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Burk CM, Shreffler WG. Triggers for eosinophilic esophagitis (EoE): The intersection of food allergy and EoE. J Allergy Clin Immunol 2024; 153:1500-1509. [PMID: 38849185 DOI: 10.1016/j.jaci.2024.04.010] [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: 01/31/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 06/09/2024]
Abstract
Eosinophilic esophagitis and IgE-mediated food allergy are both food-triggered diseases that are increasing in prevalence. They share many clinical links, including significant comorbidity and similar food triggers, and as atopic diseases, they likely share upstream mechanisms related to barrier function and signals leading to TH2 skewing. In this review, we focus on links between eosinophilic esophagitis and IgE-mediated food allergy with an emphasis on what insights may be derived from overlapping food triggers and immune phenotypes. Through further investigation of these connections, we may be able to better understand not only IgE-mediated food allergy and eosinophilic esophagitis but also general atopic response to food proteins and evolution of allergic response to food.
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Affiliation(s)
- Caitlin M Burk
- Food Allergy Center, Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Wayne G Shreffler
- Food Allergy Center, Division of Pediatric Allergy and Immunology, and Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, and the Department of Pediatrics, Harvard Medical School, Boston, Mass
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2
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Vandenplas Y, Broekaert I, Domellöf M, Indrio F, Lapillonne A, Pienar C, Ribes-Koninckx C, Shamir R, Szajewska H, Thapar N, Thomassen RA, Verduci E, West C. An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy. J Pediatr Gastroenterol Nutr 2024; 78:386-413. [PMID: 38374567 DOI: 10.1097/mpg.0000000000003897] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/25/2023] [Indexed: 07/27/2023]
Abstract
A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Flavia Indrio
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France
- CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Corina Pienar
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Gastroenterology and Hepatology & Instituto de Investigacion Sanitaria, La Fe University Hospital, Valencia, Spain
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rut Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Christina West
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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3
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Molina-Infante J, Mata-Romero P, Martín-Holgado D. New approaches to diet therapy for eosinophilic esophagitis. Curr Opin Gastroenterol 2023; 39:315-319. [PMID: 37097832 DOI: 10.1097/mog.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
PURPOSE OF REVIEW An empiric step-up (2-4-6) elimination diet remains the most common dietary approach in clinical practice when treating eosinophilic esophagitis (EoE). However, research in this field has fallen behind pharmacological therapy. This review aims to summarize novel approaches to dietary therapy for EoE. RECENT FINDINGS A first prospective multicenter study in 41 pediatric patients (mean age 9 years) has evaluated the efficacy of a cow's milk elimination diet. This dietary approach led to histological remission in 51% of patients, albeit a caveat is that up to 80% of patients were receiving concomitant therapy with proton pump inhibitors. In a series of 18 adult patients with documented milk-induced EoE, ingestión of 400 ml of sterilized milk (boiled for up to 20 min) daily for 8 weeks did not induce histologic relapse in two-thirds of patients. SUMMARY Milk elimination diet is effective in one-half of pediatric EoE patients and should likely be the first choice in children with EoE (within a step-up dietary approach). Promising data on tolerance of sterilized milk in adults with milk-induced EoE (66%) merit further replication in children, which may radically improve quality of life for patients and their caregivers.
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Affiliation(s)
- Javier Molina-Infante
- Department of Gastroenterology, Hospital Universitario de Cáceres, Cáceres
- Centro de Investigacion Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pilar Mata-Romero
- Department of Gastroenterology, Hospital Universitario de Cáceres, Cáceres
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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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Ribes-Koninckx C, Amil-Dias J, Espin B, Molina M, Segarra O, Diaz-Martin JJ. The use of amino acid formulas in pediatric patients with allergy to cow's milk proteins: Recommendations from a group of experts. Front Pediatr 2023; 11:1110380. [PMID: 37033186 PMCID: PMC10073469 DOI: 10.3389/fped.2023.1110380] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
One of the most common food allergies in children is cow's milk allergy (CMA). In breast-fed infants with CMA, the mother is encouraged to avoid dairy products. If this is not possible, or in formula fed infants, use of hypoallergenic replacement formulas such as extensively hydrolyzed formulas (EHF) is recommended. However, in ∼5% of patients EHFs are not tolerated and/or allergy symptoms can persist. When EHFs are ineffective and in severe forms of CMA, amino acid-based formulas (AAF) should be considered. Six pediatric gastroenterologists with extensive experience in food allergy management reviewed scientific publications and international clinical practice guidelines to provide practical recommendations on AAF. The guidelines reviewed had discrepancies and ambiguities around the specific indications for using formulas as a milk substitute. The panel recommends AAFs as the first therapeutic option in anaphylaxis due to CMA, in acute and chronic severe food protein-induced enterocolitis syndrome, in CMA associated with multiple food allergy, and in cases of eosinophilic esophagitis not responding to an extended exclusion diet or not eating solids. The main benefit of AAF is its absence of residual allergenicity, making it a safe treatment option in severe CMA patients who do not tolerate or respond to an EHF.
