Six-food Elimination Diet Research Articles

Cost-Effectiveness Analysis of Current Treatment Options for Eosinophilic Esophagitis.

The management strategies for eosinophilic esophagitis (EoE) include proton pump inhibitors (PPI), swallowed topical steroids (tCS), elimination diets, and the biologic agent dupilumab, although there remains little guidance on the selection of initial treament. We performed cost-effectiveness analyses to compare these approaches of first-line therapy. A Markov model was constructed from a payer perspective to evaluate the cost-effectiveness of first-line therapies for EoE, including PPI, tCS, and six-food elimination diet (SFED), with.crossover in treatments for primary and secondary non-response. The primary outcome was incremental cost-effectiveness ratio (ICER) at two- and five-year time horizons. Secondary analyses included modeling from a societal perspective that also accounted for patient-specific costs, as well as a separate simplified model comparing dupilumab to tCS and PPI. In the base-case scenario (five-year time horizon), the average costs were SFED:$15,296.81, PPI:$16,153.77, and tCS:$20,975.33 as initial therapy, with SFED being the dominant strategy (more effective/less costly), while PPI offered the lowest cost on a two-year time horizon. From a societal perspective, PPI was the dominant initial strategy on both two- and five-year time horizons. Amongst pharmacologic therapies, PPI was the most cost-effective first-line option. Dupilumab was not cost-effective relative to tCS, unless the quarterly cost is reduced from $7,311 to $2,038.50 per price threshold analysis under permissive modeling conditions. SFED was the most effective/least costly first-line therapy from payer perspective, while PPI was more cost-effective from societal perspective. PPI is also the most cost-effective pharmacologic strategy. Dupilumab requires substantial cost reductions to be considered cost-effective first-line pharmacotherapy.

Six-Food Elimination Diet Is Less Effective During Pollen Season in Adults With Eosinophilic Esophagitis Sensitized to Pollens.

The role of inhaled and swallowed aeroallergens in treatment outcomes of adult patients with eosinophilic esophagitis (EoE) is unclear. We hypothesized that the pollen season contributes to the failure of the 6-food elimination diet (SFED) in EoE. We compared outcomes of patients with EoE who underwent SFED during vs outside of the pollen season. Consecutive adult patients with EoE who underwent SFED and skin prick test (SPT) for birch and grass pollen were included. Individual pollen sensitization and pollen count data were analyzed to define whether each patient had been assessed during or outside of the pollen season after SFED. All patients had active EoE (≥15 eosinophils/high-power field) before SFED and adhered to the diet under the supervision of a dietitian. Fifty-eight patients were included, 62.0% had positive SPT for birch and/or grass, whereas 37.9% had negative SPT. Overall, SFED response was 56.9% (95% confidence interval, 44.1%-68.8%). When stratifying response according to whether the assessment had been performed during or outside of the pollen season, patients sensitized to pollens showed significantly lower response to SFED during compared with outside of the pollen season (21.4% vs 77.3%; P = 0.003). In addition, during the pollen season, patients with pollen sensitization had significantly lower response to SFED compared with those without sensitization (21.4% vs 77.8%; P = 0.01). Pollens may have a role in sustaining esophageal eosinophilia in sensitized adults with EoE despite avoidance of trigger foods. The SPT for pollens may identify patients less likely to respond to the diet during the pollen season.

Does eosinophilic esophagitis exist in India?

Eosinophilic esophagitis (EoE) has evolved over the last three decades with a better understanding of the natural course of the disease. The prevalence of EoE is higher in Western countries with increasing reports of the incidence of EoE in the east. There is less data on EoE in India. We have noticed an increase in the number of cases of EoE diagnosed in our center over the last few years. In this study, all patients with high clinical suspicion of EoE were included and prospectively evaluated with endoscopic features and esophageal biopsies. Seventeen of 73 patients were diagnosed with EoE based on clinical, endoscopic and histopathologic features. One patient was lost to follow-up and 16 of the 17 patients were initiated on standard-of-care treatment and followed up for a minimum of fourweeks. Treatment with proton pump inhibitors with six-food elimination diet is highly effective in most patients with afew patients requiring systemic steroids and endoscopic treatment. In conclusion, this study highlights that EoE exists in India with varied manifestations and a high index of clinical suspicion is necessary for diagnosis. It also emphasizes the need for increasing awareness of the entity of EoE, among both patients and doctors. Further, large-scale, multi-centric population-based studies are necessary to estimate the prevalence in our country.

