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Eosinophilic esophagitis: food vs environment allergen triggers

Question:

8/11/2017

I have a young male teen who presented for allergy testing after recent diagnosis with EoE. Symptoms are trouble swallowing food and meds, and two episodes of food stuck in his lifetime. EGD showed 27 Eos /HPF in mid esophagus with furrowing evident. Lower esophagus has an ulcer. No abnormalities of GE junction or duodenum. Food skin testing for 60 foods showed + to hazelnut and almond only; both of which he consumes regularly. He has numerous significant pollen allergies per history and testing and is also positive to dust but not significantly on skin test, but very symptomatic with dust. GI placed him on Prilosec 40 mg BID and symptoms are now controlled and plan a repeat EGD in 3 months. I would like to know if allergen immunotherapy (SCIT) helps if there is data to suggest that SCIT independently has benefit in EoE, controlling for dietary changes. I have asked patient to avoid those two nuts, even though he has never noticed symptoms with them and wonder if I should start SCIT for purpose of helping his EoE not for his nasal allergies. He tolerates his nasal allergies and is not bothered enough to start SCIT for hay fever alone. I have done a preliminary literature search and found that SCIT and dietary changes combined can help, but nothing about any sequential endoscopies i.e. one after dietary changes, and then a second EGD after SCIT to determine if SCIT alone benefits EoE.

Answer:

I shared your inquiry with Marc Rothenberg, MD, PhD. Dr Rothenberg indicated that skin testing unfortunately does not have any strong predictive value for identifying the triggers for EoE, and there is little data that aeroallergens can be the primary trigger. The patient’s atopic background is consistent with this being antigen driven, and it is most likely food, and milk is the most common food, but polysensitization (multiple foods) is likely involved. PPI treatment has now become an important therapeutic for esophageal eosinophilia, and about 30% of patients will respond to PPI monotherapy.      
 
Jacqueline A. Pongracic, MD, FAAAAI