroenterologist.
Interpretation bands for the EREFS Score. Apply clinical judgement and local guidance.
References
- Hirano I et al. Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system. Gut. 2013;62(4):489-495.
- NICE TA850. Dupilumab for treating eosinophilic oesophagitis. NICE. 2023.
Related
Curated clinical cross-links plus same-class fallbacks.
- Dupilumab · Biologic (IL-4 / IL-13 receptor antagonist)
- Dupilumab (CRSwNP) · IL-4Rα Inhibitor (Anti-IL-4/IL-13)
- Benralizumab · Anti-IL-5 receptor alpha monoclonal antibody (anti-eosinophilic biologic)
- Dupilumab (Moderate-Severe Asthma) · Anti-IL-4/IL-13 receptor alpha monoclonal antibody (type 2 inflammation biologic)
- Mepolizumab (Eosinophilic GPA) · Biologic — Anti-IL-5 Monoclonal Antibody
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.