Bringing dietary therapy for eosinophilic oesophagitis under scientific scrutiny

In The Lancet Gastroenterology & Hepatology, Kara L Kliewer and colleagues report results from the first major multicentre, randomised trial of dietary therapy in patients with eosinophilic oesophagitis. 1 Kliewer KL Gonsalves N Dellon ES et al. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. Lancet Gastroentrol Hepatol. 2023; (published online Feb 27.)https://doi.org/10.1016/S2468-1253(23)00012-2 Google Scholar The detailed study of patient outcomes, along with the assessment of transcriptomic and other markers, give valuable insights into the benefits and limitations of dietary therapy. Their objective evidence shows that the value of dietary therapy, in particular the six-food elimination diet (6FED), might have been overestimated in previous studies. 2 Gonsalves N Yang GY Doerfler B Ritz S Ditto AM Hirano I Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012; 142: 1451-1459 Summary Full Text Full Text PDF PubMed Scopus (480) Google Scholar , 3 Lucendo AJ Arias A Gonzalez-Cervera J et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol. 2013; 131: 797-804 Summary Full Text Full Text PDF PubMed Scopus (305) Google Scholar , 4 Infante J Modolell I Alcedo J et al. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: the 2-4-6 study. J Allergy Clin Immunol. 2018; 141: 1365-1372 Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar In their study, histological remission to less than 15 eosinophils per high-power field (eos/hpf) occurred in only 23 (34%) of 67 patients on the one-food elimination diet (1FED; eliminating animal milk) and 25 (40%) of 62 patients on the 6FED at 6 weeks. Kliewer and colleagues also show that the margin between 1FED and 6FED is not significant in terms of both histological remission and symptom improvement. Given the complexity of life when trying to avoid six foods and the great difficulty in sustaining such an effort for more than a year, this evidence on the value of keeping dietary therapy simple is important. As well as being easier to comply with, a single-food elimination diet (or perhaps a two-food elimination diet avoiding milk and wheat 2 Gonsalves N Yang GY Doerfler B Ritz S Ditto AM Hirano I Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012; 142: 1451-1459 Summary Full Text Full Text PDF PubMed Scopus (480) Google Scholar ) requires fewer repeat endoscopies than the seven endoscopies needed to determine which foods are relevant in the multifood approach. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trialHistological remission rates and improvements in histological and endoscopic features were similar after 1FED and 6FED in adults with eosinophilic oesophagitis. 6FED had efficacy in just less than half of 1FED non-responders and steroids had efficacy in most 6FED non-responders. Our findings indicate that eliminating animal milk alone is an acceptable initial dietary therapy for eosinophilic oesophagitis. Full-Text PDF

One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial

Empirical elimination diets are effective for achieving histological remission in eosinophilic oesophagitis, but randomised trials comparing diet therapies are lacking. We aimed to compare a six-food elimination diet (6FED) with a one-food elimination diet (1FED) for the treatment of adults with eosinophilic oesophagitis. We conducted a multicentre, randomised, open-label trial across ten sites of the Consortium of Eosinophilic Gastrointestinal Disease Researchers in the USA. Adults aged 18-60 years with active, symptomatic eosinophilic oesophagitis were centrally randomly allocated (1:1; block size of four) to 1FED (animal milk) or 6FED (animal milk, wheat, egg, soy, fish and shellfish, and peanut and tree nuts) for 6 weeks. Randomisation was stratified by age, enrolling site, and gender. The primary endpoint was the proportion of patients with histological remission (peak oesophageal count <15 eosinophils per high-power field [eos/hpf]). Key secondary endpoints were the proportions with complete histological remission (peak count ≤1 eos/hpf) and partial remission (peak counts ≤10 and ≤6 eos/hpf) and changes from baseline in peak eosinophil count and scores on the Eosinophilic Esophagitis Histology Scoring System (EoEHSS), Eosinophilic Esophagitis Endoscopic Reference Score (EREFS), Eosinophilic Esophagitis Activity Index (EEsAI), and quality of life (Adult Eosinophilic Esophagitis Quality-of-Life and Patient Reported Outcome Measurement Information System Global Health questionnaires). Individuals without histological response to 1FED could proceed to 6FED, and those without histological response to 6FED could proceed to swallowed topical fluticasone propionate 880 μg twice per day (with unrestricted diet), for 6 weeks. Histological remission after switching therapy was assessed as a secondary endpoint. Efficacy and safety analyses were done in the intention-to-treat (ITT) population. This trial is registered on ClinicalTrials.gov, NCT02778867, and is completed. Between May 23, 2016, and March 6, 2019, 129 patients (70 [54%] men and 59 [46%] women; mean age 37·0 years [SD 10·3]) were enrolled, randomly assigned to 1FED (n=67) or 6FED (n=62), and included in the ITT population. At 6 weeks, 25 (40%) of 62 patients in the 6FED group had histological remission compared with 23 (34%) of 67 in the 1FED group (difference 6% [95% CI -11 to 23]; p=0·58). We found no significant difference between the groups at stricter thresholds for partial remission (≤10 eos/hpf, difference 7% [-9 to 24], p=0·46; ≤6 eos/hpf, 14% [-0 to 29], p=0·069); the proportion with complete remission was significantly higher in the 6FED group than in the 1FED group (difference 13% [2 to 25]; p=0·031). Peak eosinophil counts decreased in both groups (geometric mean ratio 0·72 [0·43 to 1·20]; p=0·21). For 6FED versus 1FED, mean changes from baseline in EoEHSS (-0·23 vs -0·15; difference -0·08 [-0·21 to 0·05]; p=0·23), EREFS (-1·0 vs -0·6; difference -0·4 [-1·1 to 0·3]; p=0·28), and EEsAI (-8·2 vs -3·0; difference -5·2 [-11·2 to 0·8]; p=0·091) were not significantly different. Changes in quality-of-life scores were small and similar between the groups. No adverse event was observed in more than 5% of patients in either diet group. For patients without histological response to 1FED who proceeded to 6FED, nine (43%) of 21 reached histological remission; for patients without histological response to 6FED who proceeded to fluticasone propionate, nine (82%) of 11 reached histological remission. Histological remission rates and improvements in histological and endoscopic features were similar after 1FED and 6FED in adults with eosinophilic oesophagitis. 6FED had efficacy in just less than half of 1FED non-responders and steroids had efficacy in most 6FED non-responders. Our findings indicate that eliminating animal milk alone is an acceptable initial dietary therapy for eosinophilic oesophagitis. US National Institutes of Health.

