Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts.
Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts.
Clin Gastroenterol Hepatol. 2018 Nov;16(11):1730-1737.e2. doi: 10.1016/j.cgh.2018.04.013. Epub 2018 May 3.
BACKGROUND & AIMS: Elimination diets are effective treatments for eosinophilic esophagitis (EoE), but foods that activate esophagitis are identified empirically, via a process that involves multiple esophagogastroduodenoscopies (EGDs). No optimized approach has been developed to identify foods that activate EoE. We aimed to compare clinical strategies to provide data to guide treatment.
We developed a computer-based simulation model to determine promising empiric elimination strategies based on reported prevalence values for foods that activate EoE. We conducted a review, searching PubMed through October 1, 2017, for prospective and retrospective studies of EoE and diet. Each patient in our simulated cohort was assigned a profile comprising as many as 12 foods known to induce EoE, including dairy, wheat, eggs, soy, nuts, seafood, beef, corn, chicken, potato, pork, and/or rice. To balance the strategy success rate with the number of EGDs required for food identification, we applied an efficiency frontier approach. Strategies on the frontier were the most efficient, requiring fewer EGDs for higher or equivalent success rates relative to their comparable, neighboring strategies.
In all simulations, we found the 1,4,8-food and 1,3-food strategies to be the most efficient in identifying foods that induce EoE, resulting in the highest rate of the correct identification of food triggers balanced by the number of EGDs required to complete the food elimination strategy. Both strategies begin with elimination of dairy; if EoE remission is not achieved, the 1,3 diet proceeds to eliminate wheat and eggs in addition to dairy, and the 1,4,8 strategy removes wheat, eggs, dairy, and soy. In the case of persistent EoE after the second round of food elimination, the 1,3-food strategy terminates, whereas the 1,4,8-food diet eliminates corn, chicken, beef, and pork. The 1,4,8-food diet resulted in correct identification of foods that activated esophagitis in 76.68% of patients, with a mean of 4.13 EGDs and a median of 6 EGDs. The 1,3-food strategy identified foods that activated esophagitis in 42.76% of patients, with a mean of 3.36 EGDs and a median of 2 EGDs required.
In this modeling analysis, we found the 1,4,8-food and 1,3-food elimination strategies to be the most efficient in detection of foods that induce EoE in patients. However, the ideal elimination strategy will vary based on clinical priorities. Additional research on specific foods that induce EoE are needed to confirm the predictions of this model.
消除饮食是治疗嗜酸性食管炎（EoE）的有效方法，但能引发食管炎的食物是通过食管胃十二指肠镜检查（EGD）的经验过程来确定的。目前还没有开发出优化的方法来确定引发 EoE 的食物。本研究旨在比较临床策略，提供指导治疗的数据。
我们开发了一种基于计算机的模拟模型，根据报道的引发 EoE 的食物的流行率值，确定有前途的经验性消除策略。我们通过检索 PubMed，对截至 2017 年 10 月 1 日的 EoE 和饮食的前瞻性和回顾性研究进行了综述。我们模拟队列中的每个患者都有一个包括多达 12 种已知能诱发 EoE 的食物的特征，包括奶制品、小麦、鸡蛋、大豆、坚果、海鲜、牛肉、玉米、鸡肉、土豆、猪肉和/或大米。为了平衡策略成功率与识别食物所需的 EGD 数量，我们应用了效率前沿方法。前沿策略是最有效的，与可比的相邻策略相比，它们需要更少的 EGD 来获得更高或同等的成功率。
在所有模拟中，我们发现 1、4、8 种食物和 1、3 种食物策略在识别诱发 EoE 的食物方面最为有效，通过所需的 EGD 数量来平衡食物消除策略完成后的食物触发的正确识别率。这两种策略都从消除奶制品开始；如果 EoE 缓解没有达到，1、3 饮食除了奶制品外，还会添加小麦和鸡蛋；而 1、4、8 策略则会消除小麦、鸡蛋、奶制品和大豆。在第二轮食物消除后持续存在 EoE 的情况下，1、3 食物策略结束，而 1、4、8 饮食则消除玉米、鸡肉、牛肉和猪肉。1、4、8 种食物饮食在 76.68%的患者中正确识别出了诱发食管炎的食物，平均需要 4.13 次 EGD，中位数为 6 次 EGD。1、3 食物策略在 42.76%的患者中识别出了诱发食管炎的食物，平均需要 3.36 次 EGD，中位数为 2 次 EGD。
在这项建模分析中，我们发现 1、4、8 种食物和 1、3 种食物消除策略在检测引发 EoE 的食物方面最为有效。然而，理想的消除策略将取决于临床重点。需要对具体的引发 EoE 的食物进行更多的研究，以证实该模型的预测。
