Evidence suggests that the non-invasive procedure was successful with respect to reintroduction of food, but some food triggers were not addressed in some patients.

A new report suggests that the use of a non-invasive esophageal sponge may be successful in providing dietary management for patients with eosinophilic esophagitis (EoE).

However, the authors added that there were some differences between their biopsy results and biopsy results, indicating a need for further study. The report has been published Clinical gastroenterology and hepatology.

For some patients with EoE, a chronic inflammatory disease mediated by dietary antigens, pharmacological therapy is used to control the disease. However, the authors say that the majority of patients (about 70%) respond to the six-food elimination diet (SFED). The diet calls for the elimination of common allergy-causing foods such as dairy, wheat, soy, and eggs. If symptoms improve, patients then reintroduce foods individually to see which foods cause symptoms to return.

The problem, according to the authors, is that tracking EoE activity typically requires multiple endoscopies, which is invasive and costly. Thus, the researchers sought to evaluate a new instrument, the esophageal sponge on a string (Cytosponge), which can be used in an outpatient setting without sedation. According to the authors, previous studies have shown that this method can provide more than 80% accuracy in assessing the histological activity of EoE compared to endoscopy and biopsy.

To evaluate this method as a tool for targeted elimination therapy, the investigators recruited 22 patients who responded to SFED. Patients underwent re-introduction of food, followed by cytological examination of the sponge of the esophagus. Foods were classified as “triggers” if sponge cytology revealed eosinophil counts greater than 15 eosinophil cells per high power field (eos/hpf). Patients were also assessed using the EoE Symptom Activity Index (EEsAI), Endoscopic Reference Scores (EREFS), and biopsy histology before diet therapy, after diet therapy, and 4 weeks after food reintroduction to see if the results were in line with expectations based on sponge therapy.

The investigators found that both EEsAI scores and endoscopic scores were similar at time points after dietary therapy and after food reintroduction. However, biopsy histology showed that peak eosinophil count was higher after refeeding compared with post-diet therapy: 20.0 (range 5.0–51.5) vs. 2.0 (range 1.0–4.0; P < 0.001). The authors say this suggests that some food triggers have been overlooked. At the same time, they said peak eosinophils were still lower after food reintroduction compared to before dietary therapy, suggesting a benefit.

“When assessed after reintroduction of food, sponge cytology and biopsy histology were consistent in 59% of cases using a threshold of < 15 eos/hpf and in 68% of cases using a threshold of < 6 eos/hpf," they wrote.

The authors stated that the sponge method resulted in a significant reduction in mucosal eosinophils in all patients and identified food antigen triggers in most patients.

“Unfortunately, at the individual patient level, the correlation between Cytosponge eosinophil count and other measures of EoE activity, including biopsy histology, was not consistent,” they said.

However, patients preferred the sponge method, which the researchers say costs only 15% of the cost of using endoscopy to control food reintroduction.

“The sponge study is performed without sedation during a typical 30-minute office visit without the need for a driver or skipping work or school,” they wrote. “The sponge may also have safety benefits, as patients are not exposed to the small but quantifiable risk of upper sedation endoscopy.”

The authors say they use Cytosponge in their practice when patients have well-controlled symptoms and have a lumen greater than 13 mm. They said the new technique could be a strong argument for encouraging patients to use dietary elimination therapy.

“Our data also indicate that, as in biopsy histology, levels of esophageal eosinophilia measured with Cytosponge are unlikely to be the only endpoint, but complement other measures of EoE activity such as EREFS and symptom scoring systems,” they concluded.


Alexander J. A., Ravi K., Simrk T. S. et al. Use of an esophageal sponge for reintroduction of food in eosinophilic esophagitis. Clin Gastroenterol Hepatol. Published online June 10, 2022 doi:10.1016/j.cgh.2022.05.029

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