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Appanna R, Gargano D, Caputo A, De Bartolomeis F, Ricciardi L, Santonicola A, Stefanelli B, Caiazza L, Guarciariello M, D'Antonio A, D'Auria R, Conti V, Casolaro V, Iovino P. Changes in mucosal IgG4 +- and IL-10 +-cell frequencies in adults with eosinophilic esophagitis on a two-food elimination diet. Clin Immunol 2023; 257:109853. [PMID: 38013163 DOI: 10.1016/j.clim.2023.109853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
Eosinophilic esophagitis (EoE) is increasingly diagnosed in patients with dysphagia. Type-2 immunity can induce EoE histopathology via non-IgE-dependent mechanisms, possibly involving IgG4 and IL-10. To elucidate the contribution of this response to EoE pathogenesis, we examined its association with clinical and histologic endpoints in adult EoE patients given a two-food elimination diet. IgG4- and IL-10-expressing cells were counted in esophageal biopsies and serum food-specific IgG4 measured at baseline and follow-up. Variables were correlated with histologic measures of disease activity. Patients exhibited significant reduction in esophageal eosinophilia and overall histology. A significant decrease in IL-10+-cell frequencies correlated with histologic changes. In contrast, a decline in serum and esophageal IgG4, while substantial, did not correlate with IL-10+-cell frequencies or histologic parameters. These results suggest a critical role of IL-10 in EoE pathogenesis. Conversely, IgG4 expression, while reflecting exposure to food antigens, is not obviously related to EoE histopathology or IL-10 expression.
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Affiliation(s)
- Ramapraba Appanna
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | | | - Alessandro Caputo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy; San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | | | - Luca Ricciardi
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Antonella Santonicola
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy; San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Berenice Stefanelli
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Laura Caiazza
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | | | - Antonio D'Antonio
- San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Raffaella D'Auria
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Valeria Conti
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy; San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Vincenzo Casolaro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy; San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy.
| | - Paola Iovino
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy; San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy.
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Abramson L, Smeekens JM, Kulis MD, Dellon ES. Food-specific IgA levels in esophageal biopsies are not sufficiently high to predict food triggers in eosinophilic esophagitis. Immun Inflamm Dis 2023; 11:e1029. [PMID: 37773691 PMCID: PMC10523942 DOI: 10.1002/iid3.1029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is an immune-mediated disease, characterized by Th2-type inflammation linked to specific foods. No currently available allergy tests reliably identify food triggers in EoE, leading to empiric dietary elimination strategies. Recently, milk- and wheat-specific IgA in esophageal brushings were linked to clinical food triggers. In this study, we aimed to determine whether food-specific IgA from esophageal biopsies is associated with known food triggers. METHODS A prior cohort of 21 patients (median age 39 years) with confirmed EoE underwent empirical elimination diets and subsequent reintroduction of foods to determine triggers. Archived baseline biopsies were used to quantify levels of peanut-, milk-, soy-, egg-, wheat-specific and total IgA by enzyme-linked immunosorbent assay. RESULTS Overall, 13 patients (62%) responded to the dietary elimination as determined by histology (<15 eos/hpf), with milk and egg being the most common triggers. Biopsies had varying amounts of total IgA, while food-specific IgA was only detectable in 48 of 105 (46%) samples. Food-specific IgA was normalized to total IgA for each sample and stratified by whether a food was a known trigger. For all foods tested, there were no significant differences in IgA between positive and negative triggers. CONCLUSIONS Food-specific IgA in esophageal biopsies was not associated with previously identified food triggers in this cohort. Future studies comparing food-specific IgA in esophageal brushings, mucous scrapings, and biopsies from patients with known triggers will be critical to determining whether food-specific IgA may serve as a biomarker for identification of EoE triggers.
