Non-IgE-mediated food allergy

Eosinophilic Oesophagitis

Eosinophilic oesophagitis (EoE) can present in both children and adults. In children, the main symptoms are often vomiting and GI symptoms, whereas the classic symptoms in adults include dysphagia, reflux and food impaction. There may be less evidence of structural changes in children, but adults may have developed rings, strictures and narrowing of the oesophagus due to eosinophilic re-modelling. Diagnosis is through endoscopic evaluation and biopsy, with an eosinophil count of >15 eosinophils per high powered field generally taken as the marker of EoE. Symptom management in children will usually be an exclusion diet. The exclusion of six foods (milk, egg, wheat, seafood, peanuts/tree nuts and soy) was initially shown to provide symptomatic relief, and more recently good outcomes have been shown with the elimination of four foods (milk, wheat, egg, soy). Current practice is often to exclude the main trigger, milk and wheat, and step up to 4-food exclusion if there are still some symptoms. Dietary elimination has been found to improve symptoms, reduce eosinophilic infiltrate in oesophageal mucosa, and improve endoscopic markers of inflammation. For adolescents and adults, topical steroids are often used, when diet has been less successful, or the patient does not wish to try the dietary option.

FPIES

Food Protein Induced Enterocolitis Syndrome (FPIES) generally occurs in early childhood and usually in formula-fed infants, with a reported prevalence of 0.34% in an unselected birth cohort. The acute presentation, which might be confused with sepsis, is characterised by specific symptoms, usually profuse vomiting, pallor, lethargy and occasionally hypotension, and typically an increase in neutrophils. These symptoms usually manifest between 1-4 hours after the ingestion of a food trigger, most commonly cow’s milk or soy, although other food triggers, including rice, oats, chicken, fish and egg have also been reported.  The history is key to diagnosis, as specific IgE tests or SPT are usually negative, and a challenge not usually undertaken due to the symptom severity. FPIES often resolves in early childhood around the age of 3 years, so follow-up is important to determine whether a challenge is indicated. FPIES has also been reported in adults, characterised by delayed onset (1-3 hours) symptoms of vomiting, abdominal pain and diarrhoea usually after eating shellfish, although reactions to milk, egg and wheat have also been reported.

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