Dietary therapies for eosinophilic esophagitis

Abstract

Eosinophilic esophagitis (EoE) represents a prevalent chronic esophageal disorder. Since the condition was first described, its pathophysiology has been known to have an immune-allergic origin, but the high response rate to dietary therapies based on feeding patients exclusively with amino acid-based elemental formulas (with complete elimination of table foods) has clearly established EoE as a particular form of food allergy. Nevertheless, the management of EoE in clinical practice remains widely heterogeneous, with topical steroids being a therapeutic mainstay. However, a growing body of evidence points to dietary therapy as an effective treatment option for both children and adults with EoE, as this approach is capable of achieving a sustained symptomatic and histological response without resorting to drugs. This article reviews the available data on the major types of dietary therapy for EoE, including elemental formula diets, skin allergy testing-directed elimination diets and empirical elimination diets based on common food allergens.

Keywords::

• diet
• diet therapy
• eosinophilic esophagitis
• food hypersensitivity
• food reintroduction
• treatment

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Dietary intervention has been demonstrated to be a therapeutic option for eosinophilic esophagitis (EoE), that seems to be almost equivalent to topical steroids in terms of achieving histopathological remission.

• After initial studies assessing the efficacy of dietary interventions in pediatric EoE patients, recent prospective studies in adults have also demonstrated that the response in terms of histological remission and symptom improvement rates are comparable to those previously reported in children.

• Preliminary results indicate that dietary therapy may offer a potential long-term remission of EoE without the risk of drug-related side effects.

  • Exclusive feeding with an elemental formula is the most effective option for treating EoE, followed by an empirical six-food elimination diet. Because the results vary widely, the least effective option is the skin allergy testing-directed elimination diet, which limits this option to experienced clinicians and for use in children.

  • Due to the disadvantages of elemental diets, in which all table food is restricted, and to the wide variability in the efficacy of skin allergy testing-directed diets, empirical six-food elimination diets (and their variants) will probably become the treatment of choice for most EoE cases in the near future.

  • Further multicenter and trans-oceanic comparative studies are necessary to determine the true effectiveness of each dietary strategy. Emphasis should be placed on discovering new minimally or non-invasive markers of disease activity and accurate tests for detection of EoE food triggers in order to replace the repeated endoscopies needed in food reintroduction protocols.