December 2014: Post summaries and take home points

Food allergy series: Risk factors for developing food allergies

  • Genetics is a factor in development of food allergies.
  • Poor skin integrity makes food allergies more likely.
  • Children with peanut or tree nut allergies usually react on the first ingestion.
  • Household peanut exposure is a risk factor for peanut allergy in infants.
  • Not clear if maternal diet while gestating can affect food allergies.
  • Low vitamin A and low vitamin D are risk factors.
  • Sun exposure and vitamin D deficiency may be connected to food allergies.
  • Hygiene hypothesis posits that changes in hygiene and cleaning has caused immune changes that may lead to allergies.
  • Gut microbiota also important in food allergies.

Food allergy series: FPIES (Part 1)

  • FPIES is the most severe GI food hypersensitivity that is not IgE mediated.
  • Thought to be caused by a delayed allergic pathway.
  • Causes profuse, repetitive comiting, diarrhea, acute dehydration, lethargy and weight loss.
  • Vomiting usually occurs 1-3 hours after eating offending food.
  • Vomiting is seen in 100% of cases.
  • Diarrhea is seen in 24% of cases.
  • Can cause low blood pressure and hypothermia.
  • Chronic symptoms can develop if food is not avoided.
  • About 75% of patients look seriously ill.
  • 15% have blood pressure low enough to require hospitalization.
  • FPIES usually onsets between 1-3 months of age, but can be as late as 12 months.
  • Symptoms usually occur 1-4 weeks after introducing cow’s milk or soy.
  • About 30% later develop atopic conditions.
  • 20% have family history of food allergies.
  • 80% react to more than one food.
  • Usually improve after beginning casein hydrolysate based formula.

Food allergy series: FPIES (part 2)

  • FPIES is diagnosed clinically.
  • Endoscopy and biopsy is often performed to rule out other conditions.
  • GI tract of FPIES patients shows inflammatory changes, such as ulceration and bleeding.
  • Baseline intestinal absorption is usually normal.
  • Food specific IgE is not usually present.
  • FPIES is managed with diet.
  • Exclusive breastfeeding can be protective against FPIES.
  • Oral food challenges require significant precautions and medical supervision.
  • Challenges are recommended every 18-24 months in asymptomatic patients.
  • 60% of FPIES cases resolve by three years of age.
  • In the US, only 25% of cases resolve by three years of age.
  • Most FPIES patients have some form of atopic disease.
  • Some patients may change from an FPIES type reaction to an IgE allergy type reaction.
  • Prevalence is different in different populations.
  • Median age for resolution of FPIES depends on the food and ranges from 4-7 years of age.
  • FPIES overwhelmingly affects very young children.
  • In very rare cases, older children and adults develop FPIES to fish or shellfish.

Food allergy series: Eosinophilic gastrointestinal disease (Part 1)

  • Eosinophilic gastrointestinal disease (EGID) is when eosinophils cause disease in the GI tract.
  • Eosinophils are white blood cells with similar functions to mast cells.
  • Eosinophils fight infections and participate in allergic response.
  • Eosinophils can degranulate.
  • Many GI conditions can elevate eosinophils in the GI tissue.
  • No consensus on what is a high eosinophil count/hpf.
  • Eosinophilic gastroenteritis can affect any part of the GI tract, but usually the stomach and small intestine.
  • Eosinophilic gastroenteritis causes swelling of the Gi tract, eosinophils in the tissue and ulcerations.
  • 50-70% of eosinophilic gastroenteritis is thought to be from allergic reactions.
  • The reason for eosinophilic gastroenteritis is not clear.
  • Eosinophilic esophagitis is 15 or more eosinophils/hpf in at least one field.
  • Eosinophilic esophagitis can be allergic or not.
  • Eosinophilic colitis is a rare condition with sudden onset colon inflammation with eosinophil infiltration that often spontaneously resolves.
  • Eosinophilic enteritis is limited to the small intestine.
  • Allergic proctocolitis affects rectum and/or colon of children under the age of 2.
  • Allergic proctocolitis can be the result of food allergy, most often soy or cow’s milk.

Food allergy series: Eosinophilic gastrointestinal disease (Part 2)

  • There are many conditions that can cause eosinophils to be increased in the GI tract.
  • Allergy associated colitis is when eosinophils aggregate in the small and large intestines as the result of an allergic reaction.
  • Hypereosinophilic syndrome is when people have too many eosinophils in the blood. Rarely, this causes eosinophils to become elevated in the colon.
  • Crohn’s disease causes inflammation of the digestive tract. Eosinophils in the GI tract can be elevated due to inflammation.
  • Ulcerative colitis causes inflammation of the colon. Eosinophils can be elevated in the colon due to inflammation.
  • Collagenous colitis causes inflammation of the colon and rectum. Eosinophils can be elevated. It may occur due to drug reactions.
  • Lymphocytic colitis causes inflammation of large portions of the colon. Eosinophils can be elevated in the mucosal layer.
  • Autoimmune colitis is when autoimmune patients experience colon inflammation. Eosinophils and mast cells are usually found together in affected tissue.
  • Graft versus host disease is a complication of a bone marrow transplant. Eosinophils can be elevated, including in the GI tract.
  • Peripheral/intestinal T cell lymphoma is a cancer that usually affects the small intestine. Eosinophils infiltrate the affected tissue.

