Eosinophilic Esophagitis: The Food-Antigen Connection

David A. Johnson MD


November 03, 2014

Author's Note: The recent literature focusing on improving our understanding of eosinophilic esophagitis (EoE) has been explosive. This review will highlight a couple of the more clinically relevant articles, which should guide changes in clinical practice.

Dietary Elimination Therapy Is an Effective Option for Adults With Eosinophilic Esophagitis

Wolf WA, Jerath MR, Sperry SL, Shaheen NJ, Dellon ES
Clin Gastroenterol Hepatol. 2014;12:1272-1279

Study Summary

EoE has been categorized as a food allergy because of evidence of disease remission with dietary elimination. Although swallowed corticosteroids have been shown to be effective, disease relapse is likely upon discontinuance. Dietary elimination therapy may be more durable if specific food groups to withdraw can be identified.

Wolf and colleagues demonstrated that dietary modification is an effective nonpharmacologic intervention in patients with EoE. This was a retrospective cohort study from a database of adults with EoE diagnosed using consensus guidelines. These adults underwent dietary food group exclusion either by using targeted elimination identified through allergy skin prick testing or patient report or by following a six-food group elimination diet (SFED), which involved removal of dairy, wheat, soy, nuts, seafood, and eggs. Patients were taken off steroids for 4 weeks before beginning dietary therapy. If clinical improvement was observed with SFED, one food group was sequentially reintroduced every 6 weeks. Endoscopy with biopsies was performed until all food groups were reintroduced, and the foods that induced recrudescence of EoE were identified.

Symptom improvement, endoscopic appearance improvement, and biopsy resolution to less than 15 eosinophils/high-power field (eos/HPF) are shown in the Table.

Table. Improvement in Targeted vs Six-Food Elimination Diets

Resolution Criteria Targeted Elimination Six-Food Elimination Diet
Symptom improvement 68% 78%
Endoscopic improvement 53% 56%
Histologic improvementa 32% 56%

a Eosinophil count <15 eos/HPF

In patients who responded with eosinophil counts lower than 15 eos/HPF and underwent food reintroduction, symptom recurrence was highest with dairy (44%) and eggs (44%), followed by wheat (22%) and shellfish, legumes, or nuts (11% each).


Identifying and directing therapy toward the allergenic food groups should lead to sustainable benefit, although long-term follow-up on this approach is needed.

The histologic improvement associated with the SFED was nonsignificantly better, but it raises the question of whether the routine referral of these patients to allergy testing is needed. Moreover, this analysis preceded the recent categorization of proton pump inhibitor (PPI)-responsive eosinophilia. Most data support the finding that four food groups (milk, eggs, wheat, and nuts) are the most prevalent food antigens identified in these patients.

A recent study[1] showed that EoE in adults is associated with immunoglobulin (Ig)G4 and not mediated by IgE. Serum-specific IgE allergy testing (the radioallergosorbent test) has been entirely replaced by nonradioactive enzyme-linked immunosorbent IgE assay testing, used in building elimination diets, and has no support for use in adults. Although atopic patch testing assesses the presence of non-IgE cell-mediated food reactions, I favor the food elimination diet without allergy testing or referral to an allergist as a more pragmatic approach.



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