Allergic colitis medical therapy: Difference between revisions

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{{Allergic colitis}}
{{Allergic colitis}}
{{CMG}}; {{AE}}{{QS}}
{{CMG}}; {{AE}}{{QS}}
==Overview==
==Overview==
The mainstay of treatment of allergic colitis is dietary management.
The mainstay of treatment of allergic colitis is dietary management. Medical therapy includes [[allergen]] avoidance, treatment of severe manifestations of the [[allergy]], and eventual reintroduction of the [[allergy]] into the diet.  


==Medical Therapy==
==Medical Therapy==
Management relies on the food avoidance, prompt treatment of accidental reactions, anticipatory guidance regarding introduction of new foods, and periodic reevaluations for tolerance.
Dietary management of allergic colitis involves elimination of the [[allergen]] from the diet of the patient, treatment of severe manifestation, periodic reintroduction of the offending food after a period of avoidance to check for tolerance, and guided introduction to new food.<ref name="pmid21134568">{{Cite journal
Avoidance
| author = [[Joshua A. Boyce]], [[Amal Assa'ad]], [[A. Wesley Burks]], [[Stacie M. Jones]], [[Hugh A. Sampson]], [[Robert A. Wood]], [[Marshall Plaut]], [[Susan F. Cooper]], [[Matthew J. Fenton]], [[S. Hasan Arshad]], [[Sami L. Bahna]], [[Lisa A. Beck]], [[Carol Byrd-Bredbenner]], [[Carlos A. Jr Camargo]], [[Lawrence Eichenfield]], [[Glenn T. Furuta]], [[Jon M. Hanifin]], [[Carol Jones]], [[Monica Kraft]], [[Bruce D. Levy]], [[Phil Lieberman]], [[Stefano Luccioli]], [[Kathleen M. McCall]], [[Lynda C. Schneider]], [[Ronald A. Simon]], [[F. Estelle R. Simons]], [[Stephen J. Teach]], [[Barbara P. Yawn]] & [[Julie M. Schwaninger]]
The principles of avoidance are similar to IgE-medi- ated food allergy. Extensively hydrolyzed casein for- mula is recommended for infants that cannot breast- feed, because concomitant CM and soy FPIES occur in up to 40% of cases.6,9 In the majority of infants with CM and/or soy FPIES, symptoms resolve within 3–10 days of starting extensively hydrolyzed casein for- mula. Rarely, patients need amino acid-based formula
| title = Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report
or bowel rest and temporary i.v. fluids.9 Infants with multiple food FPIES, especially those breastfed are at risk to develop food refusal and may benefit from feeding therapy.37,38
| journal = [[The Journal of allergy and clinical immunology]]
| volume = 126
| issue = 6
| pages = 1105–1118
| year = 2010
| month = December
| doi = 10.1016/j.jaci.2010.10.008
| pmid = 21134568
}}</ref><ref name="pmid22050274">{{Cite journal
| author = [[S. Koletzko]], [[B. Niggemann]], [[A. Arato]], [[J. A. Dias]], [[R. Heuschkel]], [[S. Husby]], [[M. L. Mearin]], [[A. Papadopoulou]], [[F. M. Ruemmele]], [[A. Staiano]], [[M. G. Schappi]] & [[Y. Vandenplas]]
| title = Diagnostic approach and management of cow's-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines
| journal = [[Journal of pediatric gastroenterology and nutrition]]
| volume = 55
| issue = 2
| pages = 221–229
| year = 2012
| month = August
| doi = 10.1097/MPG.0b013e31825c9482
| pmid = 22569527
}}</ref><ref>{{Cite journal
| title = ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant
| journal = [[Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine]]
| volume = 6
| issue = 6
| pages = 435–440
| year = 2011
| month = December
| doi = 10.1089/bfm.2011.9977
| pmid = 22050274
}}</ref><ref name="pmid10634300">{{Cite journal
| author = [[A. M. Lake]]
| title = Food-induced eosinophilic proctocolitis
| journal = [[Journal of pediatric gastroenterology and nutrition]]
| volume = 30 Suppl
| pages = S58–S60
| year = 2000
| month =
| pmid = 10634300
}}</ref><ref name="pmid25976434">{{cite journal| author=Nowak-Węgrzyn A| title=Food protein-induced enterocolitis syndrome and allergic proctocolitis. | journal=Allergy Asthma Proc | year= 2015 | volume= 36 | issue= 3 | pages= 172-84 | pmid=25976434 | doi=10.2500/aap.2015.36.3811 | pmc=4405595 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25976434  }} </ref><ref name="pmid22282379">{{Cite journal
| author = [[Elisabeth De Greef]], [[Bruno Hauser]], [[Thierry Devreker]], [[Gigi Veereman-Wauters]] & [[Yvan Vandenplas]]
| title = Diagnosis and management of cow's milk protein allergy in infants
| journal = [[World journal of pediatrics : WJP]]
| volume = 8
| issue = 1
| pages = 19–24
| year = 2012
| month = February
| doi = 10.1007/s12519-012-0332-x
| pmid = 22282379
}}</ref><ref name="pmid23919257">{{Cite journal
| author = [[Rosan Meyer]], [[Catharine Fleming]], [[Gloria Dominguez-Ortega]], [[Keith Lindley]], [[Louise Michaelis]], [[Nikhil Thapar]], [[Mamoun Elawad]], [[Vijay Chakravarti]], [[Adam T. Fox]] & [[Neil Shah]]
| title = Manifestations of food protein induced gastrointestinal allergies presenting to a single tertiary paediatric gastroenterology unit
| journal = [[The World Allergy Organization journal]]
| volume = 6
| issue = 1
| pages = 13
| year = 2013
| month =
| doi = 10.1186/1939-4551-6-13
| pmid = 23919257
}}</ref><ref name="pmid21762530">{{Cite journal
| author = [[Sandra Lucarelli]], [[Giovanni Di Nardo]], [[Ginevra Lastrucci]], [[Ylenia D'Alfonso]], [[Adriana Marcheggiano]], [[Tatiana Federici]], [[Simone Frediani]], [[Tullio Frediani]] & [[Salvatore Cucchiara]]
| title = Allergic proctocolitis refractory to maternal hypoallergenic diet in exclusively breast-fed infants: a clinical observation
| journal = [[BMC gastroenterology]]
| volume = 11
| pages = 82
| year = 2011
| month =
| doi = 10.1186/1471-230X-11-82
| pmid = 21762530
}}</ref><ref name="pmid24723091">{{Cite journal
| author = [[Yvan Vandenplas]], [[Elisabeth De Greef]] & [[Bruno Hauser]]
| title = Safety and tolerance of a new extensively hydrolyzed rice protein-based formula in the management of infants with cow's milk protein allergy
| journal = [[European journal of pediatrics]]
| volume = 173
| issue = 9
| pages = 1209–1216
| year = 2014
| month = September
| doi = 10.1007/s00431-014-2308-4
| pmid = 24723091
}}</ref><ref name="pmid24131740">{{Cite journal
| author = [[Adriana Chebar Lozinsky]] & [[Mauro Batista de Morais]]
| title = Eosinophilic colitis in infants
| journal = [[Jornal de pediatria]]
| volume = 90
| issue = 1
| pages = 16–21
| year = 2014
| month = January-February
| doi = 10.1016/j.jped.2013.03.024
| pmid = 24131740
}}</ref>
 
