Eosinophilic gastrointestinal disorders (EGIDs) are a group of rare, chronic conditions characterized by an elevated number of eosinophils (a type of white blood cell) infiltrating the gastrointestinal tract. These disorders include eosinophilic esophagitis (EoE), eosinophilic gastritis (EoG), eosinophilic gastroenteritis (EoGE), and eosinophilic colitis (EoC). While EoE has received more attention, the prevalence of non-esophageal EGIDs like EoG, EoGE, and EoC appears to be on the rise. In EoG/EoGE, eosinophils infiltrate the gastric and/or intestinal tissue, potentially affecting multiple bowel layers (mucosal, submucosal, serosal). Symptoms often correlate with the affected bowel layer, including abdominal pain, nausea, vomiting, early satiety, weight loss, and diarrhea. The pathogenesis of EoG/EoGE, however, remains poorly understood. Diet is a treatment option for eosinophilic disorders, including eosinophilic esophagitis (EoE), eosinophilic gastritis (EoG), eosinophilic enteritis (EoN) and eosinophilic colitis (EoC).
What is Eosinophilic Gastritis?
Eosinophilic gastritis (EG) is a rare disease affecting the stomach. It involves the buildup of eosinophils, a type of white blood cell, leading to inflammation and damage. EG can affect individuals of all ages and is considered a chronic condition. However, symptoms can often be managed through regular testing and dietary changes guided by a healthcare provider.
Eosinophils are a component of the immune system, produced in the bone marrow. Normally, they constitute a small percentage (1-5%) of white blood cells. Allergens, infections, medications, or cancer can trigger an increase in eosinophil production (eosinophilia). These cells release enzymes and proteins to combat unhealthy cells. In EG, an overproduction of eosinophils causes inflammation in the stomach tissues (gastritis) or other organs.
EG can affect people of all ages, but is most often diagnosed in adults between 30 and 50 years old. Slightly more males than females develop the disease. Individuals with a history of allergic disorders or a family history of related diseases may be at higher risk. Common allergic conditions associated with EG include:
- Asthma.
- Drug allergies.
- Eczema (atopic dermatitis).
- Allergic rhinitis (hay fever).
Types of Eosinophilic Gastrointestinal Disorders (EGIDs)
Eosinophilic gastritis is one type of eosinophilic gastrointestinal disease (EGID). These conditions can affect different parts of your digestive system. You may have more than one disorder at once (which happens when you have high numbers of eosinophils). The six main types of EGID include:
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- Eosinophilic colitis (EC): Involves the large intestine (colon).
- Eosinophilic duodenitis: Affects the first part of your small intestine.
- Eosinophilic enteritis (EoN): Affects your small bowel.
- Eosinophilic esophagitis (EoE): The most common EGID, involves your esophagus.
- Eosinophilic gastritis (EG): Involves your stomach.
- Eosinophilic gastroenteritis (EGE): Primarily affects your stomach and small intestine.
Other types of eosinophilic disease that can affect your GI system are:
- Hypereosinophilic syndrome: Involves the blood and any organ.
- Eosinophilic granulomatosis with polyangiitis (EGPA): Can affect many organs, including your heart.
Dietary Interventions for Eosinophilic Gastritis
Given the potential role of food allergens in triggering EGIDs, dietary interventions have emerged as a key management strategy. The goal of dietary therapy is to reduce inflammation by identifying and eliminating trigger foods. Several dietary approaches are used, including elemental diets and elimination diets.
Elemental Diets
An elemental diet involves the consumption of nutritionally complete, amino acid-containing formulas. These formulas, often called "elemental formulas," provide protein in the form of amino acids, the basic building blocks of protein. This approach bypasses the need for the body to break down whole proteins, potentially reducing the allergic response. When consumed in the prescribed amount, elemental formulas can provide all the necessary calories, vitamins, and minerals.
A prospective single-center study published by Gonsalves et al. in The Journal of Allergy and Clinical Immunology investigated the effect of an elemental diet on adults with eosinophilic gastritis or gastroenteritis. The study prospectively enrolled adult patients between 18 and 65 years old with a diagnosis of EoG/EoGE to receive elemental formula as their sole nutrition for six weeks. The primary endpoint was the percentage of participants with complete histologic remission (<30 eos/HPF in both stomach/duodenum). Exploratory outcomes were improvement in symptoms, endoscopy, blood eosinophilia, quality of life, physician global assessment, and EoG-relevant gastric transcriptome and microbiome. Fifteen adults completed the trial and all subjects had complete histologic remission in the stomach and duodenum after dietary intervention. Subjects also had significant improvement in other outcome measures including symptoms, endoscopic changes, physician global assessment, patient reported outcomes and molecular signature. This study demonstrated improvement in histologic, endoscopic, symptomatic, quality of life, and molecular parameters after treatment.
Considerations for Elemental Diets:
- Chronic Kidney Disease: Exercise caution in patients with chronic kidney disease taking multiple diuretics when implementing this method.
- Cost: The cost of implementing the formula diet is also of concern, as formula insurance coverage is only universal in some US states. Costs in other countries may also mean access to this treatment may vary.
