Dietary management of eosinophilic esophagitis
- Seema S Aceves, MD, PhD
Seema S Aceves, MD, PhD
- Associate Professor of Pediatrics and Medicine
- University of California, San Diego
- Rady Children's Hospital, San Diiego
- Section Editors
- Scott H Sicherer, MD, FAAAAI
Scott H Sicherer, MD, FAAAAI
- Section Editor — Food Allergy
- Professor of Pediatrics
- Icahn School of Medicine at Mount Sinai
- Nicholas J Talley, MD, PhD
Nicholas J Talley, MD, PhD
- Section Editor — Motility Disorders
- Professor of Medicine, University of Newcastle, Australia
- Adjunct Professor of Medicine and Epidemiology and Consultant, Mayo Clinic, Rochester, MN
- Adjunct Professor, University of North Carolina
Eosinophilic esophagitis (EoE) has been 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" that is not responsive to acid blockade with a proton pump inhibitor (PPI), unlike gastroesophageal reflux disease (GERD) or PPI responsive esophageal eosinophilia . The management of EoE includes dietary, pharmacologic, and endoscopic interventions. It is uncertain whether treatment of symptoms alone is sufficient or if complete resolution of eosinophilic inflammation is also required.
This topic reviews the clinical evidence for the role of food allergies in EoE and elimination and elemental diets for the treatment of EoE. The various types of allergy testing used in the diagnostic evaluation of EoE are reviewed separately. Other aspects of disease pathogenesis, clinical manifestations, general diagnostic evaluation, additional treatment options, and prognosis are also discussed elsewhere. (See "Eosinophilic esophagitis (EoE): Genetics and immunopathogenesis" and "Allergy testing in eosinophilic esophagitis" and "Clinical manifestations and diagnosis of eosinophilic esophagitis" and "Treatment of eosinophilic esophagitis" and "Patient education: Eosinophilic esophagitis (The Basics)".)
ROLE OF FOOD ALLERGY IN EoE
Food allergy is defined by a recurrent and predictable immune response upon ingestion of a food antigen. The mechanism of food allergy can vary from immediate immunoglobulin E (IgE)-mediated hypersensitivity to chronic autoimmune reactions driven by antigen-specific T cells. (See "Pathogenesis of food allergy", section on 'Types of reactions' and "Clinical manifestations of food allergy: An overview".)
The pathogenesis of EoE appears to depend largely upon delayed, cell-mediated hypersensitivity. Evidence for this is based both upon clinical reactions in human subjects and on animal models that rely on the presence of T cells for disease induction [2,3]. Disease induction and/or propagation have not been shown to rely on IgE-mediated mechanisms, even though IgE sensitization to foods is common in EoE and the prevalence of food-induced anaphylaxis is higher in children with EoE [4-8]. In addition, EoE triggered by a specific food has developed after resolution of IgE-mediated allergy to the same food .
The relationship between gastric acid/gastroesophageal reflux disease (GERD), esophageal eosinophilia, and food allergies still requires clarification. As an example, whether acid can induce epithelial barrier damage that predisposes to food sensitization or whether acid suppression allows for increased IgE sensitization remains to be systematically studied. (See "Pathogenesis of food allergy".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Liacouras CA, Furuta GT, Hirano I, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128:3.
- Mishra A, Schlotman J, Wang M, Rothenberg ME. Critical role for adaptive T cell immunity in experimental eosinophilic esophagitis in mice. J Leukoc Biol 2007; 81:916.
- Gonsalves N, Yang GY, Doerfler B, et al. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 2012; 142:1451.
- Erwin EA, James HR, Gutekunst HM, et al. Serum IgE measurement and detection of food allergy in pediatric patients with eosinophilic esophagitis. Ann Allergy Asthma Immunol 2010; 104:496.
- Spergel JM, Andrews T, Brown-Whitehorn TF, et al. Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests. Ann Allergy Asthma Immunol 2005; 95:336.
- Spergel JM, Brown-Whitehorn TF, Beausoleil JL, et al. 14 years of eosinophilic esophagitis: clinical features and prognosis. J Pediatr Gastroenterol Nutr 2009; 48:30.
