eMedicine Specialties > Allergy and Immunology > Major Allergic Diseases

Food Allergies: Differential Diagnoses & Workup

Author: Scott H Sicherer, MD, Associate Professor of Pediatrics, Mount Sinai School of Medicine of New York University
Contributor Information and Disclosures

Updated: Sep 2, 2009

Differential Diagnoses

Anorexia Nervosa
Gastroenteritis, Bacterial
Auriculotemporal syndrome
Gastroenteritis, Viral
Bulimia
Gastroesophageal Reflux Disease
Celiac Sprue
Giardiasis
Clostridium Difficile Colitis
Hiatal Hernia
Constipation
Inflammatory Bowel Disease
Diverticulitis
Intestinal Motility Disorders
Dumping Syndrome
Irritable Bowel Syndrome
Esophageal Motility Disorders
Lactose Intolerance
Esophageal Spasm
Trichosporon Infections
Esophageal Stricture
Urethral Diverticula
Esophagitis
Urticaria
Factitious Disorder
VIPomas
Food Poisoning
Vocal Cord Dysfunction
Gastritis, Acute
Wasp Stings
Gastritis, Chronic
Whipple Disease

Workup

Laboratory Studies

  • Serum testing for specific IgE antibodies to foods44
    • Specific IgE antibodies to foods can be quantified by in vitro laboratory methods. The term RAST (radioallergosorbent test) is antiquated because modern methods do not use radiation. This test and skin prick testing both measure food-specific IgE antibodies. This in vitro test may offer advantages when skin testing is limited by dermatographism, generalized dermatitis, or a clinical history of severe anaphylactic reactions to a given food.
    • This form of testing provides information similar to skin prick tests, but it is more expensive.
    • Studies have correlated the outcomes of physician-supervised oral food challenges with the test results. While the studies generally show increasing risks of reaction with increasing concentrations of allergen, the specific correlations vary among studies.2,45,46
    • Studies (so far primarily using one brand of test system) have reported levels highly indicative of allergy (>95%).45,47 However, specific results have varied among studies, which is probably due to differences in patient selection, interpretation of positive outcomes, and other factors. Only a few foods have been analyzed in this manner (primarily peanut, egg, and milk), and predictive results are different for the different foods.
    • Test systems vary with regard to measurements, and similarly reported results may not be equivalent.48 The clinician should also be aware of different reporting units that are not interchangeable with one another (eg, class vs units vs percentage).
    • The concentration of food-specific IgE does not correlate very well with severity of an allergy.
  • Peripheral serum measurements of eosinophils or total IgE concentrations: Results from these tests support but do not confirm the diagnosis of food allergy. Likewise, normal values do not exclude diagnosis.
  • Basophil histamine-release assays: These tests are mainly limited to research settings and have not been shown conclusively to provide reproducible results useful for diagnostic testing in a clinical setting.
  • Additional diagnostic tests are under study, for example, to determine if analysis of IgE epitope binding or IgE binding to particular proteins in a food provides additional diagnostic information.

