Strategy for Food Reintroduction Following Empiric Elimination and Elemental Dietary Therapy in the Treatment of Eosinophilic Gastrointestinal Disorders

[Eosinophilic gastrointestinal diseases with esophageal involvement: Analysis of 212 patients]

BACKGROUND

Primary eosinophilic gastrointestinal diseases (EGID) are chronic inflammatory disorders of the gastrointestinal tract with unknown etiology. Features, utility, and evolution are still unknown in screening for EGID in adult patients with eosinophilic esophagitis (EoE).

OBJECTIVES

To evaluate the prevalence, characteristics, comorbidities, and evolution of EGID in adults diagnosed with EoE and investigate differences between both groups.

METHODS

Prospective unicenter observational and analytical study. Gastric and duodenal biopsies were obtained during upper baseline endoscopy in all consecutive EoE adult patients evaluated. A colonoscopy with colon biopsies was performed upon persistent diarrhea and normal duodenal biopsies.

RESULTS

212 EoE patients were included. Nine patients (4.3%) also showed significant eosinophilic infiltration in at least one organ within the digestive tract. The most common site affected was the small bowel (78%). Gastrointestinal symptoms (43% vs. 100%, p<0.002) and, more specifically, either abdominal pain or diarrhea (17% vs. 78%, p<0.001), some food sensitizations, and digestive comorbidities (p<0.05) were significantly more common in patients with EGID. Gastrointestinal symptoms were present in 94/212 (44%) patients, of whom 9 (10%) had EGID. Considering only abdominal pain or diarrhea, 20% suffered from it.

CONCLUSIONS

EGID rarely coexist with EoE, even when gastrointestinal symptoms are present. These findings advise against routine gastric, duodenal, or colon biopsies in adult EoE patients with gastrointestinal symptoms. Most of the characteristics of EoE do not change due to having EGID except gastrointestinal symptoms, digestive comorbidities, and sensitizations to some foods. The evolution was generally favorable despite intermittent adherence to treatment, especially maintenance.

The use of amino acid formulas in pediatric patients with allergy to cow's milk proteins: Recommendations from a group of experts

One of the most common food allergies in children is cow's milk allergy (CMA). In breast-fed infants with CMA, the mother is encouraged to avoid dairy products. If this is not possible, or in formula fed infants, use of hypoallergenic replacement formulas such as extensively hydrolyzed formulas (EHF) is recommended. However, in ∼5% of patients EHFs are not tolerated and/or allergy symptoms can persist. When EHFs are ineffective and in severe forms of CMA, amino acid-based formulas (AAF) should be considered. Six pediatric gastroenterologists with extensive experience in food allergy management reviewed scientific publications and international clinical practice guidelines to provide practical recommendations on AAF. The guidelines reviewed had discrepancies and ambiguities around the specific indications for using formulas as a milk substitute. The panel recommends AAFs as the first therapeutic option in anaphylaxis due to CMA, in acute and chronic severe food protein-induced enterocolitis syndrome, in CMA associated with multiple food allergy, and in cases of eosinophilic esophagitis not responding to an extended exclusion diet or not eating solids. The main benefit of AAF is its absence of residual allergenicity, making it a safe treatment option in severe CMA patients who do not tolerate or respond to an EHF.

Association of fecal calprotectin level with eosinophilic gastrointestinal disease in Iranian pediatrics

Introduction

Fecal calprotectin (FC) is a noninvasive biomarker for assessing the inflammatory status of the gastrointestinal tract. The aim of this study was to determine the association between FC levels and Eosinophilic colitis (EC) before and after treatment in pediatrics.

Method

In this cross-sectional study, 330 patients with rectorrhagia and FC levels > 200 μg/g were included in the study. Patients were then subjected to colonoscopy, and if 30 or more eosinophils were observed in the pathology of at least two parts of the colon, EC was diagnosed. Of the 330 patients included in the study, 14 patients were diagnosed as EC. Treatment included seven food elimination diet (food allergens) for 3 months. After 3 months, FC levels were repeated and colonoscopy was performed.

Results

The mean age of the children was 5.9 years. After the elimination diet, the number of eosinophils in all segments of colon significantly decreased (P < 0.001) and according to the pathology report, the number of eosinophils improved in 42.9% of patients. Also, the mean number of segments involved in the colon of patients was significantly decreased (P < 0.001). Mean FC levels were significantly decreased after 3 months (P < 0.001). The cut-off point of 114 μg/g of FC had sensitivity (75%), specificity (67%), positive predictive value (75%), negative predictive value (67%), accuracy (71.4%), and area under the ROC curve (0.708) acceptable in predicting EC.