Elimination Diets
An elimination diet involves avoiding specific foods that are suspected of triggering EGID symptoms. This approach aims to identify and remove food allergens from the diet. A common starting point is the six-food elimination diet (SFED), which involves avoiding the six most commonly implicated dietary antigens:
Read also: Comprehensive Gastritis Guide
- Milk (dairy products)
- Soy
- Eggs
- Wheat
- Nuts (peanuts and tree nuts)
- Seafood (fish and shellfish)
The six-food elimination diet involves avoiding all foods that contain the six most commonly implicated dietary antigens in the United States.
Food Reintroduction:
After a period of elimination (typically 4-8 weeks), foods are reintroduced one at a time to identify specific triggers. Food trials are used to determine what specific foods trigger a patient’s symptoms, with the goal of adding back non-triggering foods into the diet. In general, food trials consist of eating the trial food in a specified amount and frequency over a period of time. The serving size, frequency of consumption and length of the trial vary by the patient age and the trial food.
Researchers reintroduced one food item to the participants’ diets every 3 to 5 days. If participants didn’t experience a symptom recurrence, researchers added more foods sequentially.
Case Study:
One study successfully treated a 22-year-old woman with eosinophilic gastroenteritis (EGE) using a multiple food-elimination diet. The patient was diagnosed with EGE based on histopathological findings and initially treated with oral prednisolone. The symptoms immediately improved, although they recurred when prednisolone was tapered to a low dose. The patient was then treated with a multiple food-elimination diet, including milk, soy, eggs, wheat, nuts, seafood, and rice. During dietary treatment, dairy products and eggs were identified as causative foods of the symptoms, and prednisolone was ceased.
In this case, an antigen-specific IgE antibody was identified only for shrimp, and there was no relationship between total IgE level and symptoms. With the use of this food-elimination diet, dairy products and eggs were identified as causative foods, and the patient’s symptoms disappeared with a diet free of those foods.
Read also: Managing Weight Loss Due to Gastritis
Considerations for Elimination Diets:
Allergy Testing: It is difficult to identify causative foods because an individual’s response to an elimination diet does not always correlate with laboratory and skin food allergy tests, such as allergen-specific IgE tests or patch and scratch tests.
GI-Expert Dietitian: It is now time to meet with a GI-expert dietitian.
Soybean Oils: Highly refined soybean oils found in vegetable oil do not usually contain soy protein and are allowed on SFED. Cold pressed and expeller pressed oils can be sources of soy protein and should be avoided.
Additional Dietary Recommendations for Gastritis
While specific dietary recommendations for eosinophilic gastritis primarily focus on identifying and eliminating trigger foods, general dietary guidelines for gastritis can also be beneficial in managing symptoms.
Foods to Include:
- Anti-Inflammatory Foods: Since gastritis involves inflammation, incorporating anti-inflammatory foods can be helpful. Examples include:
- Leafy green vegetables (cabbage, kale, spinach, arugula)
- Oily fish (salmon, mackerel, sardines)
- Nuts (almonds, walnuts, hazelnuts)
- Fruits (strawberries, blueberries, cherries, raspberries)
- Olive oil
- Probiotic Foods: Probiotic foods may help improve gut health. Examples include:
- Natural yogurt
- Sauerkraut
- Miso
- Kefir
- Tempeh
- Kimchi
- Sourdough bread
- Foods that may benefit gastritis: Berries, fermentable fibers, and whole grains may benefit gastritis.
Foods to Avoid:
- Foods that worsen gastritis symptoms: Sweets, spicy foods, salty foods, meat, barbecue foods, snacks, fried foods, and sour foods.
- Foods that increase the risk of inflammation: Red and processed meats, refined carbohydrates (white bread, pasta), sugary foods and candies, sodas and sweetened drinks.
- Other dietary and lifestyle habits that may increase the risk of gastritis: Alcohol consumption, smoking, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- Other things that worsen symptoms: Eating too fast, irregular mealtimes, irregular meal sizes, eating in restaurants, eating leftover food.
General Lifestyle Recommendations
In addition to dietary modifications, certain lifestyle changes can help manage eosinophilic gastritis and gastritis in general:
- Quit smoking: Smoking can irritate the stomach lining.
- Limit or avoid alcohol consumption: Alcohol can also irritate the stomach.
- Manage stress: Stress can increase gastric acid levels.
- Avoid long-term use of NSAIDs: These medications can damage the stomach lining.
- Follow hygiene guidelines: Proper handwashing and food safety practices can help prevent H. pylori infection.
Medical Treatments
Medications that can decrease stomach acid and help relieve symptoms of gastritis include:
- Over-the-counter antacids, such as Pepto Bismol
- H2 blockers, which are also known as acid reducers, such as cimetidine (Tagamet) and famotidine (Pepcid)
- Proton pump inhibitors, such as omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid)
- Antibiotics if there is a bacterial infection
- Treatment to boost levels of vitamin B12 and iron, if there is a deficiency
- Appropriate treatment if they confirm that Crohn’s disease or another underlying condition is present
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