- Sugnanam KK, Collins JT, Smith PK, et al. Dichotomy of food and inhalant allergen sensitization in eosinophilic esophagitis. Allergy 2007; 62:1257.
- Spergel JM, Brown-Whitehorn TF, Cianferoni A, et al. Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet. J Allergy Clin Immunol 2012; 130:461.
- Maggadottir SM, Hill DA, Ruymann K, et al. Resolution of acute IgE-mediated allergy with development of eosinophilic esophagitis triggered by the same food. J Allergy Clin Immunol 2014; 133:1487.
- Lieberman JA, Morotti RA, Konstantinou GN, et al. Dietary therapy can reverse esophageal subepithelial fibrosis in patients with eosinophilic esophagitis: a historical cohort. Allergy 2012; 67:1299.
- Dohil R, Newbury R, Fox L, et al. Oral viscous budesonide is effective in children with eosinophilic esophagitis in a randomized, placebo-controlled trial. Gastroenterology 2010; 139:418.
- Straumann A, Bussmann C, Zuber M, et al. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008; 6:598.
- Klinnert MD. Psychological impact of eosinophilic esophagitis on children and families. Immunol Allergy Clin North Am 2009; 29:99.
- Henderson CJ, Abonia JP, King EC, et al. Comparative dietary therapy effectiveness in remission of pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2012; 129:1570.
- Molina-Infante J, Martin-Noguerol E, Alvarado-Arenas M, et al. Selective elimination diet based on skin testing has suboptimal efficacy for adult eosinophilic esophagitis. J Allergy Clin Immunol 2012; 130:1200.
- Wolf WA, Jerath MR, Sperry SL, et al. Dietary elimination therapy is an effective option for adults with eosinophilic esophagitis. Clin Gastroenterol Hepatol 2014; 12:1272.
- Kelly KJ, Lazenby AJ, Rowe PC, et al. Eosinophilic esophagitis attributed to gastroesophageal reflux: improvement with an amino acid-based formula. Gastroenterology 1995; 109:1503.
- Archer DC, Barrie Edwards G, Kelly DF, et al. Obstruction of equine small intestine associated with focal idiopathic eosinophilic enteritis: an emerging disease? Vet J 2006; 171:504.
- Markowitz JE, Spergel JM, Ruchelli E, Liacouras CA. Elemental diet is an effective treatment for eosinophilic esophagitis in children and adolescents. Am J Gastroenterol 2003; 98:777.
- Orenstein SR, Shalaby TM, Di Lorenzo C, et al. The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children. Am J Gastroenterol 2000; 95:1422.
- Liacouras CA, Spergel JM, Ruchelli E, et al. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol 2005; 3:1198.
- Kagalwalla AF, Sentongo TA, Ritz S, et al. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis. Clin Gastroenterol Hepatol 2006; 4:1097.
- Kagalwalla AF, Shah A, Li BU, et al. Identification of specific foods responsible for inflammation in children with eosinophilic esophagitis successfully treated with empiric elimination diet. J Pediatr Gastroenterol Nutr 2011; 53:145.
- Spergel JM, Brown-Whitehorn T, Beausoleil JL, et al. Predictive values for skin prick test and atopy patch test for eosinophilic esophagitis. J Allergy Clin Immunol 2007; 119:509.
- Peterson KA, Byrne KR, Vinson LA, et al. Elemental diet induces histologic response in adult eosinophilic esophagitis. Am J Gastroenterol 2013; 108:759.
- Abu-Sultaneh SM, Durst P, Maynard V, Elitsur Y. Fluticasone and food allergen elimination reverse sub-epithelial fibrosis in children with eosinophilic esophagitis. Dig Dis Sci 2011; 56:97.
- Syrigou E, Angelakopoulou A, Zande M, et al. Allergy-test-driven elimination diet is useful in children with eosinophilic esophagitis, regardless of the severity of symptoms. Pediatr Allergy Immunol 2015; 26:323.
- Rodríguez-Sánchez J, Gómez Torrijos E, López Viedma B, et al. Efficacy of IgE-targeted vs empiric six-food elimination diets for adult eosinophilic oesophagitis. Allergy 2014; 69:936.
- Lucendo AJ, Arias A, Tenías JM, et al. Serum IgE-targeted elimination diets for treating eosinophilic esophagitis: things are not what they seem. Allergy 2014; 69:1567.
