Elemental Diet Decreases Inflammation and Improves Symptoms in Adult Eosinophilic Oesophagitis Patients

M. J. Warners; B. J. Vlieg-Boerstra; J. Verheij; B. D. van Rhijn; M. T. J. Van Ampting; L. F. Harthoorn; W. J. de Jonge; A. J. P. M. Smout; A. J. Bredenoord

Disclosures

Aliment Pharmacol Ther. 2017;45(6):777-787. 

In This Article

Abstract and Introduction

Abstract

Background Eosinophilic oesophagitis (EoE) is a chronic disease, driven by food allergens. Elemental diets are effective for the management of children with EoE, but studies on the effect of elemental diets in adults are scarce and poor palatability challenges dietary adherence.

Aim To assess the effects of an elemental diet (Neocate, Nutricia, Utrecht, the Netherlands) on the inflammation, symptoms and endoscopic signs in adult EoE patients.

Methods In this prospective study, 21 patients with active EoE, confirmed by biopsies showing ≥15 eosinophils per microscopic high power field (HPF) and symptoms of oesophageal dysfunction were included. Patients underwent endoscopy before and 4 weeks after diet. Histological disease activity (peak eosinophil count/HPF), and endoscopic signs were scored by physicians. Symptoms and adherence to the diet were evaluated by questionnaires. Serum total IgE levels and total eosinophil counts were determined and the expression of inflammatory cytokines was analysed by qPCR.

Results In total, 17 (81%) of the patients completed the diet, of whom 12 (71%) showed complete histological response (≤15 eosinophils/HPF) and 4 (24%) showed partial histological response (≥50% reduction of baseline eosinophil count). Peak eosinophil counts decreased significantly after the diet from 40 to 9 per HPF (P ≤ 0.001). A marked improvement in endoscopic signs was observed. Symptoms decreased significantly in all subjects, and 15 patients (88%) became completely asymptomatic (P ≤ 0.001). In 14 patients (82%), blood eosinophil count and serum IgE decreased (P ≤ 0.05).

Conclusion Elemental diet reduces eosinophilic inflammation and induces clinical remission in adult patients with eosinophilic oesophagitis.

Introduction

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated disease of the oesophagus, clinically characterised by dysphagia and food impaction.[1] There has been a substantial increase in prevalence of EoE in the Western world, and EoE has become the main cause of dysphagia in children and young adults.[2–4] Although the pathophysiology of EoE is complex and only partly understood, food allergens are thought to be the trigger of a T-helper 2 (Th-2) cell-mediated immune response, whereby associated inflammatory cytokines can initiate or maintain the process of tissue remodelling of the oesophagus.[5,6] The theory of EoE being an allergy-driven disease is further supported by the studies showing that EoE can be brought in remission by dietary management.[7]

EoE can be managed using pharmaceutical [(topical) corticosteroids)] and/or dietary therapy. Topical steroids are moderately effective in paediatric and adult EoE patients.[8,9] However, side effects preclude long-term use, and since the underlying cause is not affected, the inflammation recurs once the (topical) steroid is withdrawn.[8,10,11] Studies have shown that, without treatment, progressive narrowing of the oesophagus occurs.[12] Dietary elimination of disease-triggering allergens could provide a long-term, drug-free and sustainable solution, which is desirable since EoE is a chronic disease and most patients are children or young adults. The three main approaches in dietary management are (i) allergy test-directed elimination, based on positive allergy test results, (ii) empiric elimination, based on most common allergic triggers (i.e. milk, wheat, egg, soy, peanuts/tree nuts, and fish/shellfish) and (iii) elimination of all table foods and substitution by an exclusively elemental (amino acid-based) diet. A recent systematic review showed that empiric elimination diets yield moderate response rates (71%), whereas the effect of test-directed elimination diets is questionable (45%).[13] On the other hand, elemental diets are highly effective in children, showing rapid resolution of symptoms and histological remission in more than 95% of the patients.[2,13,14] The effect of an elemental diet has only been investigated once in adult patients with EoE.[15] In that study by Peterson et al., the elemental diet induced complete histological disease remission in 72% of the patients. However, symptoms did not improve and drop-out rates were rather high (38%). Patient adherence to an elemental diet is challenging, not only in adults but also in children, due to unpalatability and monotony of the formula. Nevertheless, over the past decade the quality and variability in the formulas has improved. More research on the effect and feasibility of elemental diets in adult patients with EoE is thus required.

The aim of this study was to assess the efficacy of an exclusive elemental diet (Neocate Nutricia, Utrecht, the Netherlands) on the eosinophilic inflammation, symptoms and endoscopic signs in adult EoE patients. In addition, we evaluated patient adherence to a new improved formula with two available flavours.

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