Dietary Treatment of Eosinophilic Esophagitis

Emerging evidence supports impaired epithelial barrier function as the key initial event in the development of eosinophilic esophagitis (EoE) and other allergic diseases. Symptom resolution, histologic remission, and prevention of both disease and treatment-related complications are the goals of treatment. Successful dietary treatments include elemental, empirical elimination and allergy test directed diets. Dietary therapy with exclusive elemental diet offers the best response. Cow’s milk, wheat, egg, soy, peanut/tree nut, and fish/shellfish are the 6 food antigens most likely to induce esophageal inflammation.

Key points

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Dietary treatment offers the prospect of inducing and maintaining prolonged disease remission without the potential complications associated with pharmacologic therapy.
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Elemental diet is superior to all other therapies for the treatment of eosinophilic esophagitis.
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Empirical elimination diet offers distinct advantages over allergy test directed diets.

Introduction

Eosinophilic esophagitis (EoE) is an immune-mediated chronic inflammatory disorder of the esophagus that is triggered by food antigens in most patients. Dietary therapy has been established as an effective first-line therapy in children with EoE. However, support for the effectiveness of dietary therapy in adults is only now beginning to emerge in the literature. The highest response rates of up to 96% are achieved with dietary treatment, and thus, dietary approach is superior to the other available therapies to treat EoE. The natural history of EoE is progression to remodeling and subepithelial fibrosis. Dietary treatment has been shown to reverse subepithelial fibrosis and is likely to alter the natural history of EoE.

The goals of dietary treatment in EoE include: (1) symptom resolution; (2) maintenance of sustained histologic remission and thus prevention of disease-related complications, including fibrosis and strictures; and (3) prevention of iatrogenic treatment-related adverse reactions, such as nutritional deficiencies.

Because food antigens trigger eosinophilic inflammation, the dietary approach of identification and exclusion of causative food antigens to induce and maintain both clinical and histologic remission addresses the root cause of the disease. The current recommendations for treatment of EoE with diet are based on several retrospective and observational studies in children as well as prospective studies in adults. The available dietary approaches include: (1) elemental diet with an amino acid–based complete liquid formulation, (2) empirical or nondirected elimination diet with elimination of several common food antigens from the diet, and (3) directed elimination diet based on the results of allergy testing. The type of dietary treatment selected should be tailored to the needs of the individual patient. The treatment selection in children depends on the age of the patient, the presence of comorbid malnutrition, and feeding aversion. In adults and older children, the diet selection depends on the comfort and acceptance of the specific elimination diet. Outcomes of the different dietary approaches are summarized in Table 1 .

Table 1

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