Can we determine appropriate foods to eliminate to treat Eosinophilic Esophagitis?
Published Online: June 29, 2012
Eosinophilic Esophagitis (EoE) is an allergic condition with symptoms isolated to the esophagus. The symptoms range from not growing to reflux and difficulty swallowing. These symptoms are due to eosinophils, a special type of white blood cells going to the esophagus, a location where eosinophils are not normally present. The disease is due to food allergies in almost all pediatric patients, but standard allergy testing does not identify the correct food.
In an article published in The Journal of Allergy and Clinical Immunology (JACI), Spergel and colleagues at The Children’s Hospital of Philadelphia identified which foods were responsible for disease in a large retrospective analysis over 1,000 pediatric patients. Foods to cause EoE were identified in a rigorous method by showing changes in biopsy findings before and after addition of a single food. They also had two additional categories of food reactions (symptoms and IgE mediated reactions). IgE mediated reactions are the classic reaction of hives, vomiting, and anaphylaxis occurring immediately after eating a food. Diets were compared after all foods were reintroduced except for the foods causing symptoms and biopsy changes. Spergel et al also examined the use of standard skin prick testing as well as atopy patch testing to identify if allergy testing could identify which food caused disease.
The researchers were able to identify that milk was the primary cause of disease and seen in 2/3 of the patients and milk elimination by itself cured 30% of patients. Milk, egg, wheat, soy, peanut, and meats were the most common foods that caused disease by symptoms or biopsy. Over half of the patients react to only two foods, but approximately 25% reacted to four or more foods. The other interesting findings that these patients were highly allergic with nearly three-quarters of the patients having some other allergy and the rate of anaphylaxis and hive reactions to foods were seen in nearly 16% of the patients.
The authors examined various diet plans and compared them to elimination diets based on allergy testing. Standard allergy testing and atopy patch testing had low predictive value for identifying the food that was causing disease, but it was better indicating a food was not causing disease (negative predictive value) with the notable exception of milk. The researchers at CHOP found that diet based on empiric elimination (guessing) work as well as allergy testing (about 50%) for both. But, the best approach was either allergy testing with empiric milk elimination or empiric elimination of milk, egg, wheat, soy, chicken, pork, turkey, and beef with a cure rate over 75%.
Spergel et al found that foods can be identified in most patients with EoE with milk, egg, and wheat being the most common. Both allergy testing directed therapy and empiric directed therapy can be used in the treatment of patients with eosinophilic esophagitis.
The Journal of Allergy and Clinical Immunology (JACI) is the official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.