Food avoidance and prolonged drug-free remission in adult eosinophilic esophagitis
Published Online: February 4, 2013
Eosinophilic esophagitis (EoE), a food-allergy associated, chronic esophageal disorder characterized by symptoms of esophageal dysfunction and a predominant eosinophilic inflammation, has become increasingly prevalent during the past few years in both children and adults. Because elimination diets based on food-allergy test results have proved to be of limited use due to their inconsistent results, most patients are treated with swallowed topical steroids. However, empirical exclusion of major potential food antigens has recently arisen as a promising therapy for these patients.
A study published recently in The Journal of Allergy and Clinical Immunology (JACI) by Dr. Alfredo J. Lucendo and co-workers has investigated the prolonged efficacy of empirical food exclusion in adults suffering from EoE: 67 patients were treated exclusively with a diet avoiding cereals, milk, eggs, fish/seafood, legumes/peanuts, and soy for 6 weeks. EoE remission (i.e., symptom resolution and biopsy normalization) was documented in three-fourths of the subjects. After sequentially reintroducing all excluded single-foods and conducting subsequent endoscopic exams and biopsies, the authors were able to identify specific EoE food triggers through documented disease recurrence. Among the triggers, milk, wheat, eggs, and legumes were found to be the most common causes of EoE. Even more importantly, for the first time research has provided evidence that continued avoidance of offending foods from the diets of patients with EoE can lead to maintained disease remission in terms of symptoms and esophageal inflammation for up to 3 years.
The authors also assessed the reliability of immunoglobulin E (IgE)-based allergy tests in guiding food exclusion: serum specific IgE and skin prick tests were performed in each patient before initiating the diet. Interestingly, IgE-driven hypersensitivity showed limited usefulness in identifying EoE triggers, exhibiting extremely low concordance with the results of food-reintroduction challenges. As a consequence, the authors suggest that the main pathophysiological mechanism leading to EoE might not be IgE-mediated allergies, but rather a delayed hypersensitivity reaction against common, regularly consumed foods.
After analyzing these results, the authors raise the question of whether empirical exclusion diets should be tailored to specific areas and based on the staple diets and food-sensitization profiles of the region in which the EoE patient is being treated. While this possibility must be further explored, the present research opens the door to a new, feasible, drug-free maintenance therapy for EoE patients.
The Journal of Allergy and Clinical Immunology (JACI) is an official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.