Dietary Therapy in Eosinophilic Esophagitis

Eosinophilic esophagitis in children: A multicenter study evaluating current practices in Mexico

Background

Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition characterized by eosinophil infiltration in the esophagus, leading to symptoms such as food impaction and growth delays. Despite its increasing recognition, there is significant variability in diagnostic and treatment practices, particularly in pediatric populations.

Objectives

This study aimed to evaluate the current diagnostic and treatment practices for EoE in children across multiple centers in Mexico, identify common clinical presentations, and assess the role of IgG4 in EoE.

Methods

A retrospective analysis was conducted on 32 pediatric patients diagnosed with EoE. Data on clinical symptoms, endoscopic findings, histologic analysis, allergy assessments, and treatment approaches were collected. The presence of IgG4-positive plasma cells was also evaluated.

Results

The median age was 10.6 years, with a diagnostic delay of 15.5 months. Acute food impaction was the most common symptom, and 82% had a personal history of atopy. Endoscopic abnormalities were observed in 71% of patients. Histologic analysis confirmed EoE in 83.8% of biopsy samples, with eosinophil counts averaging 17 to 24 per high-power field. IgG4-positive plasma cells were present in 76.5% of patients. Treatment varied, with many receiving proton pump inhibitors and topical corticosteroids, but patients treated with dupilumab showed significant improvement.

Conclusions

The study highlights the challenges in diagnosing and managing EoE in children, emphasizing the need for standardized practices and comprehensive evaluations. The presence of IgG4-positive plasma cells suggests a potential role in EoE pathophysiology. Further research is needed to establish effective treatment guidelines and confirm the potential of dupilumab as a therapeutic option.

Allergy-Test-Based Elimination Diets for the Treatment of Eosinophilic Esophagitis: A Systematic Review of Their Efficacy

Eosinophilic esophagitis (EoE) is an immune-mediated esophageal disorder, linked with sensitization to food and airborne allergens. Dietary manipulations are proposed for the management of EoE inflammation and are often successful, confirming the etiological role of food allergens. Three different dietary approaches are widely used: the elemental, the empirical, and the allergy-test-driven approach. We performed a systematic review to assess the evidence on the association of allergens, detected by allergy tests, with clinically confirmed triggers of EoE. We systematically searched PubMed, Scopus, Embase, and the Cochrane Library, through 1 June 2021. We sought studies examining the correlation of skin-prick tests (SPT), atopy patch tests (APT), specific IgE, and serum-specific IgG4, with confirmed triggers of EoE. Data on the use of prick–prick tests were also extracted. Evidence was independently screened by two authors against predefined eligibility criteria. Risk of bias was assessed with the ROBINS-I tool. Of 52 potentially eligible studies, 16 studies fulfilling quality criteria were included. These studies used one to three different allergy tests detecting food sensitization. The positive predictive value was generally low to moderate but higher when a combination of tests was used than single-test evaluations. None of the selected studies used serum-specific IgG4. Although an extreme methodological variability was noticed in the studies, allergy-based elimination diets were estimated to be efficient in 66.7% of the cases. The efficacy of targeted elimination diets, guided by SPT, sIgE, and/or APT allergy tests, does not appear superior to empirical ones. In the future, tests using esophageal prick testing or ex vivo food antigen stimulation may prove more efficient to guide elimination diets.

Food-specific antibodies in oesophageal secretions: association with trigger foods in eosinophilic oesophagitis

BACKGROUND

Food antigens are clearly implicated in the induction and persistence of eosinophilic oesophagitis. Dietary elimination to identify triggers is tedious and expensive. Alternatives that can mitigate cost and improve patient quality of life during this process are needed.

AIMS

To test the hypothesis that antibodies against foods that trigger eosinophilic oesophagitis are secreted into the oesophageal lumen where they can be collected by oesophageal brushings.

METHODS

We evaluated food-specific immune responses within brushings in 68 patients undergoing endoscopy (12 controls, 13 resolved eosinophilic oesophagitis and 43 active eosinophilic oesophagitis). Seventeen participants identified their trigger foods via food elimination diets. Immunoglobulin A and immunoglobulin G4 antibodies against the four most common eosinophilic oesophagitis food triggers were measured using the ImmunoCAP assay in the oesophageal brushings. Food-specific antibody values were compared between active eosinophilic oesophagitis, resolved eosinophilic oesophagitis and controls.

RESULTS

Patients with active eosinophilic oesophagitis (>15 eosinophils/hpf) demonstrated increased immunoglobulin A and immunoglobulin G4 levels to common eosinophilic oesophagitis triggers compared to controls (327 ± 380 vs 150 ± 130 for immunoglobulin A, and 1534 ± 3346 vs 178 ± 123 for immunoglobulin G4, P < 0.003). Specific trigger foods were associated with elevated immunoglobulin A and immunoglobulin G4 responses compared to foods that did not trigger oesophageal eosinophilia (733 ± 469 vs 142 ± 64, P < 0.001 immunoglobulin A and 2620 ± 3228 vs 526 ± 1050, P < 0.001 immunoglobulin G4).

CONCLUSIONS

Food-specific antibodies are easily collected along the oesophageal lumen of eosinophilic oesophagitis patients. Further studies are needed to validate our preliminary findings to determine whether these antibodies can be used to guide elimination diet therapy.

Internalized Stigma in Patients with Eosinophilic Gastrointestinal Disorders

The aim of the current study is to evaluate internalized stigma in individuals diagnosed with an eosinophilic gastrointestinal disorder (EGID) and its impact on psychosocial and health-related outcomes. The final study sample consisted of 149 patients with a self-reported EGID diagnosis for at least 6 months. Participants completed measures evaluating internalized stigma, disease-specific quality of life, emotional distress (anxiety, depression) and answered questions regarding healthcare utilization. Overall, increased internalized stigma was associated with decreased disease-specific quality of life, and increased anxiety and depression. In addition, participants with greater overall internalized stigma felt that treatments were less effective, and the internalized stigma subscales of alienation and discrimination were associated with increased outpatient visits and endoscopies, respectively. Providers working with EGID patients should assess for signs of internalized stigma, such as social withdrawal and alienation. Psychogastroenterology services that deliver evidence-based psychological interventions may reduce some of the negative impacts of internalized stigma.

Eosinophilic Esophagitis

Eosinophilic esophagitis is an immune-mediated chronic disease of the esophagus. It is clinically characterized by symptoms related to esophageal dysfunction and histologically by eosinophil-rich inflammation with a peak intraepithelial eosinophil count of at least 15 eosinophils per high-power field. Both children and adults can be affected with a strong male predominance. Food appears to be the key trigger, although the exact mechanisms remain unclear. Treatment for eosinophilic esophagitis can be summarized as the 3 D's: dietary, drugs, and dilatation. The differential diagnosis includes gastroesophageal reflux disease, eosinophilic gastroenteritis, drug hypersensitivity, hypereosinophilic syndrome, infection, Crohn disease, connective tissue diseases, and vasculitis.