Multidisciplinary approach to the management of adult eosinophilic oesophagitis in the United Kingdom

Abstract

Dietary intervention is effective for the management of eosinophilic oesophagitis (EoE) in both adults and children. 1 The majority of research has been conducted in Spain or the United States, 1 with no studies of dietary intervention published in the United Kingdom. Restrictive elimination diets can be challenging and swallowed topical corticosteroids have also been shown to be an effective treatment in adults. 2 Despite their efficacy, disadvantages include risk of candidiasis, 3 potential long-term effects such as adrenal suppression 3 and off-label medication use. Proton pump inhibitors (PPIs) are effective for a proportion of patients 4 although with both PPIs and corticosteroids, the underlying triggers of this presumed antigen-mediated condition are not identified and continued use is required to maintain efficacy. 3 A key aspect in the management of any allergic disease is avoidance of relevant allergens. Through a multidisciplinary collaboration between Adult Allergy, Gastroenterology, and Dietetics, we launched a service to provide dietary intervention for adults with EoE in a UK tertiary referral centre. We recently undertook a retrospective evaluation with the aim to describe the clinical phenotype of EoE in our service and to determine the clinico-pathological response to dietary or medical interventions in this cohort (GSTT service evaluation 6195). | ME TH ODSA search of the histology reporting system was performed in patients who had oesophageal biopsies taken over 2 years using the term "eosinophil". Patients were also identified by reviewing clinical records. The resulting list was manually screened for eligible patients, namely adults (>16 years) with an oesophageal eosinophil count over 15 per high power field (hpf) and documented history of suggestive symptoms.In our pathway (Figure 1), all patients with oesophageal eosinophilia were advised to start a PPI as per previous guidelines. 5 Both responsive and non-responsive patients were offered a choice between dietary management, corticosteroids or long-term PPI if responsive. Prior to dietary intervention, patients were assessed by both an Allergist and specialist allergy dietitian. They underwent extensive allergy testing using skin prick and serum specific IgE tests and were placed on a test-directed exclusion diet if any results were positive (unless solely sensitised to tree nuts). If no target foods were identified through testing, patients were recommended to undergo the six-food elimination diet (SFED), followed by sequential food reintroduction to identify triggers. A further biopsy was taken after 6 weeks of intervention. If the SFED was not successful, steroids or an elemental diet was recommended.Eosinophil counts and histological response were compared in those who had both pre-and post-treatment endoscopies for PPIs, steroids, and dietary interventions. All were undertaken for a minimum of 6 weeks for diet and 8 weeks for PPI and corticosteroids.Complete histological response was defined as an eosinophil count of less than 5 cell...

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

“…A single centre UK study that included a dedicated dietitian reported high levels of efficacy with elimination diets in a retrospective service evaluation. 138 This approach is supported by the American Academy of Allergy, Asthma and Immunology recommendation that ‘a referral to a registered dietitian for any individual prescribed an elimination diet for EoE’. 139 Therefore, support from an experienced dietitian is recommended to mitigate these risks as well as to help the patient to succeed on the diet.…”

Descriptive Analysis of Pre-existing Data on Eosinophilic Esophagitis and Associated Morbidities in Cleveland Clinic Abu Dhabi, United Arab Emirates

“…The variety of specialists consulted by a large number of patients in the CCAD database attests to the attempt to diagnose and manage these conditions by a multidisciplinary team (MDT). In fact, recent literature promotes the management of EGIDs by an MDT, which includes a specialized dietician [ 39 - 41 ]. Diagnosis of EoE was mostly done at the gastroenterology clinic, without further information about sign and symptom presentation.…”

The multidisciplinary approach to eosinophilia

“…This is the first presentation of the rationale for the MDT in eosinophilia ( Supplementary Tables 1, 2 ; Table 1 and Figures 2 – 4 ). The MDT function is a well-established tool across medical disciplines ( 172 – 177 ), and MDTs have been implemented in departments treating eosinophilic esophagitis, possibly improving patient outcomes ( 180 , 181 ), and have also been considered in Loeffler’s endocarditis ( 182 ). However, one difference between the MDT for patients with eosinophilia and other scheduled MDTs is that the MDT for eosinophilia typically starts by challenging and discussing the working diagnosis ( Figure 5 ), whereas the diagnosis has been established unquestionably in (almost all referred patients) MDTs.…”