Dietary protein enteropathy and Gastrointestinal Food Allergy in Childhood
Gastrointestinal food allergies are a spectrum of disorders that result from adverse immune responses to dietary antigens. The named disorders include immediate gastrointestinal hypersensitivity (anaphylaxis), oral allergy syndrome, allergic eosinophilic esophagitis, gastritis, and gastroenterocolitis; dietary protein enterocolitis, proctitis, and enteropathy; and celiac disease. Additional disorders sometimes attributed to food allergy include colic, gastroesophageal reflux, and constipation. The pediatrician faces several challenges in dealing with these disorders because diagnosis requires differentiating allergic disorders from many other causes of similar symptoms, and therapy requires identification of causal foods, application of therapeutic diets and/or medications, and monitoring for resolution of these disorders.
Dietary protein enteropathy is characterized by protracted diarrhea and vomiting (in two thirds) with resulting malabsorption and failure to thrive with onset most commonly in infancy. Protein-losing enteropathy may lead to edema, abdominal distension, and sometimes anemia. The differential diagnosis must consider other causes of enteropathy (eg, infectious, metabolic, lymphangiectasia, Celiac disease). The disorder is caused by an immune response most commonly to cow milk protein, but soy, cereal grains, egg, and seafood have also been implicated. Diagnosis is based on the combined findings from endoscopy/biopsy, allergen elimination, and challenge. Biopsy reveals variable small bowel villus injury, increased crypt length, intraepithelial lymphocytes, and few eosinophils. The immune mechanisms seem to involve T cell responses and are not associated with IgE antibodies. Although features are shared with Celiac disease, this enteropathy is unlike Celiac disease because resolution generally occurs in 1–2 years and there is no increased threat of future malignancy. Dietary protein enteropathy may persist into later childhood, but the frequency of persistence of the disorder into adulthood is unknown.
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