EE55 Comparative Cost-Utility Analysis of Budesonide and the Six Food Elimination Diet (SFED) for the Prophylaxis of Patients With Eosinophilic Esophagitis (EoE) in the Austrian Setting

Budesonide orodispersible tablets (BOT) are the only approved pharmaceutical for the treatment of eosinophilic esophagitis (EoE) and the only reimbursed in-label option in Austria. This research aims to explore the cost-effectiveness of BOT versus a widely used dietary intervention, the six food elimination diet (SFED) since there are no other approved pharmaceuticals for EoE.

S3631 March of the Eosinophils: A Case of Eosinophilic Gastroenteritis, Immune Thrombocytopenia, and Iron Deficiency Anemia

Introduction: Eosinophilic gastrointestinal disorders (EGIDs) refer to eosinophilic infiltration of the gastrointestinal tract in the absence of secondary causes. Here, we present a case of a young male with immune thrombocytopenia (ITP) and biopsy-proven eosinophilic gastroenteritis that developed iron-deficiency anemia. Case Description/Methods: A 16-year old male with a past medical history significant for autism, ITP, melanoma, allergic rhinitis, and eosinophilic esophagitis presented for evaluation of chronic abdominal pain. He had an EGD in April 2018 that revealed white exudates at the gastroesophageal junction, scattered erosions in the gastric body and fundus, severe antral gastritis, and scattered erosions noted throughout the duodenal bulb. Biopsies were taken and revealed distal eosinophilic esophagitis (greater than 50/HPF), eosinophilic gastritis, and chronic inflammation of the duodenal bulb with Brunner gland hyperplasia and villous blunting. Absolute eosinophil count was higher than 2,000/uL. Given findings of persistent inflammation despite a six-food elimination diet, the patient was started on oral Budesonide, a proton-pump inhibitor, and an H2 receptor blocker. In March 2020, a repeat surveillance EGD with biopsy revealed the duodenum was free of inflammation or other diagnostic abnormalities. Roughly 28 eosinophils/HPF were present in the gastric cardia near the GEJ, and numerous eosinophils remained in the other gastric tissues sampled. B udesonide was discontinued due to patient intolerance. In early 2021, the patient was found to have microcytic anemia. Further Hematologic evaluation revealed low folate and iron levels. He was started on supplemental iron and folic acid, leading to resolution of the anemia. Iron and folate deficiency was believed to be secondary to malabsorption caused by EGE. (Figure) Discussion: Eosinophilic gastrointestinal diseases remain a rare and underexplored clinical entity. While its pathophysiology is not fully understood at this time, TH2 mediated activation of B-cells and subsequent stimulation of eosinophils locally appears to be at play. Given ITP has a TH1 predominant cytokine profile, it is unclear if there is a causal association between the two. Diagnosis of EGID necessitates histological evidence of eosinophilic infiltration of the GI tract in the absence of secondary causes or infiltration elsewhere. Dietary modification to eliminate food allergens is a reasonable initial treatment, glucocorticoids remain the mainstay of pharmacotherapy at this time.Figure 1.: Cross-section of gastric tissue stained with hematoxylin and eosin demonstrating prominent eosinophils (greater than 100 per high-power field) within the lamina propria and gastric epithelium with associated epithelial injury.