===Allergen avoidance===
*'''Breastfeeding infant''': [[Breastfeeding]] is the gold standard feeding method for infants due to its benefits and is recommended exclusively at least for the first four to six months of life. Mothers are recommended to continue [[breastfeeding]], while avoiding the food that contains the most likely [[allergen]]
*Mothers are usually instructed to eliminate one food or food group containing common [[allergens]] (e.g., [[Dairy product|dairy products]]) at a time and wait a minimum of 2 to 4 weeks. Improvement occurs in 72 to 96 hours in most cases.
*If there is no improvement in the symptoms the food is added back into the mother's diet and another suspected food eliminated
*The food should be reintroduced in the mother’s diet after improvement to see if symptoms will relapse. If there is relapse, then the food is eliminated from the mother’s diet as long as she is breastfeeding or 9 to 12 months and/ or at least 6 months after the last symptom before another attempt is made at reintroduction of the allergen
*The mother will require calcium supplements (1000 mg per day divided into several doses) during the elimination diet
*Elimination of foods should be carefully done with an experienced dietician as unnecessary avoidance of foods at an early age may lead to nutritional deficiencies and/or feeding difficulties
*Some breastfeeding patients may still have symptoms despite maternal elimination diet, In such patients breastfeeding may have to be stopped and the infant is commenced on hypoallergenic formula
 
