Treatment for Eosinophilic Duodenitis
The first-line treatment for eosinophilic duodenitis should be a combination of proton pump inhibitors (PPIs) and dietary elimination therapy, with topical corticosteroids reserved for cases that fail to respond to initial management. 1, 2
Pharmacological Treatment Options
- Proton pump inhibitors (PPIs) are recommended as first-line therapy, with omeprazole 20mg twice daily for 8-12 weeks being the standard regimen 1, 3
- Topical corticosteroids (swallowed steroids) are highly effective for inducing both histological and clinical remission in patients who fail to respond to PPI therapy 1, 3
- Treatment duration should be at least 8-12 weeks before evaluating the histological response through repeat endoscopy with biopsy 4, 3
- For patients with refractory disease, a combination of pharmacological and dietary therapy may be considered, although this approach is not routinely recommended as first-line treatment 5
Dietary Management Approaches
- Dietary elimination therapy should be conducted under the supervision of an experienced dietitian to ensure nutritional adequacy 5, 1, 4
- The empiric elimination diet approach is more effective than allergy-test directed elimination and includes several options:
- Six-food elimination diet (SFED): removes milk, wheat, eggs, soy, nuts/peanuts, and fish/shellfish, with 54-77% response rate 5, 6
- Four-food elimination diet: removes dairy, wheat/gluten cereals, egg, and legumes 7
- Two-food elimination diet: removes dairy and wheat/gluten as these are the most common triggers 4, 7
- Elemental diet (amino acid-based formula) is the gold standard for determining food antigen involvement, with 92-98% effectiveness in children, but poor palatability often requires enteral feeding 5
- After achieving remission, systematic food reintroduction should be performed to identify specific triggers, with milk, wheat, and soy being the most common food triggers 6
Important Clinical Considerations
- Allergy testing (skin prick, specific IgE, patch testing) is not recommended for guiding dietary elimination as it has poor predictive value for identifying food triggers 5
- A step-up approach (starting with 2-food elimination and progressing to 4-food or 6-food if needed) may enhance patient adherence 7
- For patients with fibrostenotic disease, endoscopic dilation combined with anti-inflammatory therapy provides better outcomes 1, 3
- Patients with refractory disease and/or significant concomitant atopic disease should be jointly managed by a gastroenterologist and specialist allergist 1, 4
Case-Specific Approaches
- In patients with confirmed food allergies, a targeted elimination diet based on identified allergens may be effective 8
- For non-atopic individuals with eosinophilic duodenitis, a combination of H2 inhibitors, PPIs, and budesonide for 12 weeks has shown success 2
Monitoring and Follow-up
- Endoscopy with biopsy while on treatment is essential to assess response, as symptoms may not always correlate with histological activity 1, 3
- If symptoms recur during treatment, repeat endoscopy should be performed to evaluate histological status 4
- Maintenance therapy should be considered for patients who achieve histological response, as relapse rates are high after treatment withdrawal 3