Update on dietary therapy for eosinophilic esophagitis in children and adults

Abstract

Eosinophilic esophagitis (EoE) is a chronic inflammatory esophageal disease triggered predominantly, but not excusively, by food antigens. Elimination diet thus remains the only therapy targeting the cause of the disease. Importantly, EoE is a unique form of non-IgE mediated food allergy, largely dependant upon delayed, cell-mediated hypersensitivity. Areas covered: A comprehensive review of literature to summarize and update the most relevant advances on dietary therapy for pediatric and adult EoE patients is conducted. Expert commentary: None of the currently available food allergy tests adequately predict food triggers for EoE, especially in adults. Elemental diet (exclusive feeding with aminoacid-based formulas) and empiric six-food elimination diet, withdrawing cow´s milk, wheat, egg, soy, nuts and fish/seafood for 6 weeks, have consistently shown the best cure rates. However, their high level of restriction and need for multiple endoscopies (top-down approach) have been a deterrent for patients and physicians. Less restrictive empiric schemes, like a four-food (animal milk, gluten-containing cereals, egg, legumes) or a two-food (animal milk and gluten-containing cereals) elimination diet have lately shown encouraging results. Therefore, a novel step-up strategy (2-4-6) may enhance patient uptake and promptly identify most responders to empiric diets with few food triggers, besides saving unnecessary dietary restrictions and endoscopic procedures.

The use of amino acid‐based nutritional feeds is effective in the dietary management of pediatric eosinophilic oesophagitis

“…ESPGHAN recommends the TED is followed for 8 to 12 weeks, which involves the exclusion of foods based on results of specific IgE tests, including SPTs and atopy patch tests (APTs) . However, the specificity of the TED is poor, less commonly used and recent guidelines do not endorse its use . ESPGHAN recommends the EED is followed for 8 to 12 weeks which involves the exclusion of six common food containing allergens: cow's milk, wheat, soy, egg, peanuts, and fish/shellfish .…”

“…2,4 However, the specificity of the TED is poor, less commonly used and recent guidelines do not endorse its use. 10,16 ESPGHAN recommends the EED is followed for 8 to 12 weeks which involves the exclusion of six common food containing allergens: cow's milk, wheat, soy, egg, peanuts, and fish/shellfish. 2 This diet is more widely followed in practice with greater success and recent guidelines favor its use compared with TED and ED.…”

“…17 Furthermore, results of elimination diets that sequentially exclude these foods in groups of two, before eliminating all six foods, known as the "step-up" diet, have demonstrated promising remission rates (43% in children), and are becoming common in practice. 16,18 Many guidelines that define EoE fail to define histological remission by the number of eosinophils/ hpf, although ACG guidelines state that endpoints of EoE include improvements in histology which could imply <15 eosinophils/hpf is successful. 2,4,10 A systematic review found most studies used <5 eosinophils/hpf as criteria for histological remission, although some classed histological improvement up to ≤15 eosinophils/hpf, demonstrating a large variation.…”

Dietary therapy for eosinophilic esophagitis

“…4 Since then, numerous series have replicated the effectiveness of a dietary elimination diet for EoE in children and adults. 5 Unlike drug therapy (eg, proton pump inhibitors, topical corticosteroids, or both) and/or endoscopic dilation, dietary elimination therapy potentially offers an effective nonpharmacologic treatment, with continued food avoidance targeted as a long-term, drug-free disease control option. In addition, dietary therapy is the only treatment targeting the cause of the disease.…”

“…After documenting remission and subsequent individual food reintroduction, the final goal will be lifelong elimination of identified culprit foods, usually one to 3 food groups, including dairy, gluten-containing cereals, and/or eggs. 5 Therefore it is crucial to begin with the end in mind for both patients and physicians. This aspect should be carefully discussed between physicians, patients, and their relatives before implementing any dietary therapy in clinical practice.…”