Dietary therapy for eosinophilic esophagitis

Eosinophilic esophagitis is a chronic, immune-mediated esophageal disease triggered predominantly, but not exclusively, by food antigens. Presently, available food allergy tests are suboptimal to predict food triggers for eosinophilic esophagitis, especially in adults. Elemental diets (exclusive feeding with amino acid-based formulas) and empiric 6-food elimination diets (withdrawing milk, wheat, egg, soy, nuts, and fish/seafood for 6 weeks) have consistently shown the best efficacy rates. However, their high level of restriction and need for multiple endoscopies have hampered their implementation in clinical practice. Currently, milk, wheat/gluten, and egg are the most common food triggers in children and adults from the United States, Spain, and Australia. Hence less restrictive empiric schemes, such as a 4-food elimination diet (dairy, gluten-containing cereals, egg, and legumes) or a 2-food elimination diet (dairy and gluten-containing cereals) have been lately developed with good efficacy rates (2-food elimination diet, 43%; 4-food elimination diet in adults, 54%; and 4-food elimination diet in children, 64%). A step-up approach (2-4-6) might result in prompt recognition of a majority of responders with few food triggers, reducing the number of endoscopies and costs and shortening the diagnostic process. Standardization of food reintroduction, novel food allergy testing, and studies evaluating a milk elimination diet in children and the long-term outcomes of dietary interventions are warranted.