Gastroenterology

Gastroenterology

Volume 142, Issue 7, June 2012, Pages 1451-1459.e1
Gastroenterology

Original Research
Clinical—Alimentary Tract
Elimination Diet Effectively Treats Eosinophilic Esophagitis in Adults; Food Reintroduction Identifies Causative Factors

https://doi.org/10.1053/j.gastro.2012.03.001Get rights and content

Background & Aims

Adults with eosinophilic esophagitis (EoE) typically present with dysphagia and food impaction. A 6-food elimination diet (SFED) is effective in children with EoE. We assessed the effects of the SFED followed by food reintroduction on the histologic response, symptoms, and quality of life in adults with EoE.

Methods

At the start of the study, 50 adults with EoE underwent esophagogastroduodenoscopies (EGDs), biopsies, and skin-prick tests for food and aeroallergens. After 6 weeks of SFED, patients underwent repeat EGD and biopsies. Histologic responders, defined by ≤5 eosinophils/high-power field (eos/hpf) (n = 32), underwent systematic reintroduction of foods followed by EGD and biopsies (n = 20). Symptom and quality of life scores were determined before and after SFED.

Results

Common symptoms of EoE included dysphagia (96%), food impaction (74%), and heartburn (94%). The mean peak eosinophil counts in the proximal esophagus were 34 eos/hpf and 8 eos/hpf, before and after the SFED, and 44 eos/hpf and 13 eos/hpf in the distal esophagus, respectively (P < .0001). After the SFED, 64% of patients had peak counts ≤5 eos/hpf and 70% had peak counts of ≤10 eos/hpf. Symptom scores decreased in 94% (P < .0001). After food reintroduction, esophageal eosinophil counts returned to pretreatment values (P < .0001). Based on reintroduction, the foods most frequently associated with EoE were wheat (60% of cases) and milk (50% of cases). Skin-prick testing predicted only 13% of foods associated with EoE.

Conclusions

An elimination diet significantly improves symptoms and reduces endoscopic and histopathologic features of EoE in adults. Food reintroduction re-initiated features of EoE in patients, indicating a role for food allergens in its pathogenesis. Foods that activated EoE were identified by systematic reintroduction analysis but not by skin-prick tests.

Section snippets

Study Design

This was a prospective clinical trial from 2006 to 2010 performed at a single university medical center. The study was designed to examine the effectiveness of SFED in adults with EoE. All patients underwent an elimination diet for 6 weeks followed by esophagogastroduodenoscopy (EGD) and biopsy. Patients who achieved histologic remission underwent systematic, sequential food reintroduction with follow-up endoscopies and biopsies to identify specific food triggers.

Study End Points

The primary study end point was

Patient Characteristics and Clinical Features

Fifty patients (25 men) completed the initial 6-week SFED treatment period, and 20 patients completed the reintroduction process. Demographics are listed in Table 1. Thirty patients were not included in the analysis of the reintroduction process because of a lack of adequate response or incomplete data acquisition for the following reasons: nonresponse (8), partial response (7), moved out of state (3), and still completing the reintroduction process (12). Forty-two of 50 patients were on

Discussion

Our prospective study showed a high degree of effectiveness of the SFED in the treatment of both symptoms and histopathology in adults with EoE.20 Seventy-eight percent of patients achieved greater than a 50% reduction in peak eosinophil counts, with 70% achieving ≤10 eos/hpf and 64% achieving ≤5 eos/hpf after treatment. Coinciding with resolution in pathology, dysphagia symptom scores improved significantly after the SFED. The systematic reintroduction of food in patients who achieved an

Acknowledgments

The authors thank Northwestern EoE patients and families for their research participation, the academic and contributed services gastroenterology faculty and fellows at Northwestern for assistance with patient recruitment; Ms Chrissy Ebert–Nelson for coordination of IRB documentation; Dr Laurie Keefer for assistance with interpretation of quality of life data; and Dr Mary Kwasny for statistical support.

References (24)

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This article has an accompanying continuing medical education activity on page e14. Learning Objectives: Upon completion of this assessment, successful learners will be able to understand the evidence supporting the use of dietary therapy in adult eosinophilic esophagitis.

Conflicts of interest The authors disclose no conflicts.

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