Predictors of histologic response to dietary therapy in eosinophilic oesophagitis.

Dietary therapy successfully treats eosinophilic oesophagitis (EoE), but limited data exist on predictors of patient response. To determine response rates and toidentify predictors of histologic response to elimination diets in adults with EoE METHODS: This was aretrospective, single-centre study of adults with PPI-refractory EoE undergoing dietary therapy with six food elimination diet (SFED) or extended six food elimination diet (ExSFED) in an outpatient setting from January 2012 to January 2019. Patient demographics, radiologic and endoscopic findings, endoscopic reference (EREF) scores, histology and symptoms were evaluated before and after food elimination. Histologic response was assessed via tissue obtained from endoscopically-guided biopsy or Cytosponge. Dietary therapy adherence was assessed via structured phone interview. Multivariable logistic regression analysis was performed to identify predictors of dietary response. We included 68 patients, of whom 62% had a histologic response to dietary therapy (81% to SFED, 19% to ExSFED). Median duration of follow-up was 45 months (IQR, 34-53 months). On multivariable analysis, higher pre-SFED EREF score was the only variable associated with dietary non-response (OR 0.07, 95% CI 0.49, 0.98; p= 0.04). In adults with EoE, histologic dietary non-response to SFED was associated with a higher pre-SFED EREF score, suggesting that fixed structural disease may predict dietary non-response. Our additional observations of poor correlation between symptomatic and histologic flares, and identification of ExSFED responders, suggest that histologic confirmation should be sought before committing patients to lifelong dietary changes. We also recommend the consideration of restricting legumes and corn in SFED non-responders as ExSFED detected additional dietary responders.

Long-Term Outcomes of the Six-Food Elimination Diet and Food Reintroduction in a Large Cohort of Adults With Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is an immune-mediated inflammatory condition with tissue eosinophilia resulting in esophageal dysfunction. The six-food elimination diet (SFED) is an EoE treatment approach that removes milk, wheat, soy, eggs, tree nuts/peanuts, and fish/shellfish. After histologic remission, food reintroduction occurs to identify a food trigger. Outcomes from large series of adults undergoing SFED and food reintroduction as clinical care are not known. A retrospective review (2006-2021) of adult patients with EoE from an academic center was completed. Patients were classified as full responders (<15 eos/hpf) after SFED. If reintroduction was pursued, food triggers identified were recorded. Two hundred thirteen patients completed SFED. One hundred fifteen patients (54%) had response <15 eos/hpf after SFED. Seventy-seven percent of responders had symptom improvement. Thirty-two percent of initial nonresponders underwent repeat dietary elimination. Fifty-eight percent of patients (n = 123) achieved <15 eos/hpf after either initial or extended SFED. Seventy-eight percent of responders underwent food reintroduction. Sixty-nine percent had 1 food trigger identified, 24% had 2 allergens identified, and 4% had 3 allergens identified. The most common food triggers identified were milk, wheat, and soy. This study describes the largest cohort reported of adult patients with EoE completing SFED with food reintroduction. The overall SFED histologic response was 54%, which increased to 58% with 1 additional round of dietary therapy, suggesting that 31% may respond in a second attempt. Most patients who completed food reintroduction had a single food trigger identified. Dietary elimination with specific food trigger identification is a feasible alternative to medical therapy for adults with EoE.

Ruxolitinib Treatment in an Adolescent With Chronic Graft-Versus-Host Disease Mimicking Eosinophilic Gastrointestinal Disorders: A Case Report

Eosinophilic gastrointestinal disorders (EGIDs) are well-documented entities in pediatric solid organ transplantation. However, the diseases are rare after bone marrow transplantation (BMT). We present an adolescent male with hemoglobin E-β-thalassemia who underwent BMT and developed chronic graft-versus-host disease (GVHD) mimicking EGIDs. Initially, the patient presented with a presumed diagnosis of eosinophilic gastroenteritis (subserosal type) and received corticosteroids for 12 weeks. Six months after corticosteroids cessation, he again developed abdominal pain, treated with corticosteroids, azathioprine, and a six-food elimination diet. Still, he later had similar symptoms with persistent hypereosinophilia. The patient was subsequently diagnosed with chronic GVHD after excluding various potential causes. Ruxolitinib also led to significant clinical improvement and the disappearance of eosinophilia. The differential diagnosis of chronic GVHD should be a concern in BMT recipients with persistent gastrointestinal symptoms and eosinophilia. Ruxolitinib may be a treatment option in children with a steroid-refractory disease.

