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Food Allergy – A multisystem disorder

I wish to declare the following conflicts of interest:

  • Research funding: NIHR, FARE, NPB, ITN (NIH), Thermo Scientific, Stallergenes, Meridien foods
  • Conference fees: BSACI, MEDA, Danone, Mead-Johnson, ALK

EGID and allergic diseases

Overlap in clinical presentation

Allergy in EoE vs. UK population

Allergic March including EGID

Atopic eczema

Emollients: 500g/week

Topical steroids

Allergic rhinitis

Treatment of allergic rhinitis

Seasonal variability of EoE

  • Most commonly diagnosed in spring in paediatric patients
  • 5% patients had seasonal variation confirmed by biopsy

  • Other studies in adults and adolescents no seasonality
  • Frederickson NW et al. Un Europ Gastroenterol 2014;2(2):69-76
  • EoE induced by aeroallergen exposure (grass and HDM)

Immunotherapy and EoE

  • Two studies have shown EoE resolution/ improvement after HDM immunotherapy
  • Induction of EoE following pollen immunotherapy
  • Systematic review: Egg, milk, peanut OIT induced EoE in 2.7%

Role of allergy testing for EoE

  • 53 children with confirmed EoE on biopsy
  • 80% children had either inhalant or food sensitization
  • Most common specific IgE raised to cow’s milk
  • Allergy testing not related to symptoms/endoscopy findings

EoE histological remission rate

Progression to IgE mediated allergy

EoE consensus recommendations

  • ‘SPT, sIgE and APT can help identify foods that are associated with EoE but these tests are not sufficient alone to make the diagnosis of food allergy-driven EoE.’
  • ‘Medically supervised food reintroduction might be necessary for patients with positive SPT or sIgE because of loss of tolerance during food avoidance might results in significant reactions on reintroduction’

Summary

  • High rates of concurrent allergic rhinitis, eczema, asthma and IgE mediated food allergy in EGID
  • Allergy-testing directed elimination diet less useful than empirical elimination diets
  • Consider risk of IgE mediated allergy after prolonged avoidance
  • Joint working of Allergists & Gastroenterologists

Characteristics of EGID patients and family

Topical steroid potency

Aetiology

Eosinophils and TH2 cytokines

  • Atopic eczema
  • Nasal lavage allergic rhinitis
  • BAL asthma
  • EoE biopsy

Mechanism of sensitization

IgE mediated allergy:

  • Epicutaneous ovalbumin exposure leads to increased eosinophils in BAL and hyperresponsiveness to metacholine

Eosinphilic eosophagitis:

  • Epicutaneous followed by intranasal challenge to ovalbumin / Aspergillus leads to EoE

Epicutaneous + intranasal allergen challenge EoE

ARIA Classification of allergic rhinitis

Topical steroids

Food vs. aeroallergen sensitivity in EoE

 

 

 

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