Food allergy series: Eosinophilic gastrointestinal disease (Part 3)

  • 70% have family history of allergies
  • 10% have immediate family member with EGID
  • Can cause abdominal pain, GI dysmotility, vomiting, diarrhea, trouble swallowing, anemia, low blood protein and failure to thrive
  • Can cause malabsorption
  • EGID patients are very sensitive to foods. Eggs, milk and fish are most common problem foods.
  • Elimination diets are mainstays of treatment
  • Complete resolution often seen with elemental amino acid diet
  • Reintroduction of foods is not usually tolerated
  • Steroids effective but don’t produce lasting results
  • Mast cells often increased in EGID biopsies
  • Current treatment options not great

Food allergy series: Eosinophilic esophagitis (Part 1)

  • EoE patients are three times more likely to be male than female
  • Most patients have history of atopic disease
  • Usually presents in childhood or after third decade of life
  • Adults tend to have trouble swallowing, food impaction and upper abdominal pain
  • Children have less specific symptoms, including vomiting, abdominal and chest pain
  • 50-60% have at least one atopic condition
  • 15-43% have IgE mediated food allergies, are at greater risk for food induced anaphylaxis
  • No consensus on how many eosinophils/hpf is high

Food allergy series: Eosinophilic esophagitis (Part 2)

  • Endoscopy with biopsy is only reliable diagnostic method
  • May look normal by eye, so multiple biopsies should be taken
  • Mast cells are increased in EoE more than in GERD
  • Other tests rule like esophageal manometry, pH testing and barium swallows can help rule out other conditions
  • Important to exclude GERD
  • 40-50% EoE patients have increased in blood eosinophils
  • When EoE is effectively treated, blood eosinophil count decreases
  • Patients with EoE are found to have overexpression of several proteins
  • Other genetic links have been found

Food allergy series: Mast cell food reactions and the low histamine diet

  • Minimizes histamine in food consumed
  • Histamine from outside sources can induce mast cell degranulation
  • Common problem foods for mast cell patients, like alcohol, vinegar and aged cheeses, are high histamine and cause degranulation
  • There are many different versions of this diet. I use this one.
  • Avoid fermented foods, preservatives, dyes, leftovers, anything overly ripe, canned and pickled products
  • Recommends strict adherence for four weeks to determine if it works
  • Not all recipes labelled low histamine are low histamine

Food allergy series: Eosinophilic esophagitis (part 3)

  • Treatment first rules out GERD or PPI responsive esophageal eosinophilia by treatment with PPIs for 8-12 weeks
  • Some patients have primary EoE and secondary GERD
  • Dietary management is the cornerstone of EoE treatment
  • Dietary management is very effective in children, can achieve remission
  • Food tolerance is unlikely to be achieved even with long erm elimination
  • Steroids effective, but do not produce lasting benefits
  • Fluticasone and oral viscous budesonide effective in studies
  • Cromolyn has no clear benefit for EoE
  • Leukotriene receptor antagonists like Singulair might help, not clear
  • 11-55% of EoE patients suffer food impaction and require emergency intervention
  • Esophageal rings are common in EoE patients
  • Strictures larger than 1 cm in 11-31% of adults with EoE
  • Esophageal perforation can occur and may require surgery
  • Esophageal cancer and generalized EGID are not known to result from progression of EoE
  • Esophageal dilation is sometimes to treat difficulty swallowing and impaction

Food allergy series: Eosinophilic colitis

  • Can occur secondarily to many conditions, such as liver transplant and scleroderma
  • Less than 100 cases of primary eosinophilic colitis reported in literature
  • Experience lower GI symptoms, such as abdominal pain, constipation, diarrhea and rectal bleeding
  • More severe cases can cause malabsorption, obstructions, free fluid in the abdomen in weight loss
  • Symptoms often sudden onset, sudden resolve – relapsing/remitting
  • Dense eosinophilic infiltration in colon
  • Infiltration can occur in one large contiguous region or smaller isolated regions
  • No true consensus on what constitutes above average eosinophil count in GI tract
  • Sometimes have too many eosinophils in blood
  • Patients often have elevated total IgE
  • Treated with elimination diet, steroids, ketotifen and immunosuppressants

 

 

3 Responses

  1. Sheila Cooper July 18, 2015 / 11:47 pm

    My grandson (age 4.6) has FPIES to wheat, oat (possibly rice) and salmon.
    My grand niece (nearly age 6) has severe EoE and can tolerate about 10 foods.
    (The mothers of these two children are cousins.)
    I (age 72) was recently diagnosed with intermittent atypical microscopic colitis.

    Are these diseases all related?

    • Lisa Klimas July 19, 2015 / 12:57 am

      FPIES and EoE are related in that they both cause severe allergic type reactions to food. We have a reasonable understanding of EoE, but FPIES is much less well defined. So they are related in that they are both “food allergies” but it’s not clear if they are related beyond that.

      The microscopic colitis can be from a lot of things. Do you have food allergies, or reactions to foods? Eosinophilic colitis is extremely rare, and while FPIES can cause colitis, it causes severe reactions and is phenomenally rare in adults.

      • Sheila Cooper February 14, 2016 / 1:27 am

        Just noticed your reply, sorry. My dx has been changed (second opinion) to IBS. I’m better controlled but still have it. I don’t seem to have an obvious problem with specific foods. Doctor not at all interested in pursuing food reaction or linking it to the EoE or FPIES children in the family.

        Thanks for your reply. Can gut dysbiosis cause all these problems?

Comments are closed.