Cost and accessibility of empiric food elimination diets for treatment of eosinophilic oesophagitis.

This study aimed to investigate and compare the cost, affordability, and accessibility of three elimination diet approaches for the treatment of patients with eosinophilic esophagitis: the two-, four- and six-food elimination diets and with comparison to a standard diet. An evidence-based modelling process was undertaken for costing and accessibility, including the development of three hypothetical reference families; four food baskets were modified from an established benchmark for each diet. Baskets were costed across eastern Melbourne, Australia. Affordability was modelled using two incomes: the equivalised disposable household income and welfare payments for reference families. Affordability was defined as <30% of the median weekly household income and food stress defined as >25% of a median weekly household income. All elimination diets were significantly more expensive than a standard diet and may be unaffordable for those receiving welfare. Prices significantly increased as the number of food allergens eliminated increased. Most items for a two-food elimination diet were available at major supermarkets; however, items for nutritionally complete four- and six-food elimination diets required a visit to a second store. A step-up approach, commencing with a two-food elimination diet, instead of starting with a six-food elimination diet, may alleviate affordability barriers for most family types, which may enhance compliance. Clinicians should consider family type, financial situation, as well as accessibility of allergen-free foods in the patient's residential area when deciding on the most appropriate dietary or therapeutic treatment approach for eosinophilic oesophagitis.

Dietary treatment of eosinophilic gastrointestinal disorders in children.

To provide an overview of recent developments on dietary treatment of eosinophilic gastrointestinal disorders (EGID) in children. Food antigens are the main triggers of eosinophilic esophagitis (EoE); however, currently available allergy tests cannot reliably identify eliciting antigens. Studies evaluating the six-food empiric elimination diet (6FED-milk, wheat/gluten, egg, soy/legumes, nuts and fish/seafood) have shown histological remission rates of 72%. Milk, egg, wheat/gluten, and, to a lesser extent, soy/legumes were the most frequent food triggers with only one or two culprit foods identified for most patients. A 4-food elimination strategy afforded a 64% remission rate. A step-up two-four-six food elimination diet generated a 43% remission rate at the two-food elimination stage, and similar reported rates for 4FED and 6FED. Endoscopic procedures were reduced by a 20% compared with 6FED. In a prospective study including 63 children, exclusive milk elimination has been effective in 44% of them. Controlled elimination and reintroduction with histological assessment is necessary. Dietary therapy of EoE has evolved from more restrictive to less restrictive diets to provide better balance between efficacy vs. nutritional deficiencies and quality of life. Data on efficacy of dietary therapy in other EGIDs are very scarce.

Case Report: Importance of dietary modification in successful management of eosinophilic gastroenteritis

Introduction: Eosinophilic gastroenteritis (EGE) is an extremely rare inflammatory disorder with an estimated prevalence of 22-28/100 000. We herein, present a case of EGE in an elderly patient which was successfully managed with dietary restriction. Case report: A 70-year-old male with a history of gastroesophageal reflux disorder (GERD), atopic dermatitis and asthma presented with 2 weeks history of foul-smelling non-bloody diarrhea associated with nausea, vomiting and weight loss. Physical examination was significant for dry oral mucosa and loss of skin turgor. Lab findings were significant for a hemoglobin of 13.2 g/dl, hematocrit of 38.5%, mean corpuscular volume of 86.3%, white blood cell count of 24,200/mm3, albumin of 2.2 g/L, stool fat of 70g, stool osmolar gap of 115, C-reactive protein 1.47. Erythrocyte sedimentation rate, HIV test were unremarkable. Infectious stool work-up was negative. Computed tomography of the abdomen was unremarkable. The mucosa appeared mildly inflamed on upper endoscopy and colonoscopy, and biopsies showed eosinophilic infiltration of the mucosal and muscular layers. A diagnosis of eosinophilic gastroenteritis was made after other causes such as parasitic infection, drug use and malignancy were ruled out. The patient was counseled on a six-food elimination diet which successfully resolved his diarrhea. The patient did not have any relapses with dietary modification on follow-up. Discussion: The recurrence rate of EGE is 50%. Steroids improve symptoms in 90% of cases but the recurrence rates are high. The type, dose and duration of steroid therapy is unclear. Sodium cromoglicate, ketotifen, and Montelukast are other proposed treatments, the results being inconclusive. Bowel resection is performed in intestinal obstruction, but medical therapy is needed as recurrence in other segments in common. Dietary modification, a therapy with no side-effects should be the first line of treatment as it can result in resolution sparing the patient of steroid induced side effects.