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Affiliation(s)
- Lior Abramson
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and SwallowingUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Johanna M. Smeekens
- Division of Allergy and Immunology, Department of PediatricsUNC School of MedicineChapel HillNorth CarolinaUSA
| | - Michael D. Kulis
- Division of Allergy and Immunology, Department of PediatricsUNC School of MedicineChapel HillNorth CarolinaUSA
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Esophageal Diseases and SwallowingUniversity of North CarolinaChapel HillNorth CarolinaUSA
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Carucci L, Votto M, Licari A, Marseglia GL, Berni Canani R. Food allergy: cause or consequence of pediatric eosinophilic esophagitis? Potential implications of ultraprocessed foods in prevention and management. FRONTIERS IN ALLERGY 2023; 4:1138400. [PMID: 37456790 PMCID: PMC10344695 DOI: 10.3389/falgy.2023.1138400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by eosinophilic infiltration, leading to esophageal dysfunction, inflammation, and fibrotic remodeling. In the last few decades, there has been an increased prevalence of EoE at an alarming rate in the pediatric age. The pathogenesis of EoE is still largely undefined, and this limits the definition of effective strategies for the prevention and management of this condition. EoE is considered a multifactorial disease arising from a negative interaction between environmental factors and genetic background, causing an impaired esophageal epithelial barrier with subsequent abnormal allergen exposure activating type 2 (Th2) inflammation. Food antigens have been suggested as key players in Th2 inflammation in pediatric patients with EoE, but emerging evidence suggests a potential role of other dietary factors, including ultraprocessed foods, as possible triggers for the occurrence of EoE. In this paper, we discuss the potential role of these dietary factors in the development of the disease, and we propose a new approach for the management of pediatric patients with EoE.
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Affiliation(s)
- Laura Carucci
- Department of Translational Medical Science, University of Naples “Federico II,”Naples, Italy
- ImmunoNutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples “Federico II,”Naples, Italy
| | - Martina Votto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberto Berni Canani
- Department of Translational Medical Science, University of Naples “Federico II,”Naples, Italy
- ImmunoNutritionLab at the CEINGE Advanced Biotechnologies Research Center, University of Naples “Federico II,”Naples, Italy
- European Laboratory for the Investigation of Food-Induced Diseases, University of Naples Federico II, Naples, Italy
- Task Force for Microbiome Studies, University of Naples Federico II, Naples, Italy
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Eosinophilic Esophagitis—What Do We Know So Far? J Clin Med 2023; 12:jcm12062259. [PMID: 36983260 PMCID: PMC10051236 DOI: 10.3390/jcm12062259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Eosinophilic esophagitis is a Th-2 antigen-mediated disease in which there is an influx of eosinophils to all layers of the esophagus, triggering an inflammatory response. Chronic inflammatory process causes esophageal remodeling, leading to difficulties in swallowing. Food impaction, heartburn, and chest pain are other characteristic (but not pathognomonic) symptoms in adults. Although the disease has only been described since in the early 1970s, its incidence and prevalence are rapidly growing, especially in Western countries. According to the diagnostic guidelines, there should be at least 15 eosinophils visible per high-power field in biopsies obtained from different sites in the esophagus upon endoscopy with relevant esophageal symptoms. Other diseases that can cause esophageal eosinophilia should be ruled out. Eosinophilic esophagitis treatment may be challenging; however, new methods of management have recently emerged. The currently used proton pump inhibitors, topical corticosteroids, and elimination diet are combined with biological treatment. New methods for disease diagnostics and clinical course assessment are also available. This review presents current knowledge about the disease, supported by the latest research data.
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Visaggi P, Baiano Svizzero F, Savarino E. Food elimination diets in eosinophilic esophagitis: Practical tips in current management and future directions. Best Pract Res Clin Gastroenterol 2023; 62-63:101825. [PMID: 37094908 DOI: 10.1016/j.bpg.2023.101825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/16/2023] [Indexed: 04/26/2023]
Abstract
Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated disease of the esophagus characterized by symptoms of esophageal dysfunction and an eosinophil-predominant inflammation. Seminal reports identified the role of food allergens in the pathogenesis of the disease by demonstrating that food avoidance could lead to the resolution of esophageal eosinophilia in EoE patients. Although pharmacological treatments for EoE are increasingly being investigated, the exclusion of trigger foods from the diet still represents a valuable option for patients to achieve and maintain disease remission without drugs. Food elimination diets are variegated, and one size does not fit all. Accordingly, before starting any elimination diet, patients' characteristics should be thoroughly evaluated, and a rigorous management plan should be defined. This review provides practical tips and considerations to succeed in the management of EoE patients undergoing food elimination diets, as well as recent advances and future perspectives on food avoidance strategies.
