Changing the Dietary Approach with Eosinophilic Esophagitis

A recent study (AF Kagalwalla, JB Wechsler, K Amsen, S Schwartz, M Makhija, A Olive, CM Davis, M Manuel-Rubio, Seth Marcus et al.  Clin Gastroenterol Hepaot, 2017; 1698-1701) is going to help shake up the dietary management of eosinophilic esophagitis (EoE).  Our group GI Care for Kids, led by Seth Marcus, was one of the four centers which participated in this study of a four food elimination diet (FFED or 4-FED).

This prospective study enrolled 78 patients. IN those who did not respond to twice daily proton pump inhibitor therapy, subjects were instructed to restrict cow’s milk, wheat, egg, and soy. Patients underwent serial challenges (8 week for a challenge) with followup upper endoscopy to each food to determine response; 25 patients completed the challenge to all four foods. Key findings:

  • 64% (n=50) had remission (Eos <15/hpf) with the FFED
  • Symptom scores decreased in 91% of the histologic responders
  • Among those who completed additional challenges: 22/26 (85%) had reactions to cow’s milk, 10/30 (33%) had reactions to wheat, 14/40 (35%) had reactions to eggs, and 8/43 (19%) had reactions to soy
  • Among those (n=25) who completed challenges to all four foods, reactions to food: 84% milk, 28% wheat, 8% eggs, 8% wheat
  • Among those (n=25) who completed challenges to all four foods, reactions occurred to a single food-groups in 64%, two food-groups in 20%, three-food groups in 8%, and four-food groups in 8%.  Thus 36% had more than a single-food group reaction.

This study shows that the FFED provides similar efficacy to the six-food elimination diet (SFED) and is less restrictive.  It offers the prospect of less time to complete food reintroduction and fewer upper endoscopies

Limitations: nonrandomization, absence of control group, selection bias.  The fact that 24 patients dropped our before completing reintroduction highlights the difficulty of maintaining these diets in clinical practice.

In the associated editorial (S Eluri, ES Dellon, pages: 1668-9), the authors reiterate that the SFED (or 6-FED), which includes nuts and seafood, had histologic response rates typically between 69%-72% and that this study shows a similar response. They note that dairy elimination alone has had response rates ranging from 43% to 65%.

In addition, they discuss a 2-food elimination diet (milk and wheat).  In a recent study (J Molina-Infante, et al. Gastroenterol 2017; 152: S207), the authors started with a 2-FED with histologic response of 43% and if not responding would advance to 4-FED and 6-FED.  This approach was more efficient and further limited endoscopies.

My take: In those patients who are treated with a dietary approach, the 4-FED is a sensible initial therapeutic approach and an improvement from the 6-FED.  Though there is slightly higher initial response to 6-FED, the 4-FED allows more efficiency at identifying the trigger foods and lessened patient burdens with regard to endoscopy, diet complexity, and cost.

Related study: EA Erwin et al. JPGN 2017; 65: 520-5. This study showed that patients multiple IgE antibodies (≥ 0.1 IU/mL) to foods correlated with the likelihood of identifying eosionphilic esophagitis (≥ 15 eos/hpf):

  • In this cohort, among males, positive IgE antibodies to zero foods had a positive predictive value of 22%, 1-3 foods 52%, and 4-5 foods of 77%
  • In this cohort, among females, positive IgE antibodies to zero foods had a positive predictive value of 10%, 1-3 foods 29%, and 4-5 foods of 56%

Related blog posts:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

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#NASPGHAN17 Eosinophilic Esophagitis Session

This blog entry has abbreviated/summarized these presentations. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

This is a long post –highlighting four separate talks on eosinophilic esophagitis.

PPI Use in Esophageal Eosinophilia: Recommendations from the recent AGREE conference

Glenn Furuta  Children’s Hospital of Colorado

Key points:

The term PPI-REE (proton pump inhibitor-responsive eosinophilic esophagitis) may not be needed.  PPI-REE is quite similar to eosinophilic esophagitis based on molecular and clinical features.  The main difference being that this subset responds to PPI therapy.