1727 Importance of DIETARY Modification in Successful Management of Eosinophilic Gastroenteritis

INTRODUCTION: Eosinophilic gastroenteritis (EGE) is an extremely rare inflammatory disorder with an estimated prevalence of 22-28/100 000. We herein, present a case of EGE in an elderly patient which was successfully managed with dietary restriction. We would like to stress that food allergy is the main culprit in certain cases of EGE and dietary modification should always be the first step in the management of these cases. CASE DESCRIPTION/METHODS: A 70-year-old male with a history of GERD, atopic dermatitis and asthma presented with 2 weeks history of foul-smelling non-bloody diarrhea associated with nausea, vomiting and weight loss. Physical examination was significant for dry oral mucosa and loss of skin turgor. Lab findings were significant for a Hb/Hct (g/dl/%) of 13.2/38.5, MCV of 86.3%, WBC count of 24,200/mm3, albumin of 2.2 g/L, stool fat of 70g, stool osmolar gap of 115, CRP of 1.47. ESR, HIV test, infectious stool work-up were unremarkable. CT abdomen was unremarkable. The mucosa appeared mildly inflamed on upper endoscopy and colonoscopy, and biopsies showed eosinophilic infiltration of the mucosal and muscular layers. A diagnosis of EGE was made after other causes such as parasitic infection, drug use and malignancy were ruled out. The patient was suggested a six-food elimination diet which successfully resolved his diarrhea. The patient did not have any relapses with dietary modification on follow-up. DISCUSSION: The prevalence of EGE is underestimated as it is under diagnosed given the rarity of the condition especially when it presents outside of the age spectrum. The pathogenesis of EGE remains unclear and it is hypothesized to be a hypersensitive response to certain allergens. The recurrence rate of EGE is 50% and a dietary trial could be a long-term solution. A six-food elimination diet or an elemental diet is recommended. Steroids improve symptoms in 90% of cases but the recurrence rates are high. The type, dose and duration of steroid therapy is unclear. Sodium cromoglicate, ketotifen, and Montelukast are other proposed treatments, the results being inconclusive. Bowel resection is performed in intestinal obstruction, but medical therapy is needed as recurrence in other segments in common. The clinical guidelines for the diagnosis of EGE is sparse and the treatment offered is low-evidence based. Dietary modification, a therapy with no side-effects should be the first line of treatment and can result in resolution sparing the patient of steroid induced side effects.

2569 Eosinophilic Gastroenterocolitis: A Diagnostic Conundrum and a Rare Cause of Small Bowel Strictures

INTRODUCTION: Eosinophilic gastroenterocolitis (EGE) is a rare disorder that can have several gastrointestinal manifestations depending on the site and depth of involvement. The diagnosis involves demonstration of eosinophilic infiltration of bowel wall and exclusion of other causes of peripheral eosinophilia. We present a rare case of eosinophilic gastroenterocolitis that presented as chronic diarrhea and partial gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 71-year-old male presented to the clinic for evaluation of a two-month history of watery diarrhea. He had recently been hospitalized for management of profuse diarrhea and dehydration. Extensive infectious work-up during the hospitalization was unrevealing. A colonoscopy with biopsies was negative for microscopic colitis and malabsorptive disorder, however, a prominent population of eosinophils suggestive of an allergic component was seen. The patient's symptoms were partially controlled on anti-motility agents. His current medication list was negative for any offending drugs. Physical examination revealed a mildly distended abdomen. Laboratory investigation showed a total leukocyte count 6.7 × 109/L. Differential count revealed polymorphs −50%, lymphocytes −34% and eosinophils −10%. Computed tomography with contrast showed segmental areas of narrowing in mid descending limb of the duodenum with partial gastric outlet obstruction. Esophagogastroduodenoscopy (EGD) showed multiple diaphragm-like strictures at the duodenal sweep which could not be passed with a regular EGD scope. Histologic examination of the specimens taken from the duodenal strictures revealed mildly increased plasma cells and eosinophils within the lamina propria with villous blunting, without increased intraepithelial lymphocytes. Numerous balloon-dilation sessions were needed to reestablish luminal patency. A diagnosis of eosinophilic gastroenterocolitis was made and the patient was started on a six-food elimination diet with complete resolution of his symptoms. Upon reintroduction, the culprit food were found to be cow's milk and wheat. DISCUSSION: EGE is classified based on the depth of eosinophilic infiltration as mucosal, submucosal and serosal. The most frequent sites of involvement include the stomach and the proximal small bowel. Diagnosis is often challenging and delay in treatment may lead to malabsorption and malnutrition. Although evidence of efficacy is lacking, treatment with dietary modification and corticosteroids has shown favorable outcomes.

