Michele Shuker

14 years of eosinophilic esophagitis: clinical features and prognosis.

Objective: To determine the natural history of treated and untreated eosinophilic esophagitis (EE) and examine the presenting symptoms of EE. Patients and Methods: Retrospective and prospective chart review of all patients diagnosed with EE at The Childrens Hospital of Philadelphia. EE was defined as greater than 20 eosinophils per high power field after treatment with reflux medications. Results: We identified 620 patients in our database in the last 14 years and 330 patients with greater than 1 year of follow-up for analysis. The number of new EE patients has increased on an annual basis. Of the patients presenting with EE, 68% were younger than 6 years old. Reflux symptoms and feeding issues/failure to thrive were the most common presenting symptoms for EE. Eleven patients had resolution of all of their food allergies and 33 patients had resolutions of some of their food allergies. No patients have progression of EE into other gastrointestinal disorders. Conclusions: EE is a chronic disease with less than 10% of the population developing tolerance to their food allergies. EE does not progress into other gastrointestinal diseases.

Identification of causative foods in children with eosinophilic esophagitis treated with an elimination diet.

BACKGROUND Eosinophilic esophagitis (EoE) is a chronic inflammatory disease with isolated eosinophils in the esophagus predominantly triggered by foods. The optimal testing to identify inciting foods remains unclear. OBJECTIVES We sought to determine the effectiveness of allergy testing-directed diets in patients with EoE. METHODS A retrospective analysis of all children with EoE seen at the Childrens Hospital of Philadelphia between 2000 and 2011 identified 941 patients with EoE. Skin prick tests (SPTs) and atopy patch tests (APTs) were conducted, and predictive values were calculated. IgE-mediated food reactions were also identified. A food was considered to cause EoE if its elimination led to resolution of esophageal eosinophilia or reintroduction led to reoccurrence of EoE. The effectiveness of the various elimination diets was compared with targeted food antigen elimination. RESULTS Definitive foods causing EoE were identified, with milk, egg, wheat, and soy as the most common foods in 319 patients. IgE-mediated reactions (urticaria and anaphylaxis) were seen in 15%. The negative predictive value for the combination of SPTs and APTs averaged 92%, with the exception of milk at 44%, and the positive predictive value averaged 44%. An empiric 6-food elimination diet or removal of positive foods on allergy testing (SPTs/APTs) both had a histologic success rate of 53%. Removal of foods identified on SPTs/APTs plus empiric elimination of milk leads to resolution in 77% of patients. CONCLUSION An elimination diet based on SPT/APT results leads to resolution of esophageal eosinophilia in a similar proportion of patients as empiric removal of foods but required that fewer foods be removed. These observations suggest that both methods are acceptable options.

Nutritional Management of Eosinophilic Esophagitis in Pediatric Patients

Dietary therapy is the primary method of treatment of EoE in the pediatric population. The nutritional management of children with EoE is therefore an essential component of care and underscores the important role played by the pediatric nutritionist. Currently, three nutritional or dietary approaches exist for EoE, including guided elimination diets, empiric elimination diets, and total elemental diets. Foods can be selectively eliminated from the diet using either guided removal based on allergy testing or on empiric removal of the most common foods known to cause EoE. Guided food removal utilizes the combined results of both skin prick testing (SPT) and atopy patch testing (APT) to direct dietary therapy. An alternate method is the empiric removal of the most common food allergens (milk, soy, wheat, egg, fish, shellfish, peanuts, and tree nuts); other foods also noted as common causes include corn, beef, and chicken. Both the guided and empiric methods of food removal have resulted in similar rates of improvement, with normalization of biopsies occurring about 75% of the time. The third method is the total elemental diet that is the replacement of all foods with an elemental formula. This chapter will examine these approaches with emphasis on the nutritional risks, and advantages and disadvantages of each method. A discussion of the role of the registered dietitian in managing the pediatric patient with EoE as well as information on enteral feedings and patient/family education and resources will also be included.