 

Characterization of CYP2C19*17 Polymporphisms Among Children with PPI Responsive EoE and EoE

James Franciosis et al.  Nemours Children’s Hospital Orlando

My take: This cool presentation offered a potential explanation of why some patients respond to PPIs (so called “PPI-REE”) from those with EoE that does not respond to PPIs.  This is pertinent because on a molecular basis the disease appears to be the same.  The difference in PPI-REE from EoE may be how the patient metabolizes PPI.  Those EoE patients who metabolize PPIs “extensively” are much less likely to respond to this therapy.

Eosinophilic esophagitis: Now an “Oldie” -But with increased interest and new research, a “Goodie”

Chris Liacouras  Children’s Hospital of Philadelphia

This lecture covered an enormous amount of material.  Here are a few slides.

Final Lecture (from November 3rd presentation):

Key points:

  • Endoflip is a new tool that helps determine esophageal distensibility.  Improved distensibility indicates less fibrostenotic disease which is one long-term goal.
  • Response to treatment has been correlated in improvement in Endoflip measurements.
  • There are no FDA approved medications at this point for EoE, though topical steroids may be approved soon.

#NASPGHAN17 Why Rome IV Criteria are important

More information from this year’s annual NASPGHAN meeting.

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

The following slides highlight a terrific lecture by Carlo DiLorenzo (Nationwide Children’s Hospital).  Subsequently, I’ve included slides from Miranda van Tilburg (UNC); I was unable to attend her lecture and found some of the slides via twitter.

Key points:

  • Rome IV criteria are helpful, particularly with less common presentations like rumination
  • There has been an increase in nausea.  Morning nausea can be equated as a marker of anxiety until proven otherwise.
  • There is improved wording. “After appropriate medical evaluation, the symptoms cannot be attributed to another condition” may help facilitate the diagnosis of irritable bowel syndrome, for example, in patients with IBD who are in remission.

From Miranda Tilburg:

#NASPGHAN17 Psychosocial Problems in Adolescents with IBD

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Slides from syllabus: APGNN Syllabus 2017

Key points:

  • ~30% of pediatric IBD patients have anxiety or depression.  This has not been shown to be related to disease activity.
  • Advice for parents: “Listen more and talk less.”
  • Antidepressants, when indicated, are about 6 times more likely to be helpful than detrimental

In the following slide, the term “normalize” indicates that checking on emotional health is part of a routine (eg. ‘we ask all our patients to complete this screening’)

#NASPGHAN17 Presentation: Reducing Hospitalization in Intestinal Failure Patients

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Risk Factors for Hospitalization Among Pediatric Intestinal Failure Patients

Tatyana Hofmekler, Janet Figueroa, Hilina Kassa, Rene Romero, Andi Shane.

Dr Hofmekler is now part of GI Care for Kids (my group) and provided a terrific presentation.

NASPGHAN Annual Mtg 2017

Key points:

  • In this study, there were no social or demographic factors which were identified which were associated with increased hospitalization
  • Having a colon and an ileocecal valve lowered the risk of hospitalization
  • The use of SBBO treatment was associated with increased hospitalization though this may have been a marker of more severe disease
  • Vascular catheter infections were reduced compared to study at same institution previously but remained an important risk factor for hospitalization

My take: this study illustrates the challenges in reducing hospitalization.  While the authors did not identify social/demographic factors, my experience is that there are some families who are much more capable than others in taking care of children with complex problems.  If all children had the best parents, that would truly allow the hospitalization rate to be reduced much lower.

 

#NASPGHAN17 Annual Meeting Notes (Part 2): Year in Review

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

This first slide shows the growth in NASPGHAN membership:

Year in Review

Melvin Heyman  Editor, JPGN

This lecture reviewed a number of influential studies that have been published in the past year.  After brief review of the study, Dr. Heyman summarized the key take-home point.

 

Consequences of Individual Mandate Repeal

Link: NY Times: Obamacare’s Insurance Mandate Is Unpopular. So Why Not Just Get Rid of It?

An excerpt: Without the mandate, the C.B.O. has said for years, premiums would spike, and millions fewer Americans would have health insurance. The budget office’s most recent estimate, published last week, said that the ranks of the uninsured would rise by 13 million over 10 years, and that average premiums would be 10 percent higher than under current law.