Confocal Laser Endomicroscopy With Duodenal Food Challenge Does Not Predict Triggering Food Items in Eosinophilic Esophagitis: Results From a Pilot Trial.

Abstract

Background/aims: : Targeted elimination of triggering food items is an attractive treatment option in eosinophilic esophagitis (EoE). However, no reliable biomarkers exist to identify culprit foods. In a previous uncontrolled study, 6/9 responded to duodenal food challenge (DFC), visualized by confocal laser endomicroscopy (CLE). This study aims to assess efficacy of a targeted elimination diet based on identification of nutrients that trigger acute mucosal alterations in the duodenum compared to a sham diet.

Methods: : Randomized double-blind cross-over study in EoE. After baseline endoscopy, patients with peak eosinophil count of > 15 eosinophils/high power field underwent CLE. Following baseline assessment, a solution of foods (grains/milk/egg/soy/fish/nuts) was sprayed on the duodenal mucosa, with repeat imaging thereafter. Mucosa was judged as altered in case of fluorescein leakage and particle shedding. Based on the results, patients underwent a blinded randomized 6-week cross-over elimination diet with follow-up endoscopy. Exploratory measurements were done for small intestinal permeability, eosinophil- and mast cell activation.

Results: : Seven patients completed the study. At CLE, 1 patient displayed baseline alterations, 5 reacted to 1 to 2 nutrients in 2 sessions (milk = 4, grains = 2, nuts = 2, fish = 1). There was no association between CLE results, and presence of food-specific IgE (P > 0.999). Both dietary arms resulted in a similar histological response (P > 0.999), with histological remission in only 1 patient (excluding gluten-containing grains). Permeability, eosinophil or mast cell activation were not different between arms.

Conclusions: : In this pilot blinded cross-over trial, a targeted elimination diet based on the results of CLE with DFC did not generate a superior response compared to a sham diet.