NHD CPD eArticle Vol 10.01 - Eosinophilic oesophagitis by NH Publishing Ltd

NHD CPD eArticle Volume 10.01 23rd January 2020

EOSINOPHILIC OESOPHAGITIS Many may not have heard of eosinophilic oesophagitis (EO), but it is in fact becoming one of the most prevalent oesophageal diseases. It is the leading cause of dysphagia and food impaction in children and young adults, as well as affecting the adult population.1 As diagnosing EO has improved over recent years, more focus has been put on treatment options, including dietary management. EO is the second most common cause of chronic oesophagitis after gastrooesophageal reflux disease (GORD), and occurs when there is damage to the oesophageal mucosa by esoinophils.2 Eosinophils are a type of white blood cells that make up part of our immune system, which have a beneficial role in defence and many other immune responses. However, eosinophils can also be damaging as part of the inflammatory process of allergic disease.3 Too many eosinophils result in chronic inflammation which can damage the mucosa lining the oesophagus. Guidelines on management of EO define it as a local immunemediated oesophageal disease, characterised clinically by symptoms related to oesophageal dysfunction and histologically by eosinophilpredominant inflammation. 1 The cause of EO is not yet completely understood, but it can be triggered by eating certain foods, as EO is a distinct form of food allergy.1 It is thought to affect 400 per 100,000 people, more common in males2 and has a tendency to relapse-remit.

DIAGNOSIS

EO is diagnosed with the use of an endoscopy tube, which allows doctors to take a biopsy from the oesophagus lining to assess levels of eosinophils. At least six biopsies from different locations in the oesophagus should be taken, and areas that show more than 15 eosinophils per high power field can be classed as EO. This threshold was set to help clinicians differentiate between EO and other oesophagus conditions such as GORD. Currently there are no noninvasive investigations with which to diagnose EO.1

Rebecca Gasche Specialist Dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions

SYMPTOMS

Dysphagia is a common symptom of EO and may be intermittent or continuous. The severity of dysphagia can vary and, for some, it may result in a food bolus obstruction. In children, it is common to see failure to thrive, as well as regurgitation of foods. As a result of the dysphagia caused by EO, people may develop habits such as excessive chewing of food, drinking lots of water at mealtimes

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NHD CPD eArticle and avoiding foods that could “get stuck” (eg, meats, or bread). In children, EO may result in ‘fussy eating’, or behavioural changes.2 TREATMENT

Due to the allergic nature of the disease, many pharmacological treatments are similar to those used to treat asthma, for example, the topical steroids budesonide or fluticasone. This treatment does, however, rely on a large amount of patient education and correct administration.2 Proton pump inhibitors (PPI) may be used to induce and help maintain remission of EO and, in particular, may help those patients who have GORD as well as EO. It is often found that pharmacological treatment alongside dietary management is the best treatment for EO. Oesophageal dilation may be used to provide some improvement in symptoms, but carries its own risks, such as oesophageal tears and perforation, and needs to be used in conjunction with dietary and/or drug treatment.2,4 ELIMINATION DIETS

As EO is an allergic-type immune response, it is common for patients with EO to have food allergy as a trigger for their symptoms, which is why elimination diets play a key role in identifying dietary triggers. In children, the gold standard for assessing whether food allergy is associated with a patient’s EO symptoms is to commence an elemental enteral diet and gradually introduce foods into the diet. Enteral feeding may need to be administered via a tube, and should be followed for approximately six weeks before reintroducing foods.2 This regimen ensures that all food is substituted with a liquid formula composed of amino acids, carbohydrates, fats and minerals. The success rate of elemental diets is around 90%, but, in practice, they are rarely tolerated by patients.5 Barriers to elemental diets include the high cost, unpleasant taste and the social limitations that come with complying to a strict liquid-only diet. A targeted elimination diet involves the removal of foods identified on allergy testing or patient history. Allergy testing typically involves skin prick or patch tests of a wide

Volume 10.01 - January 23rd 2020

variety of foods.6 This approach is often deemed ‘simpler’ and, therefore, preferred by patients. However, it is not commonly used, as the success rate is <50%.5 Skin prick testing used in combination with atopy patch testing, may also be used as a guide to avoid specific foods in an elimination diet trial. For adults, the most common dietary treatment is to use a six-food elimination diet, which is the preferred dietary therapy, given its relatively high success rate and acceptability by patients.5 This diet eliminates the six most common food allergens (eggs, wheat, soy, fish, dairy and peanuts) for six weeks. These foods are then reintroduced into the diet, one at a time, and the response assessed. A comprehensive meta-analysis of dietary interventions showed that this method achieved histological remission in approximately 72% of patients.5 FOLLOW UP

