Eosinophilic Oesophagitis

Eosinophilic oesophagitis (eosinophilic oesophagitis) seems to be an allergic inflammatory condition of the oesophagus that results from eosinophils, a type of white blood cell, accumulating within the mucosa. The reason they accumulate within the surface of the oesophagus is still a subject of research but the study discussed below suggests the food antigens have an important tole. Symptoms are swallowing difficulty, food impaction, and heartburn. Eosinophilic oesophagitis (EoE) was first described in children but occurs in adults as well. EoE can be associated with the development of oesophageal strictures, and often presents with food impaction, dysphagia, poor weight gain, vomiting and decreased appetite. In addition, young children with eosinophilic oesophagitis may present with feeding difficulties. It is more common in males, and affects both adults and children. Eosinophil oesophagitis (EoE) has been regarded as a food allergic reaction to food antigens because of increasing evidence for disease remission with dietary elimination. Although swallowed corticosteroids can be helpful, disease relapse often occurs when they are stopped. Dietary elimination therapy may be more effective if specific food groups can be identified if avoided. The study discussed below demonstrates the potential use of dietary restriction.

Dietary Elimination Therapy Is an Effective Option for Adults With Eosinophilic Esophagitis Wolf WA, Jerath MR, Sperry SL, Shaheen NJ, Dellon ES. Clin Gastroenterol Hepatol. 2014;12:1272-1279.

 Study Summary This study has demonstrated that changes in diet with systematic elimination of certain food groups can be as effective intervention in patients with EoE. This was a retrospective cohort study from a database of adults with EoE diagnosed using consensus guidelines. Adults underwent dietary food group exclusion either by using targeted elimination identified through allergy skin prick testing or patient report or by following a six-food group elimination diet (SFED), which involved removal of dairy, wheat, soy, nuts, seafood, and eggs. Patients were taken off steroids for 4 weeks before starting the dietary therapy. If clinical improvement was observed with SFED, one food group was sequentially reintroduced every 6 weeks.

A gastroscopy with biopsies was performed until all food groups were reintroduced, and the foods that led to a recurrence of EoE were identified. Symptom improvement, endoscopic appearance improvement, and biopsy resolution to less than 15 eosinophils/high-power field (eos/HPF) are shown below;

Resolution Criteria Targeted Elimination Six-Food Elimination Diet

Symptom improvement 68% 78%

Endoscopic improvement 53% 56%

Histologic improvementa 32% 56%

In patients who responded with eosinophil counts lower than 15 eos/HPF and underwent food reintroduction, symptom recurrence was highest with dairy (44%) and eggs (44%), followed by wheat (22%) and shellfish, legumes, or nuts (11% each).

Viewpoint ; Identifying and directing therapy toward the food group responsible should lead to sustainable benefit, although long-term follow-up is required. The histologic improvement associated with the SFED was non-significantly better, but it raises the question of whether the routine referral of these patients to allergy testing is needed. Moreover, this analysis preceded the recent categorization of proton pump inhibitor (PPI)-responsive eosinophilia. Most data support the finding that four food groups (milk, eggs, wheat, and nuts) are the most likely food antigens identified in these patients. A recent study showed that EoE in adults is associated with immunoglobulin (Ig)G4 and not mediated by IgE. Serum-specific IgE allergy testing (the radioallergosorbent test) has been entirely replaced by nonradioactive enzyme-linked immunosorbent IgE assay testing, used in building elimination diets, and has no support for use in adults. Although atopic patch testing assesses the presence of non-IgE cell-mediated food reactions, I favor the food elimination diet without allergy testing or referral to an allergist as a more pragmatic approach.

Conclusion This study supports the role of food antigens in the pathogenesis of EoE. Elimination of specific food groups (milk, egg, wheat, nuts, and shellfish) has been highly effective in resolving clinical and histologic endpoints in EoE. Allergy testing may become a standard recommendation to guide dietary intervention, in particular for patients who do not respond to PPIs.

CMH.