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Affiliation(s)
- Carmen Ribes-Koninckx
- Pediatric Gastroenterology, Hepatology and Nutrition La Fe University and Politechnic Hospital & La Fe Research Institute, Valencia, Spain
- Correspondence: Carmen Ribes-Koninckx
| | - Jorge Amil-Dias
- Emeritus, S. João University Hospital Center, Porto, Portugal
| | - Beatriz Espin
- Pediatric Gastroenterology and Nutrition Unit, Virgen del Rocio University Hospital, Seville, Spain
| | - Manuel Molina
- Department of Pediatric Gastroenterology and Nutrition, La Paz University Hospital, Madrid, Spain
| | - Oscar Segarra
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan J. Diaz-Martin
- Pediatric Gastroenterology and Nutrition, Hospital Universitario Central de Asturias, Oviedo, Spain
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6
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Almassalha LM, Hirano I. Editorial: cooking up something new for diet therapy of eosinophilic oesophagitis. Aliment Pharmacol Ther 2022; 56:1205-1206. [PMID: 36071014 DOI: 10.1111/apt.17190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Luay M Almassalha
- Division of Gastroenterology & Hepatology, Northwestern University, The Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University, The Feinberg School of Medicine, Chicago, Illinois, USA
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González-Cervera J, Arias Á, Navarro P, Juárez-Tosina R, Cobo-Palacios M, Olalla JM, Angueira-Lapeña T, Lucendo AJ. Tolerance to sterilised cow's milk in patients with eosinophilic oesophagitis triggered by milk. Aliment Pharmacol Ther 2022; 56:957-967. [PMID: 35916162 DOI: 10.1111/apt.17171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/09/2022] [Accepted: 07/20/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Cow's milk protein is the main food trigger for eosinophilic oesophagitis (EoE) in children and adults and should be continuously avoided once identified as such. AIMS To evaluate tolerance of sterilised cow's milk (boiled instead of UHT processing) with regard to maintenance of EoE remission, health-related quality of life (HRQoL), nutritional intake and allergic sensitisation in patients of all ages with milk-triggered EoE METHODS: We prospectively recruited patients in whom cow's milk was demonstrated to trigger EoE after an empirical food elimination diet-based study. They were given 200 ml of sterilised cow's milk twice daily for 8 weeks. Endoscopic assessment, peak eosinophil counts, oesophageal-related symptoms, HRQoL, blood eosinophils, eosinophil cationic protein (ECP), skin prick test and serum total and specific immunoglobulin E (IgE) to major milk proteins were monitored before and after sterilised milk intake. RESULTS Eighteen patients (13 male) in EoE remission underwent a sterilised milk challenge. Twelve maintained EoE remission (<15 eos/hpf) while EoE recurred in the remainder. Endoscopic appearances deteriorated in non-tolerant patients. HRQoL scored well at baseline and was maintained among patients tolerant to sterilised milk, but deteriorated in reactive ones. No significant changes in blood eosinophil count, ECP, tryptase or total and milk-specific IgE serum levels were observed from baseline. However, cow's milk-specific IgE increased slightly in non-tolerant patients. Clinical and histological remission were maintained in patients who regularly consumed sterilised milk for 1 year. CONCLUSION Sterilised milk did not trigger EoE in two-thirds of patients with documented milk-induced EoE, in either the short or long term.
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Affiliation(s)
- Jesús González-Cervera
- Department of Allergy, Hospital General de Tomelloso, Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain
| | - Ángel Arias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.,Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Spain.,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Pilar Navarro
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.,Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - Rocío Juárez-Tosina
- Department of Pathology, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | - María Cobo-Palacios
- Nutrition and Dietetics Unit, Hospital General de Tomelloso, Tomelloso, Spain
| | - José M Olalla
- Department of Pathology, Hospital General Mancha Centro, Alcázar de San Juan, Spain
| | | | - Alfredo J Lucendo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo, Spain.,Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain.,Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
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8
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D’Auria E, Salvatore S, Acunzo M, Peroni D, Pendezza E, Di Profio E, Fiore G, Zuccotti GV, Verduci E. Hydrolysed Formulas in the Management of Cow's Milk Allergy: New Insights, Pitfalls and Tips. Nutrients 2021; 13:2762. [PMID: 34444922 PMCID: PMC8401609 DOI: 10.3390/nu13082762] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 12/12/2022] Open
Abstract
An allergy to cow's milk requires the avoidance of cow's milk proteins and, in some infants, the use of a hypoallergenic formula. This review aims to summarize the current evidence concerning different types of hydrolysed formulas (HF), and recommendations for the treatment of IgE- and non-IgE-mediated cow's milk allergy and functional gastrointestinal disorders in infancy, for which some dietary intervention and HF may be of benefit to both immune and motor mechanisms. Current guidelines recommend cow's milk protein (i.e., whey or casein) extensively hydrolysed formula (eHF) as the first choice for cow's milk allergy treatment, and amino acid formulas for more severe cases or those with reactions to eHF. Rice hydrolysed formulas (rHF) have also become available in recent years. Both eHF and rHF are well tolerated by the majority of children allergic to cow's milk, with no concerns regarding body growth or adverse effects. Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics. Despite encouraging results on tolerance acquisition, evidence is still not conclusive, thus hampering our ability to draw firm conclusions. In clinical practice, the choice of hypoallergenic formula should be based on the infant's age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy.
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Affiliation(s)
- Enza D’Auria
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Silvia Salvatore
- Department of Pediatrics, Ospedale “F. Del Ponte”, University of Insubria, 21100 Varese, Italy;
| | - Miriam Acunzo
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, 56126 Pisa, Italy;
| | - Erica Pendezza
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Elisabetta Di Profio
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Giulia Fiore
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Gian Vincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
| | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, 20154 Milan, Italy; (M.A.); (E.P.); (E.D.P.); (G.F.); (G.V.Z.); (E.V.)
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9
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Lucendo AJ. Nutritional approach to eosinophilic esophagitis: which diet and when. Minerva Gastroenterol (Torino) 2020; 68:49-59. [PMID: 33267566 DOI: 10.23736/s2724-5985.20.02797-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dietary elimination therapy has been for a long time an option for patients with eosinophilic esophagitis (EoE) and remains the only therapy targeting the cause of the disease. Different dietary approaches have been described along the last 3 decades, and cumulative evidence has defined the effectiveness and usefulness of each approach. Elemental diets are highly effective to induce EoE remission, but unpractical in most patients. Allergy testing-directed food restrictions resulted inefficient to induce remission in a significant proportion of patients (especially adults) and show a low concordance with the dietary causes of EoE. Empiric elimination diets are currently considered the most effective drug-free treatment for patients of all ages with EoE, after widely providing reproducible results. Highly restrictive empiric six-food elimination diets have paved the way to most efficient and less restrictive step-up approaches, which now include four-food and two-food elimination diets. The potential role of milk-elimination, especially in children, should be also considered. Multiple factors including demographics, nutritional status, patient and family lifestyles, social and financial support, and acceptance of repeated endoscopies influence the results of dietary therapy. Dietary therapy in EoE should be patient centered, and the patients and/or their families together with the medical provider should participate in the decision to set up this treatment. This article updates recent knowledge on dietary therapy for EoE and provides guideline to choose the most suitable alternative for patients with EoE, as well as practical tips to achieve the best results in clinical practice.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, General Hospital of Tomelloso, Tomelloso, Spain - .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain - .,Instituto de Investigación Sanitaria La Princesa, Madrid, Spain -
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Lucendo AJ, Molina-Infante J. Dietary therapy for eosinophilic esophagitis: chances and limitations in the clinical practice. Expert Rev Gastroenterol Hepatol 2020; 14:941-952. [PMID: 32614693 DOI: 10.1080/17474124.2020.1791084] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a non-Immunoglobulin E-mediated food allergy that currently represents the main cause of dysphagia and food impaction in children and young adults. Diet remains the only therapy targeting the cause of the disease. Relevant advances in recent years allow novel approaches to dietary therapy in EoE. AREAS COVERED An up-to-date review on dietary therapy for EoE is provided, as a potential first-line anti-inflammatory therapy able to induce and maintain remission in a significant proportion of patients. Unpractical elemental diets and suboptimal food allergy testing-directed food restrictions paved the way for empiric elimination diets, which currently are to be considered as the most effective drug-free treatment for EoE. After largely restrictive empiric six-food elimination diets, most efficient step-up approaches now include four-food and two-food elimination diets. The potential of milk-elimination is also discussed. EXPERT COMMENTARY An empiric elimination diet step-up strategy should be currently considered as the initial approach for dietary treatment in EoE patients of all ages. Compared to a top-down strategy, step-up diets reduce the need for endoscopic procedures, shorten diagnostic process times, and avoid unnecessary restrictions. Furthermore, early identification of responders with few food triggers may select best candidates for maintenance dietary therapy.
