Gastrointestinal manifestations of Food protein–induced enterocolitis (FPIES)

wp-1494994478845.Gastrointestinal manifestations of Food protein–induced enterocolitis (FPIES)

International consensus guidelines for the diagnosis and management of food protein–induced enterocolitis syndrome: Executive summary—Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology

Food protein–induced enterocolitis (FPIES) is a non-IgE cell- mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high-quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence-based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.

Gastrointestinal manifestations of Food protein–induced enterocolitis (FPIES)

  • Summary Statement 14: Do not routinely obtain endoscopic evaluation as part of the evaluation of FPIES. [Strength of recommendation: Weak; Evidence strength: IV; Evidence grade: D]. In patients with chronic FPIES with emesis and FTT, upper endoscopy can reveal gastric edema, erythema, and mucosal friability, with gastric antral erosions. Colonoscopy results can be normal in the absence of rectal bleeding or diarrhea. In patients with rectal bleeding, loss of vascular pattern, spontaneous and induced friability, and variable degrees of ulceration with spontaneous bleeding can occur. Rectal histology ranges from slight infiltrate of lymphocytes and plasma cells in the lamina propria to polymorphonuclear leukocytic infiltration of the lamina propria or glands, with occasional crypt abscesses and depletion of mucus from rectal glands. Destruction of the surface epithelium can be seen. Colonic macroscopic appearance is similar to that of the rectum, with red, fragile, hemorrhagic mucosa seen within a few hours of ingesting the offending food.56 Colonic biopsy specimens show severe inflammation with increased eosinophil numbers.56 In some infants with FPIES, small intestinal damage with variable degrees of villous atrophy has been described.24 Clinically, enteropathy can cause carbohydrate malabsorption and watery stools, which are positive for reducing substances.6, 57 Gross and histologic abnormalities can revert to normal as soon as 2 days after removal of the trigger food.
  • Summary Statement 15: Do not use stool tests to make the diagnosis of FPIES. [Strength of recommendation: Weak; Evidence strength: III; Evidence grade: D] Stool eosinophils, detected by using Hansel’s stain, along with eosinophilic debris can be found in infants with FPIES.57 Results of stool cultures and/or evaluation of stool for pathogenic organisms, including parasites, should be negative. Stool leukocytes noted on trigger food challenge were included among Powell’s diagnostic criteria of FPIES, although this specific feature is rarely considered essential in light of Sicherer’s modification to the acute FPIES criteria.57 In addition, patients with chronic FPIES can have occult fecal or frank blood after elimination and then reintroduction of the trigger food to their diets.


  • Halpin, T.C., Byrne, W.J., and Ament, M.E. Colitis, persistent diarrhea, and soy protein intolerance. J Pediatr. 1977; 91: 404–407
  • Fontaine, J.L. and Navarro, J. Small intestinal biopsy in cow’s milk protein allergy in infancy. Arch Dis Child. 1975; 50: 357–362
  • Jenkins, H.R., Pincott, J.R., Soothill, J.F., Milla, P.J., and Harries, J.T. Food allergy: the major cause of infantile colitis. Arch Dis Child. 1984; 59: 326–329
  • Coello-Ramirez, P. and Larrosa-Haro, A. Gastrointestinal occult hemorrhage and gastroduodenitis in cow’s milk protein intolerance. J Pediatr Gastroenterol Nutr. 1984; 3: 215–218

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