Lymphonodular Hyperplasia on the Duodenal Bulb Indicates Food Allergy in Children

Introduction

Diagnosing gastrointestinal food allergy is a challenge. In small children, and when there is a suspicion of cow's milk allergy, a double-blind challenge test is the method of choice [1]. In older children, in other food allergies, in more delayed reactions, and if the patient has only gastrointestinal symptoms, the diagnosis is usually based on open oral challenges after an elimination period. Histologically, jejunal biopsies taken with a capsule technique from children with cow's milk protein intolerance show an enteropathy similar to that seen in celiac disease, though less pronounced and less constant [2]. In older children and adults, histological assessment of a small intestinal biopsy sample is usually normal [3] [4].

Endoscopic examination has not been established as a diagnostic procedure in children with food allergy. However, the literature includes case reports and reports on small series of children with food allergy and increased lymphoid tissue in the mucosa of the gastrointestinal tract that may be visible at endoscopy [5] [6]. Since the initiation of an endoscopy-based program for diagnosing distinct clinical entities in children with gastrointestinal complaints, our group has observed many children with lymphonodular hyperplasia (LNH) at various sites, most often at the duodenal bulb [7]. Most patients have also had food allergy.

To assess whether an endoscopic examination might serve as a specific tool to diagnose gastrointestinal food allergy, and to differentiate it from other distinct clinical and pathological states such as celiac disease, Helicobacter pylori infection, and esophagitis, a one-year consecutive series of pediatric patients undergoing esophagogastroduodenoscopy (EGD) at our institution was analyzed.

References

• 1 European Society for Paediatric Gastroenterology and Nutrition Working Group for Diagnostic Criteria for Food Allergy. Diagnostic criteria for food allergy with predominantly intestinal symptoms.  J Pediatr Gastroenterol Nutr. 1992;  14 108-112
• 2 Kuitunen P, Savilahti E, Visakorpi J, Pelkonen P. Malabsorption syndrome with cow's milk intolerance: clinical findings and course in 54 cases.  Arch Dis Child. 1975;  50 351-356
• 3 Bengtson U, Rognum TP, Brandtzaeg P, et al. IgE-positive duodenal mast cells in patients with food-related diarrhoea.  Int Arch Allergy Appl Immunol. 1991;  95 86-91
• 4 Kokkonen J, Similä S, Herva R. Gastrointestinal findings in atopic children.  Eur J Pediatr. 1980;  134 249-254
• 5 Machida H, Catto-Smith A, Gall D, et al. Allergic colitis in infancy: clinical and pathologic aspects.  J Pediatr Gastroenterol Nutr. 1994;  19 22-26
• 6 Gottrand F, Erkan T, Fabriaux JP, et al. Food-induced bleeding from lymphonodular hyperplasia of the colon.  Am J Dis Childh. 1993;  147 821-823
• 7 Kokkonen J, Karttunen T, Niinimäki A. Lymphonodular duodenitis as a sign of food allergy in children. J Pediatr Gastroenterol Nutr 1999: [in press]