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Affiliation(s)
- Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso , Tomelloso, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid, Spain.,Instituto de Investigación Sanitaria La Princesa , Madrid, Spain
| | - Javier Molina-Infante
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) , Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Caceres , Caceres, Spain
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Abstract
PURPOSE OF REVIEW The aim of this review is to highlight recent advances in dietary therapy for eosinophilic esophagitis (EoE). RECENT FINDINGS An empiric elimination diet step-up strategy is now well established as the initial approach for dietary treatment. The most common food triggers are by far cow's milk, followed by wheat and egg. Legumes seem to be important solely in Spain and other Mediterranean countries, where they are regularly consumed. Retrospective efficacy data on cow's milk elimination diet in children vary from 25 to 65%. The recently described esophageal prick test did not detect local reaction to the most common food triggers described for EoE. SUMMARY Within the step-up approach, the specific food group or groups to be first eliminated and whether if it will depend on the geographical setting and food consumption habits remain unknown. Prospective studies on cow's milk elimination diet in children and adults are definitely warranted. Better food allergy testing, identifying specific antigens involved in each food group, should be developed for an individualized therapy. As for disease prevention, we undoubtedly need to understand why foods we have been consuming since the Neolithic age have caused EoE just over the past few decades.
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12
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Specialty Infant Formulas for Milk Allergy: Current Choices and Unmet Needs. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0187-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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13
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Gomez Torrijos E, Gonzalez-Mendiola R, Alvarado M, Avila R, Prieto-Garcia A, Valbuena T, Borja J, Infante S, Lopez MP, Marchan E, Prieto P, Moro M, Rosado A, Saiz V, Somoza ML, Uriel O, Vazquez A, Mur P, Poza-Guedes P, Bartra J. Eosinophilic Esophagitis: Review and Update. Front Med (Lausanne) 2018; 5:247. [PMID: 30364207 PMCID: PMC6192373 DOI: 10.3389/fmed.2018.00247] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Eosinophilic esophagitis (EoE) was first described in the 1990s, showing an increasing incidence and prevalence since then, being the leading cause of food impaction and the major cause of dysphagia. Probably, in a few years, EoE may no longer be considered a rare disease. Methods: This article discusses new aspects of the pathogenesis, symptoms, diagnosis, and treatment of EoE according to the last published guidelines. Results: The epidemiological studies indicate a multifactorial origin for EoE, where environmental and genetic factors take part. EoE affects both children and adults and it is frequently associated with atopic disease and IgE-mediated food allergies. In patients undergoing oral immunotherapy for desensitization from IgE-mediated food allergy the risk of developing EoE is 2.72%. Barrier dysfunction and T-helper 2 inflammation is considered to be pathogenetically important factors. There are different patterns of clinical presentation varying with age and can be masked by adaptation habits. Besides, symptoms do not usually correlate with histologic disease activity. The diagnostic criteria for EoE has evolved but mainly requires symptoms of esophageal dysfunction with histologic evidence of a peak value of at least 15 eosinophils per high-power field. Endoscopies have to be repeated in order to diagnose, monitor, and treat EoE. Treatment of EoE can be started either by drugs (PPIs and topical corticosteroids) or elimination diets. The multistage step-up elimination diet management approach of EoE is promising. Endoscopic dilation is used for patients with severe dysphagia/food impaction with inadequate response to anti-inflammatory treatment. Conclusions: Research in recent years has contributed to a better understanding of EoE's pathogenesis, genetic background, natural history, allergy workup, standardization in assessment of disease activity, evaluation of minimally invasive diagnostic tools, and new therapeutic approaches. However, several unmet needs are to be solved urgently, as finding a non-invasive disease-monitoring methods and biomarkers for routine practice, the development or new therapies, novel food allergy testing to detect triggering foods, drug, and doses required for initial therapy and safety issues with long-term maintenance therapy, amongst others. Besides, multidisciplinary management units of EoE, involving gastroenterologists, pediatricians, allergists, pathologists, dietitians, and ENT specialists are needed.
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Affiliation(s)
| | | | | | - Robledo Avila
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Jesus Borja
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | - M. Pilar Lopez
- Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | | | - Mar Moro
- Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Ana Rosado
- Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | - Vanessa Saiz
- Hospital UniversitarioReina Sofía de Córdoba, Cordoba, Spain
| | | | - Olga Uriel
- Hospital Universitario de Araba, Vitoria-Gasteiz, Spain
| | - Angelina Vazquez
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Pilar Mur
- Hospital Santa Barbara, Puertollano, Spain
| | - Paloma Poza-Guedes
- Allergy Section, Hospital Universitario de La Laguna, San Cristóbal de La Laguna, Spain
| | - Joan Bartra
- Allergy Section, Pneumology Department, Hospital Clínic Universitat de Barcelona, Barcelona, Spain
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14
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Hines BT, Rank MA, Wright BL, Marks LA, Hagan JB, Straumann A, Greenhawt M, Dellon ES. Minimally invasive biomarker studies in eosinophilic esophagitis: A systematic review. Ann Allergy Asthma Immunol 2018; 121:218-228. [PMID: 29753832 PMCID: PMC6104633 DOI: 10.1016/j.anai.2018.05.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/01/2018] [Accepted: 05/08/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic, inflammatory disease of the esophagus that currently requires repeated endoscopic biopsies for diagnosis and monitoring because no reliable noninvasive markers have been identified. OBJECTIVE To identify promising minimally invasive EoE biomarkers and remaining gaps in biomarker validation. METHODS We performed a systematic review of EMBASE, Ovid MEDLINE, PubMed, and Web of Science from inception to June 6, 2017. Studies were included if patients met the 2007 consensus criteria for EoE diagnosis, a minimally invasive biomarker was assessed, and the study included at least 1 control for comparison. RESULTS The search identified 2094 studies, with 234 reviewed at full-text level, and 49 included in the analysis (20 adult, 19 pediatric, 7 pediatric and adult, and 3 not stated). Most (26 of 49) were published after 2014. Thirty-five studies included healthy controls, 9 analyzed atopic controls, and 29 compared samples from patients with active and inactive EoE. Minimally invasive biomarkers were obtained from peripheral blood (n = 41 studies), sponge or string samples (n = 3), oral or throat swab secretions (n = 2), breath condensate (n = 2), stool (n = 2), and urine (n = 2). The most commonly reported biomarkers were peripheral blood eosinophils (n = 16), blood and string eosinophil granule proteins (n = 14), and eosinophil surface or intracellular markers (n = 12). EoE biomarkers distinguished active EoE from healthy controls in 23 studies, atopic controls in 2 studies, and inactive EoE controls in 20 studies. CONCLUSION Several promising minimally invasive biomarkers for EoE have emerged; however, few are able to differentiate EoE from other atopic diseases.