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Affiliation(s)
- Pierfrancesco Visaggi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
| | - Federica Baiano Svizzero
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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Nutritional and Psychological Considerations for Dietary Therapy in Eosinophilic Esophagitis. Nutrients 2022; 14:nu14081588. [PMID: 35458150 PMCID: PMC9025426 DOI: 10.3390/nu14081588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022] Open
Abstract
The step-up empiric elimination diet, starting from one/two food groups of most local allergens remains the current gold standard for a dietary approach in eosinophilic esophagitis (EoE) patients. Milk, followed by wheat and egg, is the most frequent food that triggers EoE in pediatric and adult patients. Elimination diets, with restrictions over four food groups, may be limited to highly motivated patients, in which nutritional counseling is recommended. Malnourishment is uncommon in EoE patients and likely multifactorial (concomitant gastrointestinal eosinophilic disorders or IgE-mediated food allergies, feeding difficulties, abnormal feeding behavior). Avoidant/restrictive food intake disorder in EoE children on highly restrictive diets was lately described and may warrant specific psychological support. As for adults, quality of life may be impaired by symptom severity and dietary restrictions, aside from recently reported food impaction-related specific anxiety in up to 43% of patients. Severe symptoms, feeding dysfunction, and diet restrictions may negatively influence psychosocial adjustment for patients and their caregivers.
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Feo-Ortega S, Lucendo AJ. Evidence-based treatments for eosinophilic esophagitis: insights for the clinician. Therap Adv Gastroenterol 2022; 15:17562848211068665. [PMID: 35069803 PMCID: PMC8777364 DOI: 10.1177/17562848211068665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/03/2021] [Indexed: 02/04/2023] Open
Abstract
Eosinophilic esophagitis (EoE) is a chronic inflammatory disorder characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. Left untreated, EoE progresses to fibrous remodeling and stricture formation that impairs quality of life. Therefore, EoE requires either repeated treatments or maintenance therapy. Current guidelines recommend swallowed topical corticosteroids (STCs), proton-pump inhibitors (PPIs), or dietary intervention as initial options to induce and maintain long-term disease remission. Impractical exclusive elemental diets and suboptimal allergy testing-directed food avoidance paved the way for empirical elimination diets. These are moderately effective and highly reproducible in inducing EoE remission and allow for identification of specific food triggers. Step-up strategies, including two- and four-food rather than six-food elimination diets, should be considered as initial approaches for dietary treatment in patients of all ages, as they reduce the need for endoscopic procedures, shorten diagnostic processing time, and avoid unnecessary restrictions. Formulations of STC originally designed for asthma therapy are suboptimal for EoE treatment, with new effervescent orodispersible tablets and viscose formulations designed to coat the esophageal mucosa providing increased effectiveness at reduced doses. The anti-inflammatory effects of PPI in EoE are independent from gastric acid secretion inhibition; despite evidence from observational research, PPIs are the most commonly prescribed first-line therapy for EoE due to their accessibility, low cost, and safety profile. Double doses of PPI only induce remission in half of EoE patients, irrespective of the drug used or patients' age. Inflammatory rather than stricturing EoE phenotype and treatment duration up to 12 weeks increase chances of achieving EoE remission. Most responders effectively maintain long-term remission with standard PPI doses. Finally, endoscopic dilation should be considered in patients with reduced esophageal caliber or persistent dysphagia despite histological remission. This article provides a state-of-the-art review and updated discussion of current therapies and newly developed options for EoE.
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Affiliation(s)
- Sara Feo-Ortega
- Pediatric Gastroenterology Unit, Hospital
General de Tomelloso, Tomelloso, Spain, and Instituto de Investigación
Sanitaria de Castilla-La Mancha (IDISCAM)
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