Eosinophilic esophagitis: Pathophysiology, diagnosis, and management

Eosinophilic esophagitis (EoE) is a multifactorial esophageal inflammation, with a genetic predisposition, which combines a deficient esophageal mucosal barrier, an abnormal immune reaction to environmental allergens mediated by Th2 interleukins, immediate esophageal lesions and dysmotility, with secondary remodeling and fibrosis. Symptoms include reflux, abdominal pain, and food impaction, with a variation according to age. Fibroscopy shows major and minor endoscopic and histologic criteria, with a mucosal count≥15 eosinophils/high power field (Eo/hpf). A new entity has been defined, where gastroesophageal reflux disease (GERD) and EoE share responsibility: the PPIs-sensitive form of EoE (PPI-REE). Children with fibroscopy showing≥15 Eo/hpf need a second endoscopy following 8 weeks of PPI treatment. EoE has a strong association with other atopic disorders. Allergy testing (specific IgE blood test and skin prick tests [SPTs]) identifies patients at risk of anaphylaxis (14.8% of cases). The dietary therapy is based on a 4- to 12-week elimination test followed by endoscopy to check the disappearance of eosinophilic infiltration. The “dietary approaches are the amino acid-based formula, the allergy testing-based targeted diet, and the six-food elimination diet (empirical elimination of milk, wheat, soy, eggs, peanut/nuts, and fish/seafood). A recent first-line trial elimination of milk has been suggested, with wheat as a second elimination, if necessary. Dietary therapy allows remission and catch-up growth in 65% of cases. Swallowed topical steroids (budesonide in viscous gel or fluticasone propionate for nebulization) are an alternative, for which efficacy varies according to clinical and/or histological criteria and with relapses occurring at dosage tapering. Their use may be restricted by side effects, such as oral and/or esophageal candidiasis. The impact on long-term bone health and growth is unknown. Maintenance therapy is not standardized and is team-dependent, combining or not elimination diets and long-term steroids. The long-term risk of EoE is esophageal stenosis (25%) and endoscopic dilation may be repeated. Biotherapies have shown isolated histological improvement without significant clinical efficacy.

CASE REPORT OF A CHILD WITH HARLEQUIN ICHTHYOSIS, PROBABLE EOSINOPHILIC ESOPHAGITIS, AND MILD HYPOGAMMAGLOBULINEMIA

Introduction Harlequin ichthyosis (HI) is an often-fatal autosomal recessive congenital ichthyosis, due to mutations in the ABCA12 gene resulting in a skin barrier defect. We report the first known case of HI with probable eosinophilic esophagitis (EoE) and second report of HI with hypogammaglobulinemia. Case Description A 36-week gestation boy was diagnosed with HI, respiratory distress, and feeding difficulty after birth. At 6 weeks of age, he developed chronic emesis on a milk-based formula requiring gastric tube placement; it persisted despite elemental formula feeds and omeprazole treatment. At 19 months of age, after some food introduction, he developed emesis and sensory feeding issues. At 22 months of age, he underwent esophagogastroduodenoscopy (EGD) showing 12 eosinophils/high power field on esophageal biopsy. At 23 months of age, IgE sensitization to multiple food and some inhalant allergens was noted. He was started on swallowed budesonide and a six-food elimination diet. Repeat EGD with esophageal biopsy after 3 months showed no esophageal eosinophils. His emesis improved, but sensory feeding issues continued. Swallowed budesonide was stopped and an elimination diet for cow's milk and soy was continued. Mild hypogammaglobulinemia (low IgG and IgM, elevated IgE) with normal post-vaccination antibody responses was noted without an infection history. Discussion We report the first known child with HI and probable EoE, and the second with HI and hypogammaglobulinemia. Epithelial barrier defects occur with HI and EoE, perhaps linking the disorders. IgE food sensitization is associated with skin barrier defects, another possible link.