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Affiliation(s)
- Brittany T Hines
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Phoenix Children's Hospital, Phoenix, Arizona.
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Phoenix Children's Hospital, Phoenix, Arizona
| | - Benjamin L Wright
- Division of Allergy, Asthma and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona; Phoenix Children's Hospital, Phoenix, Arizona
| | - Lisa A Marks
- Mayo Clinic Libraries, Mayo Clinic, Scottsdale, Arizona
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Matthew Greenhawt
- Department of Pediatrics Allergy Section, Children's Hospital Colorado, University of Colorado School of Medicine Aurora, Colorado
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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15
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Teoh T, Mill C, Chan E, Zimmer P, Avinashi V. Liberalized Versus Strict Cow's Milk Elimination for the Treatment of Children with Eosinophilic Esophagitis. J Can Assoc Gastroenterol 2018; 2:81-85. [PMID: 31294369 PMCID: PMC6507290 DOI: 10.1093/jcag/gwy030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives Cow’s milk is a commonly implicated trigger in eosinophilic esophagitis (EoE). Exclusive cow’s milk avoidance has been reported previously, but the degree of elimination required for remission is unclear. Strict food avoidance may confer a risk of developing immunoglobulin E (IgE)-mediated allergy. The goal of this study was to evaluate the effectiveness of cow’s milk elimination (CME) in children with EoE and compare responses of strict and liberalized CME diets. Methods Children (≤16 years) diagnosed with EoE who were treated with exclusive CME diets were evaluated clinically and histologically. Strict diets eliminated all milk products, including ‘may-contain’ and baked milk goods. Liberalized diets eliminated obvious sources including milk, cheese, yogurt, cream-based products but permitted foods with traces of milk and baked goods. Results Cow’s milk elimination induced histological remission of <15 eosinophils per high-powered field in 18 of 31 children (58%) and complete remission in 23%. Overall, 77% had decreased eosinophils with this single intervention. Symptoms were improved in 90% of patients, regardless of histologic response. A liberalized (n=7) CME diet was associated with a nonsignificantly lower response compared with strict (n=24) elimination (29% versus 67%, P=0.099). Eight responders to strict elimination were transitioned to a liberalized diet; 63% maintained remission. Conclusion Cow’s milk elimination induced clinicopathological remission in a majority of patients with EoE, supporting its use as a first-line intervention. Liberalized CME allows dietary freedom and may prevent subsequent development of anaphylactic milk allergy but may be inferior to strict CME for improving EoE.
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Affiliation(s)
- Timothy Teoh
- University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Christopher Mill
- BC Children's Hospital, Division of Allergy and Immunology, Department of Pediatrics, Vancouver, British Columbia, Canada
| | - Edmond Chan
- University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Children's Hospital, Division of Allergy and Immunology, Department of Pediatrics, Vancouver, British Columbia, Canada
| | - Preeti Zimmer
- BC Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vancouver, British Columbia, Canada
| | - Vishal Avinashi
- University of British Columbia, Faculty of Medicine, Vancouver, British Columbia, Canada.,BC Children's Hospital, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Vancouver, British Columbia, Canada
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16
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Eke R, Li T, White A, Tariq T, Markowitz J, Lenov A. Systematic review of histological remission criteria in eosinophilic esophagitis. JGH OPEN 2018; 2:158-165. [PMID: 30483582 PMCID: PMC6207047 DOI: 10.1002/jgh3.12059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/03/2018] [Accepted: 05/07/2018] [Indexed: 12/15/2022]
Abstract
Elemental diets, dietary elimination, and steroid therapies are the most common therapies in the clinical trials for eosinophilic esophagitis (EoE). Histological findings (usually reported as eosinophils per microscopic high‐powered field [hpf]) remain the most common end‐point used to define response. Yet, the threshold for defining “response” and “remission” are ill‐defined among consensus guidelines and may vary from study to study. We conducted a systematic literature review of articles on eosinophilic esophagitis, published between January 2007 and November 2017, considering histological remission as the primary outcome. We abstracted treatment information and definitions of histological remission or response. A comparison of definitions of histological remission across and within institutions was performed. A total of 61 articles were included in this review, with approximately 60% of the studies published from centers in the United States. Histological definitions of remission of EoE ranged from 0 to ≤20 eosinophils/hpf. The most stringent criteria, ranging from 0 to ≤5 eosinophils/hpf, were commonly used in interventional trial studies that examined the effects of new treatments. We found remarkable variability in definitions between studies, treatment types, and regions. Age or epidemiological distribution of study subjects did not influence the criteria for histological remission. Clinical and histological improvements are important measures of the effects of treatment. Histological findings, the most objective measure of treatment, should provide an optimal method for comparing the effectiveness of various treatments. Yet, our findings suggest a lack of consistent remission criteria in published studies. Considering these inconsistencies, it is difficult to compare the effectiveness of various treatments.