- Kagalwalla AF, Amsden K, Shah A, et al. Cow's milk elimination: a novel dietary approach to treat eosinophilic esophagitis. J Pediatr Gastroenterol Nutr 2012; 55:711.
- Kruszewski PG, Russo JM, Franciosi JP, et al. Prospective, comparative effectiveness trial of cow's milk elimination and swallowed fluticasone for pediatric eosinophilic esophagitis. Dis Esophagus 2016; 29:377.
- Abraham JR, Persad R, Turner JM, Huynh HQ. Gluten-free diet does not appear to induce endoscopic remission of eosinophilic esophagitis in children with coexistent celiac disease. Can J Gastroenterol 2012; 26:521.
- Kagalwalla AF, Wechsler JB, Amsden K, et al. Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2017; 15:1698.
- Molina-Infante J, Arias A, Barrio J, et al. Four-food group elimination diet for adult eosinophilic esophagitis: A prospective multicenter study. J Allergy Clin Immunol 2014; 134:1093.
- Lucendo AJ, Arias Á, González-Cervera J, et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol 2013; 131:797.
- Arias A, González-Cervera J, Tenias JM, Lucendo AJ. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis. Gastroenterology 2014; 146:1639.
- Lucendo AJ. Meta-Analysis-Based Guidance for Dietary Management in Eosinophilic Esophagitis. Curr Gastroenterol Rep 2015; 17:464.
- Spergel JM, Beausoleil JL, Mascarenhas M, Liacouras CA. The use of skin prick tests and patch tests to identify causative foods in eosinophilic esophagitis. J Allergy Clin Immunol 2002; 109:363.
- Lucendo AJ, Arias Á, González-Cervera J, et al. Dual response to dietary/topical steroid and proton pump inhibitor therapy in adult patients with eosinophilic esophagitis. J Allergy Clin Immunol 2016; 137:931.
- Leung J, Hundal NV, Katz AJ, et al. Tolerance of baked milk in patients with cow's milk-mediated eosinophilic esophagitis. J Allergy Clin Immunol 2013; 132:1215.
- Lucendo AJ, Arias Á, González-Cervera J, et al. Tolerance of a cow's milk-based hydrolyzed formula in patients with eosinophilic esophagitis triggered by milk. Allergy 2013; 68:1065.
- Henry ML, Atkins D, Fleischer D, et al. Factors contributing to adherence to dietary treatment of eosinophilic gastrointestinal diseases. J Pediatr Gastroenterol Nutr 2012; 54:430.
- Kliewer KL, Venter C, Cassin AM, et al. Should wheat, barley, rye, and/or gluten be avoided in a 6-food elimination diet? J Allergy Clin Immunol 2016; 137:1011.
- Colson D, Kalach N, Soulaines P, et al. The impact of dietary therapy on clinical and biologic parameters of pediatric patients with eosinophilic esophagitis. J Allergy Clin Immunol Pract 2014; 2:587.
- Busse PJ, Nowak-Wegrzyn AH, Noone SA, et al. Recurrent peanut allergy. N Engl J Med 2002; 347:1535.
- Boyce JA, Assa'a A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-Sponsored Expert Panel Report. Nutrition 2011; 27:253.
- Clayton F, Fang JC, Gleich GJ, et al. Eosinophilic esophagitis in adults is associated with IgG4 and not mediated by IgE. Gastroenterology 2014; 147:602.
- Erwin EA, Kruszewski PG, Russo JM, et al. IgE antibodies and response to cow's milk elimination diet in pediatric eosinophilic esophagitis. J Allergy Clin Immunol 2016; 138:625.
- ROLE OF FOOD ALLERGY IN EoE
- TREATMENT OPTIONS
- DIETARY TREATMENT OPTIONS
- Elemental diets
- Elimination diets
- EFFICACY OF DIFFERENT DIETARY APPROACHES
- IMPLICATED FOODS
- CHOOSING AN ELIMINATION DIET
- INSTITUTING AN ELIMINATION DIET
- REINTRODUCTION OF FOODS
- NATURAL HISTORY OF FOOD ALLERGIES IN EoE
- SUMMARY AND RECOMMENDATIONS