*'''Formula-fed infants''': In formula-fed infants with allergic colitis, the food is substituted with extensively hydrolyzed formula
*During allergen elimination, all other food intake should be stopped to avoid misinterpretation due to cross-reactivity with other allergens
*Symptoms usually resolve within 3 to 10 days of starting the hydrolyzed formula in FPIES
*Occasionally some patients may have symptoms despite use of hydrolyzed formula, in such patients amino acid-based formula is used
 
===Treatment of severe manifestation===
*Severe clinical manifestation typically occur in FPIES than in FPIAP. This may occur either following accidental ingestion of the [[allergen]] after a period of avoidance or during allergen challenge  test or during the periodic reintroduction of the offending protein
*Periodic reintroduction should preferably be done in the hospital setting with resuscitation materials in place before its done
*[[Intravenous fluids]], [[epinephrine]], [[antiemetics]] such as [[ondansetron]], and blood products may be needed
 
===Periodic reintroduction===
*Reintroduction of the allergen into the patients diet can begin from 9 to 12 months of life or at least 6 months after the last symptom, whichever is longer in patients with [[Food protein-induced allergic proctocolitis (FPIAP)|FPIAP]], but should be avoided until 12 to 18 months in patients with [[Food protein-induced enterocolitis syndrome (FPIES)|FPIES]]
*Thereafter, re-evaluation to establish if the patient has tolerance to the trigger food can be done every 6 to 12 months
*Tolerance to the offending food usually takes longer to develop in patients with FPIES


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Gastroenterology]]
[[Category:InfectiousDisease]]
[[Category:PrimaryCare]]
{{WS}}{{WH}}

Latest revision as of 13:35, 2 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Qasim Salau, M.B.B.S., FMCPaed [2]

Overview

The mainstay of treatment of allergic colitis is dietary management. Medical therapy includes allergen avoidance, treatment of severe manifestations of the allergy, and eventual reintroduction of the allergy into the diet.

Medical Therapy

Dietary management of allergic colitis involves elimination of the allergen from the diet of the patient, treatment of severe manifestation, periodic reintroduction of the offending food after a period of avoidance to check for tolerance, and guided introduction to new food.[1][2][3][4][5][6][7][8][9][10]

Allergen avoidance

  • Breastfeeding infant: Breastfeeding is the gold standard feeding method for infants due to its benefits and is recommended exclusively at least for the first four to six months of life. Mothers are recommended to continue breastfeeding, while avoiding the food that contains the most likely allergen
  • Mothers are usually instructed to eliminate one food or food group containing common allergens (e.g., dairy products) at a time and wait a minimum of 2 to 4 weeks. Improvement occurs in 72 to 96 hours in most cases.
  • If there is no improvement in the symptoms the food is added back into the mother's diet and another suspected food eliminated
  • The food should be reintroduced in the mother’s diet after improvement to see if symptoms will relapse. If there is relapse, then the food is eliminated from the mother’s diet as long as she is breastfeeding or 9 to 12 months and/ or at least 6 months after the last symptom before another attempt is made at reintroduction of the allergen
  • The mother will require calcium supplements (1000 mg per day divided into several doses) during the elimination diet
  • Elimination of foods should be carefully done with an experienced dietician as unnecessary avoidance of foods at an early age may lead to nutritional deficiencies and/or feeding difficulties
  • Some breastfeeding patients may still have symptoms despite maternal elimination diet, In such patients breastfeeding may have to be stopped and the infant is commenced on hypoallergenic formula
  • Formula-fed infants: In formula-fed infants with allergic colitis, the food is substituted with extensively hydrolyzed formula
  • During allergen elimination, all other food intake should be stopped to avoid misinterpretation due to cross-reactivity with other allergens
  • Symptoms usually resolve within 3 to 10 days of starting the hydrolyzed formula in FPIES
  • Occasionally some patients may have symptoms despite use of hydrolyzed formula, in such patients amino acid-based formula is used

Treatment of severe manifestation

  • Severe clinical manifestation typically occur in FPIES than in FPIAP. This may occur either following accidental ingestion of the allergen after a period of avoidance or during allergen challenge test or during the periodic reintroduction of the offending protein
  • Periodic reintroduction should preferably be done in the hospital setting with resuscitation materials in place before its done
  • Intravenous fluids, epinephrine, antiemetics such as ondansetron, and blood products may be needed

Periodic reintroduction

  • Reintroduction of the allergen into the patients diet can begin from 9 to 12 months of life or at least 6 months after the last symptom, whichever is longer in patients with FPIAP, but should be avoided until 12 to 18 months in patients with FPIES
  • Thereafter, re-evaluation to establish if the patient has tolerance to the trigger food can be done every 6 to 12 months
  • Tolerance to the offending food usually takes longer to develop in patients with FPIES