Eosinophilic Esophagitis (EoE) - Successful Treatment With PPI Therapy in a Single-Center - Education and Engagement Are Key

Introduction: Recently, the international EoE consensus eliminated the cumbersome terminology of PPI-responsive esophageal eosinophilia. This supports our practice over the last 7 years of using PPI’s as first line therapy for EoE patients because of convenience, cost, and ease of administration. Here we present our single-center experience in treating EoE. Keys to success involve intense education on appropriate drug dosing, the mechanism of PPIs being anti-eosinophilic, and the key role of strict adherence to a proper PPI trial. Methods: From 2011 to 2017, patients at our institution with confirmed EoE were enrolled sequentially into a database. EoE diagnosis required the combination of clinical symptoms, endoscopic features, and histologic confirmation. In a retrospective manner, data was analyzed as outlined in Figure 1.379 Figure 1 No Caption available.Results: 77 patients (mean age 37, range 17-71, 69% male) with confirmed EoE were treated at our center. A PPI trial was completed on 71/77 (92%) patients with 50/71 (70%) patients having response. Complete response was seen in 44/50 (88%) and partial response in 6/50 (12%). Of those with a complete response, 27/32 (84%) were able to be reduced to once daily PPI maintenance therapy, but 5/32 (16%) relapsed. Of 33 patients with fibrostenotic EoE, an average of 2.3 dilatations were needed to reach a final average esophageal diameter of 17mm. Symptom relief was achieved in 85%; no perforations occurred. Ten patients (13%) were treated with topical steroids. Overall, 7/10 (70%) were steroid responsive. Selective diet elimination based on food allergy testing was successful in 7/8 (88%). Six-food elimination diet as primary therapy in one patient received a complete response. Conclusion: Our 70% response to PPI therapy in our EoE population over 7 years is on the high end of the reported range of 33-80%. The reason for our success in this unselected population may be due to intense education and engagement fostered in our patients. Our patients understand the drug mechanism of action/dosing, are very compliant with the PPI trial, and often rewarded by not needing topical steroids or diet restriction. In addition, the 85% with complete response were decreased to once daily PPIs, thereby lessening concern over potential side effects of long term high dose PPIs. Conclusion In our practice, PPIs have a 70% response rate in unselected EoE patients. Our excellent success may be related to intense education and engagement with our patients.

To Test or Not to Test? A Role for Comprehensive Food and Aeroallergen Testing in Adults With Eosinophilic Esophagitis

Introduction: Eosinophilic esophagitis (EoE) in adults is an important cause of dysphagia with treatment focused on proton pump inhibitors, topical corticosteroids, and food elimination diets. The role of allergy testing-selective elimination diets that excludes foods based upon skin testing has been questioned with strategies being replaced with increasing use of various modifications of the two, four, and six-food elimination plans. The object of this study was to retrospectively analyze our 10-year approach of comprehensively skin testing of foods and aeroallergens in adults with EoE and directing management based on these results. Methods: A medical records review of food and environmental allergy tests in adults referred for allergy evaluation with EoE between January1, 2006 through 2016. Subjects tested to a panel of 35 foods and 36 aeroallergens. Medical records were also reviewed to capture demographics, endoscopic findings, medication use, and symptoms. Results: Of the 186 adult subjects with EoE, approximately 90% of patients tested positive to at least one food or aeroallergen. The top ten food allergens were peanut>almond>green pea>soybean>green bean>egg>pistachio nut>wheat>corn>yeast. Of the aeroallergens, dust mite, cat, and tree, grass, and weed pollen were positive in over 35% of subjects. At follow-up, 83% (95/119) reported improvement in dysphagia following recommendations of food elimination and treatment of coexisting allergic conditions. Histologic improvement (61%; 19/31) and histologic remission (52%; 6/31) occurred in subjects with repeat endoscopy. Conclusion: With the rise in use of empiric food elimination diets, this study would suggest that an allergy evaluation that includes aeroallergen and broad food testing can still play a role in adults with EoE. Many of the foods currently included in the six-food elimination diet were also prevalent by allergy skin testing with some additional foods identified including the broader legumes (pea and bean), corn, yeast, rice, onion, garlic, oat, sesame seed, and coconut. Thus, a broad environmental and food allergy testing appears to be a complementary strategy to aid in the management of patients with EoE, especially in patients whom have experienced either failure or compliance issues with the empiric six-food elimination diet.

P001 A randomized controlled trial comparing six-food elimination diet vs topical steroids in inducing and maintaining remission of paediatric eosinophilic esophagitis

P001 A randomized controlled trial comparing six-food elimination diet vs topical steroids in inducing and maintaining remission of paediatric eosinophilic esophagitis