Food intolerance in patients with functional abdominal pain: Evaluation through endoscopic confocal laser endomicroscopy

Abstract

Background and study aims Gastrointestinal symptoms assumed by food intolerance are reported frequently in the general population. There is a significant difference between self-reported and objective proven food intolerance as shown by placebo controlled double blind randomized trials. This discrepancy may be overcome by endoscopic confocal laser endomicroscopy (eCLE). Patients and methods In an observational study we evaluated 34 patients with functional abdominal pain and adverse reaction to food by eCLE and local duodenal food challenge for the first time. Spontaneous and food induced transfer of fluorescein into duodenal lumen was detected 10 minutes following intravenously application of fluorescein and 10 minutes after duodenal food challenge (DFC). Results 67.6% of the patients responded with a fluorescein leakage into the duodenal lumen. Frequency rank order of food antigens that induced a response were soy (50%), wheat (46.1%), milk (20%), egg (12%) and yeast (11.5%), respectively. 23.5% of the patients showed spontaneous leakage of fluorescein suggesting leaky gut syndrome. Histology of duodenal biopsies and mast cell function were normal. Overall, 69.5% improved by the food exclusion therapy and 13% were symptom free according to eCLE. Conclusion The results of our study indicate that eCLE is a clinically useful tool to evaluate patients with functional abdominal pain and adverse reaction to food and to create an individual dietary therapy with clinically benefit for the patients.

Eosinophilic esophagitis and duodenal food challenge – evaluation through endoscopic confocal laser endomicroscopy

“…Only one patient showed this phenomenon. This is in contrast to other studies where up to 50 % of patients with disorders of the gut brain barrier had "leaky gut" [14,15]. This finding suggests that fluorescein leakage into the duodenum during eCLE is not a nonspecific phenomenon because the methodological approach in our investigated patients was the same as reported in the other groups [14,15].…”

“…This is in contrast to other studies where up to 50 % of patients with disorders of the gut brain barrier had "leaky gut" [14,15]. This finding suggests that fluorescein leakage into the duodenum during eCLE is not a nonspecific phenomenon because the methodological approach in our investigated patients was the same as reported in the other groups [14,15]. In addition, the low rate of "leaky gut" of the duodenal mucosa in our study suggests that the postulated epithelial barrier dysfunction in EoE is limited to the esophageal epithelium and not found in other parts of the gastrointestinal tract.…”

Gastrointestinal adverse reaction to food (GARF) and endoscopic confocal laser endomicroscopy (eCLE)

“…Standardized eCLE (Cellvizio System, Mauna Kea Technologies, 9 rue d Enghien, 75010 Paris, France) was applied as previously reported [6,7,8,12]. The investigations were carried out during conventional upper GI endoscopy after an eight hour fasting peri-od under propofol sedation.…”

“…Clinical tools for detecting GARF comprise nutrition diary, identification of lactose, fructose, sorbit and histamine intolerance, food allergies, mast cell disturbances, and elimination diets, respectively. In recent studies, it has been shown that endoscopic confocal laser endomicroscopy eCLE) can provide an objective measure to test mucosal reaction to duodenal food challenge (DFC), [6,7,8]. Duodenal mucosal application of specified food via the endoscope channel may induce immunemediated fluid extravasation through epithelial leaks together with cell shedding as detected by leakage of intravenously applied fluorescein into the duodenal lumen [6,7,8].…”

Comments on the use of confocal laser endomicroscopy in diagnosing protein-losing enteropathy

“…First, we would like to address some specificity and technical issues. The presence of leakiness of fluorescence into the lumen using CLE has been reported repeatedly in disorders of gut-brain interaction: patients without PLE but instead with irritable bowel syndrome or functional dyspepsia [2,3,4]. One group found that gaps per 1000 epithelial cells in the duodenum correlated with intestinal permeability in patients with functional dyspepsia [4].…”