References

  1. ↑ Joshua A. Boyce, Amal Assa'ad, A. Wesley Burks, Stacie M. Jones, Hugh A. Sampson, Robert A. Wood, Marshall Plaut, Susan F. Cooper, Matthew J. Fenton, S. Hasan Arshad, Sami L. Bahna, Lisa A. Beck, Carol Byrd-Bredbenner, Carlos A. Jr Camargo, Lawrence Eichenfield, Glenn T. Furuta, Jon M. Hanifin, Carol Jones, Monica Kraft, Bruce D. Levy, Phil Lieberman, Stefano Luccioli, Kathleen M. McCall, Lynda C. Schneider, Ronald A. Simon, F. Estelle R. Simons, Stephen J. Teach, Barbara P. Yawn & Julie M. Schwaninger (2010). "Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report". The Journal of allergy and clinical immunology. 126 (6): 1105–1118. doi:10.1016/j.jaci.2010.10.008. PMID 21134568. Unknown parameter |month= ignored (help)
  2. ↑ S. Koletzko, B. Niggemann, A. Arato, J. A. Dias, R. Heuschkel, S. Husby, M. L. Mearin, A. Papadopoulou, F. M. Ruemmele, A. Staiano, M. G. Schappi & Y. Vandenplas (2012). "Diagnostic approach and management of cow's-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines". Journal of pediatric gastroenterology and nutrition. 55 (2): 221–229. doi:10.1097/MPG.0b013e31825c9482. PMID 22569527. Unknown parameter |month= ignored (help)
  3. ↑ "ABM Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant". Breastfeeding medicine : the official journal of the Academy of Breastfeeding Medicine. 6 (6): 435–440. 2011. doi:10.1089/bfm.2011.9977. PMID 22050274. Unknown parameter |month= ignored (help)
  4. ↑ A. M. Lake (2000). "Food-induced eosinophilic proctocolitis". Journal of pediatric gastroenterology and nutrition. 30 Suppl: S58–S60. PMID 10634300.
  5. ↑ Nowak-Węgrzyn A (2015). "Food protein-induced enterocolitis syndrome and allergic proctocolitis". Allergy Asthma Proc. 36 (3): 172–84. doi:10.2500/aap.2015.36.3811. PMC 4405595. PMID 25976434.
  6. ↑ Elisabeth De Greef, Bruno Hauser, Thierry Devreker, Gigi Veereman-Wauters & Yvan Vandenplas (2012). "Diagnosis and management of cow's milk protein allergy in infants". World journal of pediatrics : WJP. 8 (1): 19–24. doi:10.1007/s12519-012-0332-x. PMID 22282379. Unknown parameter |month= ignored (help)
  7. ↑ Rosan Meyer, Catharine Fleming, Gloria Dominguez-Ortega, Keith Lindley, Louise Michaelis, Nikhil Thapar, Mamoun Elawad, Vijay Chakravarti, Adam T. Fox & Neil Shah (2013). "Manifestations of food protein induced gastrointestinal allergies presenting to a single tertiary paediatric gastroenterology unit". The World Allergy Organization journal. 6 (1): 13. doi:10.1186/1939-4551-6-13. PMID 23919257.
  8. ↑ Sandra Lucarelli, Giovanni Di Nardo, Ginevra Lastrucci, Ylenia D'Alfonso, Adriana Marcheggiano, Tatiana Federici, Simone Frediani, Tullio Frediani & Salvatore Cucchiara (2011). "Allergic proctocolitis refractory to maternal hypoallergenic diet in exclusively breast-fed infants: a clinical observation". BMC gastroenterology. 11: 82. doi:10.1186/1471-230X-11-82. PMID 21762530.
  9. ↑ Yvan Vandenplas, Elisabeth De Greef & Bruno Hauser (2014). "Safety and tolerance of a new extensively hydrolyzed rice protein-based formula in the management of infants with cow's milk protein allergy". European journal of pediatrics. 173 (9): 1209–1216. doi:10.1007/s00431-014-2308-4. PMID 24723091. Unknown parameter |month= ignored (help)
  10. ↑ Adriana Chebar Lozinsky & Mauro Batista de Morais (2014). "Eosinophilic colitis in infants". Jornal de pediatria. 90 (1): 16–21. doi:10.1016/j.jped.2013.03.024. PMID 24131740. Unknown parameter |month= ignored (help)
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