Conclusion

This study showed that FC levels can be elevated in patients with EC, which is easily corrected with a targeted elimination of food allergens.

Preliminary evidence in treatment of eosinophilic gastroenteritis in children: A case series

BACKGROUND

Eosinophilic gastroenteritis is a rare inflammatory disorder in children. However, there is still no standard guideline in the treatment of pediatric eosinophilic gastroenteritis.

AIM

To report our experience with the diagnosis and treatment of children with eosinophilic gastroenteritis.

METHODS

From January 2017 to December 2019, a total of 22 children were diagnosed with eosinophilic gastroenteritis.

RESULTS

Endoscopic examination showed eosinophil infiltration in the duodenum [mean number of eosinophils/high-power field (HPF) = 53.1 ± 81.5], stomach (mean number of eosinophils/HPF = 36.8 ± 50.5), and terminal ileum (mean number of eosinophils/HPF = 49.0 ± 24.0). All 18 children with low eosinophil infiltration (< 14%) responded well to the initial drug treatment without relapse, while two of four children with high eosinophil infiltration (> 14%) relapsed after initial methylprednisolone/montelukast treatment. In addition, children with high eosinophil infiltration (> 14%) showed symptomatic relief and histological remission without further relapse after receiving budesonide/methylprednisolone as initial or relapse treatment.

CONCLUSION

Methylprednisolone/montelukast is still the best treatment for children with low eosinophil infiltration (< 14%). Budesonide can be considered as the initial or relapse treatment for children with high eosinophil infiltration (> 14%).

A Clinical Perspective on the Dietary Therapies for Pediatric Eosinophilic Esophagitis: The Gap Between Research and Daily Practice

Pediatric eosinophilic esophagitis (ped-EoE) is an immune-mediated pathology affecting 34 per 100.000 children. It is characterized by an esophageal inflammation caused by an immune response towards food antigens that come into contact with the esophageal lining. Depending on the age of the child, symptoms can vary from abdominal pain, vomiting and failure to thrive to dysphagia and food impaction. The diagnosis of this chronic disease is based on the symptoms of esophageal dysfunction combined with an infiltration of more than 15 eosinophils per high-power field and the exclusion of secondary causes. The treatment modalities include the 3Ds: Drugs, allergen avoidance by Diet and/or esophageal Dilation. In this review we focused on the efficacy of dietary approaches in ped-EoE, which currently include the elemental diet (amino acid-based diet), the empiric elimination diet and the allergy test-directed elimination diet. Although several reviews have summarized these dietary approaches, a lack of consistency between and within the elimination diets hampers its clinical use and differences in subsequent reintroduction phases present a barrier for dietary advice in daily clinical practice. We therefore conducted an analysis driven from a clinician's perspective on these dietary therapies in the management of ped-EoE, whereby we examined whether these variations within dietary approaches, yet considered to be similar, could result in significant differences in dietary counseling.

Epidemiology and risk factors for eosinophilic esophagitis: lessons for clinicians

INTRODUCTION

The rapid expansion in the epidemiology of eosinophilic esophagitis (EoE) is being documented, along with cumulative research assessing environmental exposures associated with EoE and susceptibility due to genetic variants.

AREAS COVERED

Incidence rates for EoE of 5-10 new cases per 100,000 inhabitants annually have shown an increase in recent reports of up to 20 in some countries; the highest prevalence being reported for Europe and North America, where EoE now affects more than 1 out of 1,000 people. EoE has been shown to be associated with several disorders, Th2-mediated atopies being the most common. Patients with EoE exhibit increased frequency of asthma, allergic rhinitis and eczema, and EoE has been considered as a late component of the atopic march. Risk variants in TSLP, CAPN14 and LRCC32 genes, among others, have all been related to EoE, and interact with prenatal and early life exposure potentially modifying abundance and composition of gut microbiome. Dysregulated interactions between bacteria and mucosal immunity emerge as leading causes of EoE.

EXPERT OPINION

The expanding epidemiology of EoE, the resources needed and subsequent increasing healthcare costs require additional effort to optimize cost-effective management and unveil mechanisms that enhance the development of future preventive strategies.