Eliminating specific foods from your diet can reduce symptoms of eosinophilic esophagitis (EoE), according to the June issue of Gastroenterology.
EoE is an immune disorder in which eosinophils cause inflammation of the esophagus, leading to difficulty swallowing and food impactions. Many adults cope for years with swallowing difficulties and do not seek medical attention until they experience a long-lasting food impaction that requires emergency endoscopy.
Researchers have found that certain food allergens can cause the disease in children, so Nirmala Gonsalves et al. investigated whether a food-elimination diet might reverse the disorder in adults.
They placed 50 adults with EoE on a 6-food elimination diet—avoiding milk, soy, egg, wheat, peanuts or tree nuts, and shellfish or fish—for 6 weeks. Patients were then given questionnaires about symptoms and quality of life, and evaluated by endoscopy and biopsy analyses.
The study subjects were also given skin-prick tests for airborne allergies against tree, grass, ragweed, mold, house dust mite, cat, dog, and cockroach, along with the foods included in the elimination diet.
After 6 weeks on the diet, patients’ peak eosinophil densities decreased significantly in the proximal and distal esophagus; 78% of patients had >50% reduction in their peak eosinophil density.
Dysphagia symptom scores decreased in 94% of patients after the elimination diet, and endoscopic features improved in 78%. Physical and mental components also increased after the elimination diet, based on answers to questionnaires.
Twenty patients who had a full response to the diet participated in a food reintroduction study. The foods that caused their symptoms were identified (although results from skin-prick tests could not identify these). When these were placed back in the patients’ diets, their symptoms returned, along with endoscopic and histologic features of the disorder, in a median time of 3 days.
The most common food triggers were wheat (60%) and milk (50%), followed by soy (10%), nuts (10%), and egg (5%). Seafood was not found to induce EoE in this study. Three patients had more than one food trigger. Interestingly, none of the patients knew they had food allergies before the study.
The results of the reintroduction study show that food antigens do cause EoE, and provide insight into the pathogenesis of this inflammatory response. The findings also indicate that despite the phenotypic differences of adult and pediatric EoE, they are likely to be similar diseases.
One of the features of patients who responded to the elimination diet was that they had frequently complained of heartburn, despite acid suppression with proton-pump inhibitor therapy. This means that the EoE symptoms were not caused by acid reflux, but rather that heartburn can be caused by allergic responses to certain foods.
Although these results provide new insight into the pathogenesis of EoE in adults and provide a new treatment approach, the authors acknowledge that this was an uncontrolled study, so there might have been a selection bias for patients who were willing to undergo dietary elimination.
Nonetheless, Gonsalves et al. conclude that a 6-food elimination diet, with food reintroduction, is the most reliable method to identify foods that induce EoE in adults, and is an effective therapeutic alternative to corticosteroid therapy.
In an editorial that accompanies the article, Alex Straumann states that these findings offers a new therapeutic approach for adults with active EoE—this might be important for patients who respond inadequately to medical therapy or for those who refuse corticosteroids. It also demonstrates that adult EoE is a food-driven disease, with wheat and milk as the leading causative agents, and that adult and pediatric EoE represent a single entity, despite their different clinical manifestations.
More Information on EoE:
Read the article online. This article has accompanying CME activities.
Gonsalves N, Yang G-Y, Doerfler B, et al. Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology 2012;142:1451–1459.e1.
Read the accompanying editorial.
Straumann A. Treatment of eosinophilic esophagitis: diet, drugs, or dilation? Gastroenterology 2012;142:1409–1411.