The role of a dietitian with understanding and expertise in elimination diets, food substitution and potential sources of crosscontamination, is essential to help guide patients, particularly growing children, in helping maintain a nutritionally complete diet. This requires knowledge and understanding of the potential nutrient deficiencies caused by the elimination of a specific food, as well as the appropriate substitution for that food. Guided advice is important to ensure patients are not unnecessarily over restricting. For example, if a patient is required to avoid cow’s milk, it is important they replace this with a calcium-rich alternative. Once a patient has been identified as having a sensitivity to a particular food, or a trigger food has been identified, an experienced dietitian can help assess for and prevent contamination of the excluded foods. Crosscontamination can often occur at the levels of food manufacturing/processing, preparation, cooking, and serving, and can easily transform an antigen-free food into an antigen-containing food.7 Comprehensive understanding and educating of food manufacturing can help identify potential contamination with potential trigger foods such as milk, soy, wheat, or nuts.

Copyright © 2020 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

NHD CPD eArticle Cross-contamination during food preparation at home can be avoided by measures such as cleaning surfaces and utensils, as well as strict hand-washing between handling/cooking different foods. Educating patients on cooking skills and how to plan ahead for special occasions, can ensure that patients and their families feel confident in their food choices. Education on food labelling is also crucial, emphasising this should be checked with every purchase, as the manufacturing or processing frequently changes without clear notice to the consumer.7,8

Volume 10.01 - January 23rd 2020 SUMMARY

To conclude, EO is becoming an increasingly recognised condition and has links with dietary triggers. The symptoms may affect growth, behaviours and social outcomes. MDT management is essential for identifying, diagnosing and treating the condition. Elimination diets can help to identify specific dietary triggers and working with a specialised dietitian can help to achieve this safely, ensuring that patients avoid certain foods going forward.

References 1 Lucendo A, Molina-Infante J, Arias Á, von Arnim U, Bredenoord A, Bussmann C, Amil Dias J, Bove M, González-Cervera J, Larsson H, Miehlke S, Papadopoulou A, Rodríguez-Sánchez J, Ravelli A, Ronkainen J, Santander C, Schoepfer A, Storr M, Terreehorst I, Straumann A and Attwood S (2017). Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterology Journal, 5(3), pp 335-358 2 Lomer M and Stuart A (2014). Advanced nutrition and dietetics in gastroenterology. Chichester, England: Wiley Blackwell 3 Immunology org (2019). Eosinophils. British Society for Immunology [online]. Available at: www.immunology.org/public-information/bitesizedimmunology/células/eosinophils [Accessed 1 June 2019] 4 Guts UK (2019). Eosinophilic Diseases – Guts UK [online]. Available at: https://gutscharity.org.uk/advice-and-information/conditions/eosinophilicdiseases/#section-2 [Accessed 1 June 2019] 5 Arias A, Gonzalez-Cervera J, Tenias J, Lucendo A. Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic oesophagitis: A systematic review and meta-analysis. Gastroenterology 2014; 146: 1639-48 6 Wolf W, Jerath M, Sperry S, Shaheen N, Dellon E. Dietary elimination therapy is an effective option for adults with eosinophilic oesophagitis. Clin Gastroenterol Hepatol 2014; 12: 1272-79 7 Kagalwalla A, Wechsler J, Schwartz S and Amsden K (2014). Elimination diets in the management of eosinophilic esophagitis. Journal of Asthma and Allergy, p85. 8 Bda.uk.com (2019). Living with a food allergy [online]. Available at: www.bda.uk.com/foodfacts/living_with_a_food_allergy [Accessed 1 June 2019]

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NHD CPD eArticle Volume 10.01 - January 23rd 2020

Questions relating to: Eosinophilic oesophagitis Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

What beneficial role do eosinophils play in the immune system and how can they be damaging?

Q.2

Describe the aetiology of eosinophilic oesophagitis (EO).

Q.3

Explain why the diagnosis of EO entails at least six biopsies.

Q.4

What are the main symptoms of EO?

Q.5

Why are pharmacological treatments for EO similar to those used to treat asthma?

Q.6

Outline the gold standard for assessing EO symptoms in children.

Q.7

What allergy tests are used to assess the removal of allergenic foods?

Q.8

Describe the six-food elimination diet.

Please type additional notes here . . .