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Affiliation(s)
- Ransome Eke
- Division of Epidemiology and Biostatistics Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Tong Li
- Division of Epidemiology and Biostatistics Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Anna White
- Medical Library Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Tooba Tariq
- Department of Internal Medicine Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
| | - Jonathan Markowitz
- Division of Pediatric Gastroenterology Greenville Children's Hospital Greenville South Carolina US
| | - Andrey Lenov
- Allergy-Asthma-Immunology Clinic, Department of Pediatric and Adolescent Medicine Western Michigan University M.D. Homer Stryker School of Medicine Kalamazoo Michigan US
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17
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Nhu QM, Aceves SS. Medical and dietary management of eosinophilic esophagitis. Ann Allergy Asthma Immunol 2018; 121:156-161. [PMID: 29753831 DOI: 10.1016/j.anai.2018.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Eosinophilic esophagitis (EoE) is a disease of chronic, allergen-driven, T-helper 2 (Th2) immune-mediated inflammation that progresses to fibrostenosis of the esophagus if left untreated. There are currently no Food and Drug Administration (FDA)-approved drugs for the treatment of EoE. This review focuses on the medical and dietary management of EoE. DATA SOURCES Manuscripts on EoE treatments were identified on PubMed. STUDY SELECTIONS Original research, randomized control trials, retrospective studies, meta-analyses, case series, and on occasions, case reports of high relevance, were selected and reviewed. RESULTS Current treatment strategies available to EoE patients center on monotherapy or combination therapy with dietary modification to exclude antigenic stimulation and topical corticosteroids to control Th2-mediated tissue inflammation and pathologic remodeling. Dilation as a rescue therapy for the narrowed, fibrostenotic, symptomatic esophagus can potentially be avoided with optimal medical and elimination diet therapies. The molecular mechanisms underlying EoE pathogenesis are being unraveled, from which targeted therapies can be developed and evaluated in preclinical and clinical studies. Current clinical research efforts focus on optimization of topical corticosteroid delivery, dosing, frequency, and duration of treatment, either alone or in combination with tailored elimination diet. Preliminary clinical trials with biologics targeting interleukin (IL)-5 and IL-13/IL-4 have been completed. CONCLUSION Topical corticosteroid, elimination diet, and dilation are the current treatment modalities for confirmed EoE. The use of proton-pump inhibitors (PPI) is being suggested as a potential regimen to treat EoE, based on evolving understanding of PPI-responsive esophageal eosinophilia (PPI-REE). The complexity of EoE treatment regimens and frequent follow-ups require a multimodal, multi-disciplinary management approach to optimize patient care.
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Affiliation(s)
- Quan M Nhu
- Scripps Translational Science Institute, The Scripps Research Institute, La Jolla, California; Division of Gastroenterology & Hepatology, Department of Medicine, Scripps Clinic-Scripps Green Hospital, La Jolla, California; Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Seema S Aceves
- Division of Allergy & Immunology, Department of Pediatrics, University of California, San Diego, La Jolla, California; Division of Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, California; Rady Children's Hospital, San Diego, San Diego, California.
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18
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Meyer R, Groetch M, Venter C. When Should Infants with Cow's Milk Protein Allergy Use an Amino Acid Formula? A Practical Guide. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:383-399. [DOI: 10.1016/j.jaip.2017.09.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/04/2017] [Accepted: 09/16/2017] [Indexed: 12/18/2022]
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19
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Abstract
Eosinophilic esophagitis is characterized by dense mucosal eosinophilia with symptoms of esophageal dysfunction. Because the incidence and prevalence are increasing, understanding the available treatments is imperative. This article highlights evolution and advancements in dietary treatment, supports the notion that food antigens drive this disease, and discusses the advantages, limitations, and future of dietary therapy. Medical and dietary therapies are effective treatments and the optimal approach should be individualized based on patient goals and available local resources. Dietary therapy has been effective and further studies will help identify optimal approaches to dietary therapy.
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20
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Kliewer KL, Cassin AM, Venter C. Dietary Therapy for Eosinophilic Esophagitis: Elimination and Reintroduction. Clin Rev Allergy Immunol 2017; 55:70-87. [DOI: 10.1007/s12016-017-8660-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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21
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Groetch M, Venter C, Skypala I, Vlieg-Boerstra B, Grimshaw K, Durban R, Cassin A, Henry M, Kliewer K, Kabbash L, Atkins D, Nowak-Węgrzyn A, Holbreich M, Chehade M. Dietary Therapy and Nutrition Management of Eosinophilic Esophagitis: A Work Group Report of the American Academy of Allergy, Asthma, and Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:312-324.e29. [PMID: 28283156 DOI: 10.1016/j.jaip.2016.12.026] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/21/2016] [Indexed: 12/16/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic/immune-antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Dietary elimination therapy has been shown to be an effective, drug-free prescription for the treatment of EoE. A range of different dietary elimination therapies have been used. Regardless of the elimination diet chosen, dietary therapy requires in-depth nutrition assessment and management. Elimination diets are not without risk and may impact nutritional status, eating pleasure, and overall quality of life. With adequate guidance, dietary therapy can be effective and nutritionally balanced, and the adverse impact on lifestyle can be minimized. This work group report addresses the potential challenges of implementing an elimination diet for the management of EoE and provides instructions and tools for physicians, dietitians, and other allied health professionals to help guide them in planning elimination diets for both children and adults.
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Affiliation(s)
- Marion Groetch
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Carina Venter
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Isabel Skypala
- Allergy Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK; Department of Paediatrics, Imperial College, London, UK
| | - Berber Vlieg-Boerstra
- Onze lieve Vrouwe Gasthuis (OLVG), Department of Paediatrics, Amsterdam, The Netherlands
| | - Kate Grimshaw
- Department of Nutrition and Dietetics, Southampton's Children's Hospital, Southampton, UK; Clinical and Experimental Sciences and Human Development in Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Raquel Durban
- Division of Food Allergy, Asthma and Allergy Specialists, PA, Charlotte, NC
| | - Alison Cassin
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle Henry
- Department of Medical Affairs, Fresenius Kabi USA, LLC, Lake Zurich, Ill
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynda Kabbash
- Department of Internal Medicine, Harvard Medical School, Boston, Mass; Department of Internal Medicine, New England Baptist Hospital, Boston, Mass
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program and Allergy & Immunology Section, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Anna Nowak-Węgrzyn
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mirna Chehade
- Departments of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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22
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Vandenplas Y. Prevention and Management of Cow's Milk Allergy in Non-Exclusively Breastfed Infants. Nutrients 2017; 9:nu9070731. [PMID: 28698533 PMCID: PMC5537845 DOI: 10.3390/nu9070731] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/16/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023] Open
Abstract
Introduction: The prevention and management of cow milk allergy (CMA) is still debated. Since CMA is much less frequent in breastfed infants, breastfeeding should be stimulated. Method: Literature was searched using databases to find original papers and reviews on this topic. Results: Hydrolysates with a clinical proof of efficacy are recommended in the prevention and treatment of CMA. However, not all meta-analyses conclude that hydrolysates do prevent CMA or other atopic manifestations such as atopic dermatitis. There are pros and cons to consider partially hydrolysed protein as an option for starter infant formula for each non-exclusively breastfed infant. A challenge test is still recommended as the most specific and sensitive diagnostic test, although a positive challenge test does not proof that the immune system is involved. The Cow Milk Symptom Score (CoMiSS™) is an awareness tool that enables healthcare professionals to better recognize symptoms related to the ingestion of cow milk, but it still needs validation as diagnostic tool. The current recommended elimination diet is a cow milk based extensive hydrolysate, although rice hydrolysates or soy infant formula can be considered in some cases. About 10 to 15% of infants allergic to cow milk will also react to soy. Mainly because of the higher cost, amino acid based formula is reserved for severe cases. There is no place for infant formula with intact protein from other animals as cross-over allergenicity is high. During recent years, attention focused also on the bifidogenic effect of prebiotics and more recently also on human milk oligosaccharides. A bifidogenic gastrointestinal microbiome may decrease the risk to develop allergic disease. The addition of probiotics and prebiotics to the elimination diet in treatment may enhance the development of tolerance development. Conclusion: Breastfeeding is the best way to feed infants. Cow milk based extensive hydrolysates remain the first option for the treatment of CMA for the majority of patients, while amino acid formulas are reserved for the most severe cases. Rice hydrolysates and soy infant formula are second choice options. Partial hydrolysates with clinical proof of efficacy are recommended in some guidelines in the prevention of CMA and allergic disease in at risk infants, and may be considered as an option as protein source in starter infant formula.
