Esophageal Eosinophilia and Wall Distensibility in Eosinophilic Esophagitis (EoE) Before and After Treatment: Preliminary Outcomes

Background: Data suggests that food is a primary trigger for the development of esophageal eosinophilia in children. Six food elimination diets are effective in adults, but the efficacy of an elemental diet in adult patients with eosinophilic esophagitis (EoE) has not been reported. Aims: To determine whether adult patients with EoE exhibit clinical and histologic improvement to an elemental diet compared to their normal diet. To determine the time of response of esophageal eosinophilia to elemental diet. Methods: EoE was diagnosed by esophageal obstructive symptoms (dysphagia, chest pain, food impaction, heartburn) and esophageal biopsies demonstrating >20 eosinophils/HPF in the setting of high dose acid suppression. All subjects underwent a second EGD/biopsies 2-3 weeks after their initial EGD/biopsies to confirm stability of disease while maintaining their normal diet. After the 2nd EGD/biopsies, all patients were started on an elemental diet (Elecare, Abbott Laboratories, Columbus, Ohio) and underwent a 3d EGD/biopsies after 2 weeks of Elecare. If subjects did not completely respond (eos 20/HPF at 2nd EGD) and completed at least 2 weeks of the Elecare diet. Five subjects dropped out of the trial after 2 weeks (2 due to poor tolerance of the diet, 3 for personal reasons). One patient responded completely at 2 weeks (1 eos/hpf). The remaining 20 patients completed a 4 week trial of Elecare. Eosinophil counts did not vary significantly between the 1st and 2nd EGD's (distal 44 to 43 eos/HPF, proximal 33 to 40 eos/HPF respectively, p =0.43, p=0.43). Dramatic decreases in eosinophils were seen at 2 weeks after starting Elecare (average distal 13 eos/HPF and proximal 14 eos/HPF, p <0.001 for both) and decreases correlated with an overall clinical response to therapy at 4 weeks. Response continued less profoundly between 2 and 4 weeks on Elecare (distal 11 eos/HPF and proximal 8 eos/HPF). 11/21 (52%) responded with counts less than 8 eos/HPF by week 4. Discussion: Elemental diet resulted in marked improvement in esophageal eosinophilia in a substantial number of adults with EoE. Histologic response occurs within 2 weeks of starting the elemental diet and profound decreases in eosinophilia at 2 weeks are maintained at 4 weeks on diet. Elemental diets are useful in the treatment of EoE to provide rapid relief of symptoms and tissue eosinophilia.