title: Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors.
abstract: OBJECTIVE
  Adults with eosinophilic esophagitis (EoE) typically present with dysphagia and food impaction. A 6-food elimination diet (SFED) is effective in children with EoE. We assessed the effects of the SFED followed by food reintroduction on the histologic response, symptoms, and quality of life in adults with EoE.
  
  
  METHODS
  At the start of the study, 50 adults with EoE underwent esophagogastroduodenoscopies (EGDs), biopsies, and skin-prick tests for food and aeroallergens. After 6 weeks of SFED, patients underwent repeat EGD and biopsies. Histologic responders, defined by ≤ 5 eosinophils/high-power field (eos/hpf) (n = 32), underwent systematic reintroduction of foods followed by EGD and biopsies (n = 20). Symptom and quality of life scores were determined before and after SFED.
  
  
  RESULTS
  Common symptoms of EoE included dysphagia (96%), food impaction (74%), and heartburn (94%). The mean peak eosinophil counts in the proximal esophagus were 34 eos/hpf and 8 eos/hpf, before and after the SFED, and 44 eos/hpf and 13 eos/hpf in the distal esophagus, respectively (P < .0001). After the SFED, 64% of patients had peak counts ≤ 5 eos/hpf and 70% had peak counts of ≤ 10 eos/hpf. Symptom scores decreased in 94% (P < .0001). After food reintroduction, esophageal eosinophil counts returned to pretreatment values (P < .0001). Based on reintroduction, the foods most frequently associated with EoE were wheat (60% of cases) and milk (50% of cases). Skin-prick testing predicted only 13% of foods associated with EoE.
  
  
  CONCLUSIONS
  An elimination diet significantly improves symptoms and reduces endoscopic and histopathologic features of EoE in adults. Food reintroduction re-initiated features of EoE in patients, indicating a role for food allergens in its pathogenesis. Foods that activated EoE were identified by systematic reintroduction analysis but not by skin-prick tests.
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611-2951, USA. n-gonsalves@northwestern.edu
authors.forename: Nirmala
authors.initials: N
authors.lastname: Gonsalves
authors.forename: Guang-Yu
authors.initials: GY
authors.lastname: Yang
authors.forename: Bethany
authors.initials: B
authors.lastname: Doerfler
authors.forename: Sally
authors.initials: S
authors.lastname: Ritz
authors.forename: Anne M
authors.initials: AM
authors.lastname: Ditto
authors.forename: Ikuo
authors.initials: I
authors.lastname: Hirano
mesh_terms: D000328:Adult; D000368:Aged; D001707:Biopsy, Needle; D016099:Endoscopy, Gastrointestinal; D057765:Eosinophilic Esophagitis / Q000175:diagnosis / Q000178:diet therapy* / Q000209:etiology / Q000276:immunology; D004804:Eosinophils / Q000473:pathology; D004947:Esophagus / Q000473:pathology; D005260:Female; D005512:Food Hypersensitivity / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012882:Skin Tests; D055815:Young Adult