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Affiliation(s)
- Yvan Vandenplas
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
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23
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Benninger MS, Strohl M, Holy CE, Hanick AL, Bryson PC. Prevalence of atopic disease in patients with eosinophilic esophagitis. Int Forum Allergy Rhinol 2017; 7:757-762. [PMID: 28614630 DOI: 10.1002/alr.21968] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/29/2017] [Accepted: 04/14/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The objective of this work was to evaluate prevalence of eosinophilic esophagitis (EoE) in the United States, and analyze prevalence of atopic disease in patients with EoE. The study design was a retrospective administrative database analysis in U.S.-based outpatient settings. METHODS A retrospective claims analysis in the inpatient and outpatient setting (using MarketScan) was conducted to analyze prevalence of atopic disease diagnoses in patients with EoE in 2012, and timing of those diagnoses vs EoE. RESULTS From published evidence, prevalence of EoE was estimated at 1 to 5 patients per 10,000 and prevalence of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) concurrent to EoE ranged from 20% to 50%, 50% to 75%, and 2% to 19% cases, respectively. From 2009 and 2013, the estimated prevalence of EoE in MarketScan increased from 2.7 to 5.6 per 10,000 enrollees age 34.5 ± 18.43 years (mean ± standard deviation). Age followed a bimodal distribution with peaks at 12 and 41 years. Women accounted for 35.6% cases. Prevalence of asthma, AR, AD, and food allergies up to 12 months post-EoE diagnosis reached 44.7%, 27.1%, 25.2%, and 16.9%, respectively, with 63.5% of all patients suffering from at least 1 of these 4 diseases and 3.0% suffering from all 4. CONCLUSION The diagnosis of EoE is associated with the diagnoses of asthma, AR, AD, and food allergies. The high prevalence of these conditions in EoE patients further strengthens the hypothesis of a common pathogenesis.
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Affiliation(s)
| | | | - Chantal E Holy
- Acclarent, part of the Johnson &, Johnson Family of Companies, New Brunswick, NJ
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24
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McGowan EC, Platts-Mills TA. Eosinophilic Esophagitis From an Allergy Perspective: How to Optimally Pursue Allergy Testing & Dietary Modification in the Adult Population. Curr Gastroenterol Rep 2016; 18:58. [PMID: 27726042 PMCID: PMC5458532 DOI: 10.1007/s11894-016-0531-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathologic condition characterized by symptoms of esophageal dysfunction and eosinophil-predominant inflammation. In adults, the three most common treatment options are swallowed steroids, elimination diets, and periodic esophageal dilations. Many different elimination diets have been studied in adults, including elemental diets, allergy testing-directed diets, and empiric elimination diets. This article will review the existing data on these dietary therapies and will propose an approach to dietary management in adult EoE.
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Affiliation(s)
- Emily C McGowan
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Virginia School of Medicine, PO Box 801355, Charlottesville, VA, 22903, USA.
- Department of Medicine, Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Thomas A Platts-Mills
- Department of Medicine, Division of Allergy and Clinical Immunology, University of Virginia School of Medicine, PO Box 801355, Charlottesville, VA, 22903, USA
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25
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Arias Á, Lucendo AJ, Martínez-Fernández P, González-Castro AM, Fortea M, González-Cervera J, Yagüe-Compadre JL, Mota-Huertas T, Vicario M. Dietary treatment modulates mast cell phenotype, density, and activity in adult eosinophilic oesophagitis. Clin Exp Allergy 2016; 46:78-91. [PMID: 25640519 DOI: 10.1111/cea.12504] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 11/11/2014] [Accepted: 11/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mast cells (MCs) are abundant in the inflammatory infiltrate in eosinophilic oesophagitis (EoE), but decrease with disease remission. However, their phenotype, role in the pathophysiology of the disease, and modulation after effective dietary therapy are still unclear. OBJECTIVE To define the phenotype of oesophageal MCs, their modulation through dietary therapy, and their association with clinical manifestations of EoE. METHODS Oesophageal mucosal samples from 10 adult patients with EoE obtained before and after effective six-food elimination diet (SFED) therapy, as well as from 10 control subjects were analysed. Eosinophil and MC density were quantified. Gene expression of chemoattractants for eosinophils (CCL11, CCL24, and CCL26), MCs (SCF), and their receptors (CCR3 and SCFR, respectively) were assessed by means of qPCR. Gene and protein expression of specific MC proteases (CPA3, CMA, and TPSB2) were evaluated with qPCR and immunofluorescence. Clinical manifestations and atopic background were recorded. RESULTS MC density was significantly increased in EoE compared with controls, decreasing after dietary treatment (18.6 to 1.44 cells/hpf, respectively; P < 0.001). The MCTC subtype predominated in the oesophageal mucosa (90%) in both patients with EoE and controls. Gene expression of MC-related proteases, eotaxins, and SCF were up-regulated in patients with EoE, but significantly decreased after therapy, regardless of atopic background. Epithelial peaks of MCs and eosinophils were significantly associated (ρ = 0.80) in EoE and correlated with the symptom score (ρ = 0.78). Gene expression of MC proteases and eotaxins also correlated with the symptom score (P < 0.05). CONCLUSIONS AND CLINICAL RELEVANCE MC and its proteases seem to play a relevant role in the pathophysiology and symptoms of EoE, which can be reversed after effective dietary treatment.
