From the Guidelines
The most appropriate next step in management for this 12-year-old boy is dietary therapy (option F). Based on the clinical presentation of dysphagia, food impaction, weight loss, and endoscopic findings of linear furrows and circumferential lesions in the esophageal mucosa, this patient likely has eosinophilic esophagitis (EoE) 1. EoE is an allergic/immune-mediated condition characterized by eosinophilic infiltration of the esophageal mucosa. Given the patient's history of asthma and peanut allergy, which suggests an atopic predisposition, dietary therapy is the first-line approach. This would involve elimination of common food allergens (milk, wheat, eggs, soy, nuts, fish/shellfish) with sequential reintroduction to identify specific triggers.
Key Considerations
- The British Society of Gastroenterology and the British Society of Paediatric Gastroenterology, Hepatology and Nutrition recommend that all pediatric patients and most adult patients embarking on dietary management of EoE should be managed by a multiprofessional team of an experienced clinician, a specialist dietitian, and for selected patients, an allergist 1.
- The guidelines suggest a step-up approach to dietary management, starting with a 2-food exclusion diet for at least 8-12 weeks, followed by repeat endoscopy and reintroduction of one food at a time to establish trigger foods 1.
- Dietary management avoids medication side effects and addresses the underlying cause by removing the antigenic stimuli that trigger the inflammatory response.
- The patient should work with a dietitian to ensure nutritional adequacy during the elimination phase.
Rationale for Choice
- While topical steroids are also effective for EoE, dietary therapy is often tried first, especially in pediatric patients with known food allergies.
- The other options (pH monitoring, systemic glucocorticoids, manometry, valganciclovir, and dilation) are either not indicated for initial management of EoE or would be considered only after dietary therapy has failed.
- The American Gastroenterological Association Institute and the Joint Task Force on Allergy-Immunology Practice Parameters recommend dietary elimination as a first-line treatment for EoE, along with topical glucocorticosteroids and esophageal dilation 1.
From the Research
Diagnosis and Treatment of Eosinophilic Esophagitis
The patient's symptoms, including upper abdominal pain, difficulty swallowing solid foods, and weight loss, along with the results of the upper endoscopy showing linear, longitudinal furrows and circumferential lesions of the esophageal mucosa, are consistent with eosinophilic esophagitis (EoE) 2, 3, 4, 5, 6.
Dietary Therapy for EoE
Dietary therapy is a key component of EoE management, aiming to induce and maintain remission by eliminating causative food allergens 2, 3, 4, 5. The most effective dietary approach is often an empiric elimination diet, which involves removing common food allergens such as milk, egg, wheat, soy, peanuts, tree nuts, fish, or legumes 3, 5.
Next Steps in Management
Given the patient's diagnosis of EoE, the most appropriate next step in management would be to initiate dietary therapy. Considering the patient's allergy to peanuts and the presence of asthma, a careful approach to dietary elimination is necessary. Among the provided options, F. Dietary therapy is the most appropriate next step, as it directly addresses the underlying cause of EoE by eliminating potential food triggers 2, 3, 4, 5, 6.
Key Considerations
- The choice of dietary therapy should be based on the patient's specific needs, lifestyle, and nutritional requirements 2, 5.
- A step-up approach to dietary elimination, starting with a less restrictive diet and progressing to more restrictive diets as needed, may be beneficial 3.
- Ongoing monitoring and support from a multidisciplinary team are crucial for the success of dietary therapy in EoE management 5, 6.