Allergy testing in eosinophilic esophagitis
- Jonathan M Spergel, MD, PhD, FAAAAI
Jonathan M Spergel, MD, PhD, FAAAAI
- Professor of Pediatrics
- University of Pennsylvania School of Medicine
Eosinophilic esophagitis (EoE) was defined by a panel of experts as “a chronic, immune/antigen-mediated, esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation” . Allergy testing in EoE is warranted to identify and manage common comorbid atopic diseases (eg, asthma, allergic rhinitis) and to determine foods that may present a risk for acute allergic reactions/immediate type allergy (this is a concern for many patients with EoE at baseline and also when eliminated foods are potentially reintroduced into the diet during treatment). It may also be considered to potentially identify EoE triggers.
The evidence supporting the role of allergies in EoE and the various types of allergy testing used are reviewed here. Other aspects of disease pathogenesis, clinical manifestations, general diagnostic evaluation, and treatment (including choosing a specific elimination diet) are reviewed separately. (See "Clinical manifestations and diagnosis of eosinophilic esophagitis" and "Treatment of eosinophilic esophagitis" and "Dietary management of eosinophilic esophagitis" and "Patient education: Eosinophilic esophagitis (The Basics)".)
EVIDENCE FOR ROLE OF ALLERGIES IN EOSINOPHILIC ESOPHAGITIS
Several lines of evidence suggest that allergies play a significant role in EoE. An immune response to allergen/antigen is a primary factor in the pathogenesis of the disease, and there is evidence that both environmental allergies and food allergies are involved. In addition, the majority of patients with EoE are atopic, with asthma, allergic rhinitis, atopic dermatitis, and/or IgE-mediated food allergy.
Mechanistic studies — Evidence for allergies in EoE is supported by murine models that show that skin sensitization protocols can induce eosinophilic inflammation in the esophagus when that organ is challenged [2-4]. In addition, examination of esophageal samples has indicated that classic allergic cytokines and chemokines (interleukin [IL]-4, IL-5, IL-13, eotaxin-3) are involved in the pathogenesis of EoE [1,4-7]. Additional details on the pathogenesis of EoE are discussed separately. (See "Eosinophilic esophagitis (EoE): Genetics and immunopathogenesis", section on 'Pathogenesis'.)
Clinical response to dietary changes — The evidence for the role of food allergies in the pathogenesis of EoE is based upon the clinical response when patients are placed on various elimination diets, with resolution of symptoms and normalization of esophageal biopsies. The data are more extensive and more convincing in children than in adults. This evidence is discussed in detail separately. (See "Dietary management of eosinophilic esophagitis", section on 'Role of food allergy in EoE'.)
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- EVIDENCE FOR ROLE OF ALLERGIES IN EOSINOPHILIC ESOPHAGITIS
- Mechanistic studies
- Clinical response to dietary changes
- Association with environmental allergies
- Atopic history
- FOOD ALLERGY TESTING IN EOSINOPHILIC ESOPHAGITIS
- Skin prick testing
- Specific IgE testing
- Atopy patch testing
- Skin prick and atopy patch testing
- OUR APPROACH
- SUMMARY AND RECOMMENDATIONS