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Affiliation(s)
- Á Arias
- Research Unit, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - A J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain
| | - P Martínez-Fernández
- Idipaz Research Laboratory, Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz, Madrid, Spain.,Center for Biomedical Research on Rare Diseases (CIBERER), Instituto Carlos III, Madrid, Spain
| | - A M González-Castro
- Digestive Diseases Research Unit, Laboratory of Neuro-immuno-gastroenterology, Department of Gastroenterology, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - M Fortea
- Digestive Diseases Research Unit, Laboratory of Neuro-immuno-gastroenterology, Department of Gastroenterology, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | | | - J L Yagüe-Compadre
- Department of Pathology, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - T Mota-Huertas
- Department of Pathology, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - M Vicario
- Digestive Diseases Research Unit, Laboratory of Neuro-immuno-gastroenterology, Department of Gastroenterology, Vall d'Hebron Institut de Recerca, Hospital Universitari Vall d´Hebron, Barcelona, Spain.,Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBERehd), Spain
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Venter C, Fleischer DM. Diets for diagnosis and management of food allergy: The role of the dietitian in eosinophilic esophagitis in adults and children. Ann Allergy Asthma Immunol 2016; 117:468-471. [PMID: 27592143 DOI: 10.1016/j.anai.2016.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/07/2016] [Accepted: 08/03/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Carina Venter
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - David M Fleischer
- University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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Górriz-Gil C, Villarreal IM, Álvarez-Montero Ó, Rodríguez-Valiente A, Magaz M, García-Berrocal JR. Esofagitis eosinofílica: una entidad patológica relevante para el otorrinolaringólogo. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2016; 67:167-78. [DOI: 10.1016/j.otorri.2015.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 12/19/2022]
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Górriz-Gil C, Villarreal IM, Álvarez-Montero Ó, Rodríguez-Valiente A, Magaz M, García-Berrocal JR. Eosinophilic Esophagitis: A Relevant Entity for the Otolaryngologist. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.otoeng.2016.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Vanderhoof JA. Em tempo: uso indevido e excessivo de fórmulas de aminoácidos na alergia ao leite de vaca. REVISTA PAULISTA DE PEDIATRIA 2015; 33:379-80. [PMID: 26372079 PMCID: PMC4685555 DOI: 10.1016/j.rpped.2015.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Indexed: 11/29/2022]
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Giriens B, Yan P, Safroneeva E, Zwahlen M, Reinhard A, Nydegger A, Vavricka S, Sempoux C, Straumann A, Schoepfer AM. Escalating incidence of eosinophilic esophagitis in Canton of Vaud, Switzerland, 1993-2013: a population-based study. Allergy 2015; 70:1633-9. [PMID: 26304142 DOI: 10.1111/all.12733] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a chronic, inflammatory disease of the esophagus with a rapidly increasing incidence. However, population-based epidemiologic data on EoE are rare and limited to regions with less than 200,000 inhabitants. We evaluated the incidence and prevalence of EoE over time in Canton of Vaud, Switzerland. MATERIALS AND METHODS Canton of Vaud lies in the French-speaking, Western part of Switzerland. As of December 2013, it had a population of 743,317 inhabitants. We contacted all pathology institutes (n = 6) in this canton to identify patients that have been diagnosed with esophageal eosinophilia between 1993 and 2013. We then performed a chart review in all adult and pediatric gastroenterology practices to identify patients with EoE. RESULTS Of 263 patients with esophageal eosinophilia, a total of 179 fulfilled the diagnostic criteria for EoE. Median diagnostic delay was 4 (IQR 1-9) years. No patient was diagnosed with EoE prior to 2003. Incidence of EoE increased from 0.16/100,000 inhabitants in 2004 to 6.3/100,000 inhabitants in 2013 (P < 0.001). The cumulative EoE prevalence in 2013 was 24.1/100,000. The incidence in males was 2.8 times higher (95% CI 2.01-3.88, P < 0.001) when compared to that in females. The annual EoE incidence was 10.6 times higher (95%-CI 7.61-14.87, P < 0.001) in the period from 2010 to 2013 when compared to that in the period from 1993 to 2009. CONCLUSIONS The incidence and cumulative prevalence of EoE in Canton of Vaud, Switzerland, has rapidly increased in the past 10 years.
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Affiliation(s)
- B. Giriens
- Division of Gastroenterology and Hepatology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
| | - P. Yan
- Institute of Pathology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
| | - E. Safroneeva
- Institute of Social and Preventive Medicine; University of Bern; Bern Switzerland
| | - M. Zwahlen
- Institute of Social and Preventive Medicine; University of Bern; Bern Switzerland
| | - A. Reinhard
- Division of Otorhinolaryngology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
| | - A. Nydegger
- Division of Pediatric Gastroenterology; Department of Pediatrics; CHUV, University Hospital Lausanne; Lausanne Switzerland
| | - S. Vavricka
- Division of Gastroenterology and Hepatology; Stadtspital Triemli; Zurich Switzerland
- Division of Gastroenterology and Hepatology; University Hospital Zurich; Zurich Switzerland
| | - C. Sempoux
- Institute of Pathology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
| | - A. Straumann
- Swiss EoE Clinic; Praxis Römerhof; Olten Switzerland
- Division of Gastroenterology and Hepatology; University Hospital Basel; Basel Switzerland
| | - A. M. Schoepfer
- Division of Gastroenterology and Hepatology; Centre Hospitalier Universitaire Vaudois (CHUV); Lausanne Switzerland
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Green DJ, Cotton CC, Dellon ES. The Role of Environmental Exposures in the Etiology of Eosinophilic Esophagitis: A Systematic Review. Mayo Clin Proc 2015; 90:1400-10. [PMID: 26434965 PMCID: PMC4605837 DOI: 10.1016/j.mayocp.2015.07.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/16/2015] [Accepted: 07/22/2015] [Indexed: 12/28/2022]
Abstract
Eosinophilic esophagitis (EoE) is an emerging clinicopathologic entity defined by abnormal esophageal eosinophilic infiltration. Management of this disease is hampered by limited understanding of etiologic and controllable risk factors. The aim of this systematic review was to determine the environmental risk factors for EoE. We searched the PubMed, Web of Science, and EMBASE databases from January 1, 1950, through June 30, 2015. To identify additional relevant studies, we hand searched bibliographies of included articles. We limited the review to articles using human subjects and consisting of case reports, case series, cross-sectional and cohort studies, and clinical trials. Nineteen articles discuss the risk of environmental exposures on EoE and indicate that environment plays a large role in the etiology of EoE. Seasonal, geographic, and climate-based differences in disease prevalence have been reported, but the exact mediators of this process, possibly aeroallergens that vary over time and from place to place, remain elusive.
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Affiliation(s)
- Daniel J Green
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cary C Cotton
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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Mehta P, Furuta GT. Eosinophils in Gastrointestinal Disorders: Eosinophilic Gastrointestinal Diseases, Celiac Disease, Inflammatory Bowel Diseases, and Parasitic Infections. Immunol Allergy Clin North Am 2015. [PMID: 26209893 DOI: 10.1016/j.iac.2015.04.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The gastrointestinal (GI) tract provides an intriguing organ for considering the eosinophil's role in health and disease. The normal GI tract, except for the esophagus, is populated by eosinophils that are present throughout the mucosa, raising the possibility that eosinophils participate in innate mechanisms of defense. However, data from clinical studies associates increased numbers of eosinophils with inflammatory GI diseases, prompting concerns that eosinophils may have a deleterious effect on the gut. We present clinical features of 4 disease processes that have been associated with eosinophilia and suggest areas requiring investigation as to their clinical significance and scientific relevance.
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Affiliation(s)
- Pooja Mehta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Ave B290, Aurora, CO 80045, USA
| | - Glenn T Furuta
- Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Ave B290, Aurora, CO 80045, USA.
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Abstract
Eosinophilic esophagitis (EoE) is a relatively common chronic immune-mediated disease of the esophagus characterized clinically by symptoms of esophageal dysfunction that vary by age. Histologically, EoE results in marked esophageal eosinophilia despite treatment with high-dose proton pump inhibition. The cornerstone of treatment is dietary restriction and/or pharmacologic therapy, mainly with topical steroids. This review briefly describes dietary therapy, but focuses on the various medical options in the treatment of EoE, with an emphasis on steroid-based therapy. Numerous landmark studies are reviewed describing the symptomatic and histologic endpoints as well as safety data. The literature strongly supports the use of topical steroid therapy as a means of significantly decreasing eosinophilic mucosal disease. Specifically, high-dose fluticasone propionate appears to be very effective, and has been shown to result in the resolution of mucosal eosinophilia in a large percentage of treated patients. Long-term studies over many years will need to determine whether mucosal healing will change the natural history of this stricture-causing disease. In addition to topical therapy, various other drug-based therapies are reported, including newer immune-based monoclonal antibodies.
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Affiliation(s)
- Prerna Trivedy
- The Unterberg Children's Hospital at Monmouth Medical Center, Long Branch, NJ, USA
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Molina-Infante J, Lucendo AJ. Eosinophilic esophagitis: a practical approach to diagnosis and management. Expert Rev Gastroenterol Hepatol 2014; 8:925-34. [PMID: 24830679 DOI: 10.1586/17474124.2014.919851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Eosinophilic esophagitis (EoE) has emerged as a common cause of dysphagia and food impaction in children and adults. A trial of proton pump inhibitor (PPI) therapy is a mandatory diagnostic first step, given that at least one third of patients with suspected EoE will have PPI-responsive esophageal eosinophilia. Once EoE is diagnosed, short-and long-term therapeutic decision making may rely on patient symptoms, phenotype (inflammatory vs fibrostenotic) and preferences. Currently, the most reliable therapeutic targets are mucosal healing and caliber abnormalities resolution. Topical steroids followed by endoscopic dilation are recommended in symptomatic narrow caliber esophagus/strictures, whereas either topical steroids or dietary therapy are good short-term options for mucosal inflammation. Maintenance anti-inflammatory therapy is necessary to prevent esophageal fibrotic remodeling and stricture formation.
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Affiliation(s)
- Javier Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, C/ Pablo Naranjo s/n 10003, Caceres, Spain
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Abstract
PURPOSE OF REVIEW Eosinophilic esophagitis (EoE) is a condition characterized by dense mucosal eosinophilia in conjunction with symptoms of esophageal dysfunction. Since both the incidence and prevalence of EoE are on the rise in both children and adults, understanding the various treatment options available is imperative in choosing the proper treatment for each patient. This article will highlight the major strides in both medical and dietary treatment of EoE in the past year. RECENT FINDINGS Whereas prior studies have shown that medical therapy with topical corticosteroids is effective in treating EoE, this more recent literature highlights some of the limitations of this approach, raising awareness that development of better drug delivery models is greatly needed. The review also describes the recent advances in the field of dietary therapy for this disease, particularly in adults, and further supports the notion that the pathophysiology of this disease in children and adults is similar, with food antigens driving this disease. SUMMARY Both medical and dietary therapy are effective for treating adults and children with EoE. Choosing the optimal treatment approach should be individualized based both on patient goals and on available local resources. Future prospective clinical trials comparing these two treatment modalities are needed to help understand comparable effectiveness as well as to help understand potential predictors of response to treatment and identify optimal therapeutic endpoints.
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Abstract
Eosinophilic esophagitis (EoE) has been associated with allergic diseases of the airways and skin. Here, we review the current literature on the sensitization pattern of adult EoE patients and critically discuss the diagnostic and therapeutic tools available. Most EoE patients have elevated total IgE levels in serum and are sensitized to aero- and food allergens as assessed by measuring specific IgE levels and/or the skin prick test. Whereas in children with EoE sensitization to food allergens predominate, in adults EoE symptoms do not correlate with IgE sensitization to specific food allergens. However, in two thirds of adult EoE patients, sensitization to cross-reactive plant allergen components have been be detected, mainly to profilins and PR10 proteins. So far, food triggering EoE can only be identified by an elimination diet and following reintroduction controlled by endoscopy and histology. Further research is required to elucidate the role of allergens in the pathogenesis of EoE and develop appropriate tools for diagnostic and specific treatment.
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Affiliation(s)
- Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland
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Lucendo AJ, Arias Á. Dietary Management of Patients with Eosinophilic Esophagitis. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-014-0012-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Eosinophilic esophagitis (EoE) represents a prevalent chronic esophageal disorder. Since the condition was first described, its pathophysiology has been known to have an immune-allergic origin, but the high response rate to dietary therapies based on feeding patients exclusively with amino acid-based elemental formulas (with complete elimination of table foods) has clearly established EoE as a particular form of food allergy. Nevertheless, the management of EoE in clinical practice remains widely heterogeneous, with topical steroids being a therapeutic mainstay. However, a growing body of evidence points to dietary therapy as an effective treatment option for both children and adults with EoE, as this approach is capable of achieving a sustained symptomatic and histological response without resorting to drugs. This article reviews the available data on the major types of dietary therapy for EoE, including elemental formula diets, skin allergy testing-directed elimination diets and empirical elimination diets based on common food allergens.
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Affiliation(s)
- Angel Arias
- Research Unit, Hospital General Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
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