Other Tests

  • Diet diary
    • This consists of keeping a chronological record of all foods eaten and any associated adverse symptoms. It is an inexpensive endeavor that documents the frequency of symptoms and their occurrence in relationship to food ingestion. In addition, it encourages the patient to focus on his or her diet.
    • This record is occasionally helpful for identifying the food implicated in an adverse reaction; however, it is not usually diagnostic, especially when symptoms are delayed or infrequent.
    • Occasionally, review of the diet diary reveals that the patient is not experiencing a reaction even when eating, as an ingredient in other foods, a significant amount of a food to which he or she was thought to be allergic.
  • Elimination diet
    • This is used for diagnostic as well as treatment purposes.
    • When used as a diagnostic tool, the elimination diet requires complete avoidance of suspected foods or groups of foods for a given time period (usually 7-14 d) while monitoring for an associated decrease in symptoms. The trial elimination diet may be most useful to evaluate chronic symptoms.
    • Success depends on identifying the correct food allergen and completely eliminating it from the diet.
    • Limitations of this method include potential effects of patient or physician biases, variable patient compliance, and the time-consuming nature of the endeavor.
    • When the elimination diet is used as treatment, identified food allergens are removed from the diet indefinitely unless evidence exists that the food allergy has resolved.
  • Skin testing49,26,50
    • Prick and puncture tests are the most common screening tests for food allergy and can even be performed on infants in the first few months of life. However, the reliability of the results depends on multiple factors, including use of the appropriate extracts and testing technique, accurate interpretation of the results, and avoidance of medications that might interfere with testing (eg, antihistamines).
    • When used in conjunction with a standard criterion of interpretation and appropriate controls (eg, histamine: positive; saline: negative), these tests provide useful and reproducible clinical information in a short period (ie, 15-20 min) with minimal expense and negligible risk to the patient.
    • This is a reliable method of excluding IgE-mediated food allergies. The negative predictive accuracy is generally greater than 90%; however, the positive predictive accuracy is generally less than 50%, which limits clinical interpretation of positive skin test results. Similar to in vitro testing, interpretation of test results must consider the clinical history (to assess prior probability) and other factors such as the likelihood, from epidemiologic observations, of the food being a trigger of allergy.
    • Similar to in vitro IgE testing, the larger the skin test wheal size, the more likely that a clinical allergy exists.51,52
    • Positive skin test results, in addition to the suggestion of clinical reactivity based on the history, must often be confirmed by an oral food challenge unless the patient has a convincing history of significant food allergy.
  • Intradermal skin testing
    • The risk of inducing a systemic reaction with this type of testing is increased in comparison to the prick or puncture method; as a result, intradermal skin testing to foods should be avoided.
    • In addition, the results obtained by using this method are less specific compared to those obtained by using prick or puncture testing.
  • Patch tests
    • Patch tests are performed by exposing the skin to the food allergen for 24 hours under occlusion and then evaluating the area for erythema and papules in the subsequent 24-72 hours.
    • The test has been evaluated for diagnosis of food allergy in eosinophilic esophagitis,53 enterocolitis,54 and atopic dermatitis.55
    • Some studies show promise for this technique, but additional studies are needed to better characterize the utility of the results.
  • Some available tests have uncertain diagnostic value. The diagnostic value of performing the following tests is not currently supported by objective scientific evidence:44
    • Results from food-specific immunoglobulin G (IgG) or IgG subclass antibody concentration testing have not been proven to be helpful with diagnosis.
    • Testing for food antigen-antibody complexes has no proven diagnostic value.
    • Performing leukocyte cytotoxic tests is not supported by objective scientific evidence.
    • Results from subcutaneous provocation and neutralization testing have not been proven to be helpful for diagnosis.
    • Kinesiology-based testing is not recommended because objective scientific evidence has indicated that this type of testing does not aid in diagnosis.

Procedures

  • Food challenge confirmation of food allergy56
    • A physician-supervised (medically supervised) oral food challenge involves gradual feeding of the suspected food with careful assessment for any symptoms. If symptoms occur, the feeding is discontinued and medications are administered.
    • Food challenges are typically preceded by a period of elimination of the suspected food. They are conducted when the patient is at a stable clinical baseline and not taking medications that could interfere with observation of symptoms (eg, antihistamines).
    • Of these procedures, the double-blind, placebo-controlled food challenge (DBPCFC) is the most reliable method to help diagnose and confirm food allergy and other adverse food reactions because it eliminates both patient and observer bias. However, in a clinical setting where minimal bias is suspected, open food challenges may be preferable because blinding of the food is often not required.
    • Conduct any food challenge in a clinic or hospital setting with the personnel and equipment necessary to treat a systemic allergic reaction available at all times. Patients undergoing a food challenge should not be taking beta-blocker medications or any medication that might interfere with the treatment of anaphylaxis. If indicated by risk assessment, obtaining intravenous access may be prudent.
    • Clinically indicated oral food challenges are not generally performed when the history and test results already support a current diagnosis of allergy to the target food.
    • The decision to proceed to an oral food challenge must consider many factors, including the likelihood of a reaction, the severity of a reaction if one were to occur, the need to obtain a definitive diagnosis, and social and nutritional factors, among others.
  • Open food challenge
    • This test involves the patient ingesting the suspected food, prepared in its customary fashion (ie, the challenge food is not disguised in any way).
    • Both the patient and the observer (eg, physician, nurse) are aware of the food being ingested.
    • The open food challenge is best used in clinical practice when patient and physician bias is minimal.
    • Whenever the results are equivocal, perform a blinded challenge.
    • Patients with histories of a previous reaction should never perform an open food challenge at home, even if the chance they will develop severe symptoms is remote.
  • Single-blinded food challenge
    • This challenge involves the patient ingesting the suspected food disguised in a challenge food so the patient is unaware of the contents.
    • This type of challenge, which is suitable for clinical practice and some research investigations, is designed to reduce patient bias during the procedure. However, subjective attitudes regarding the outcome of the challenge cannot be completely eliminated.
  • Double-blind placebo-controlled food challenge57
    • DBPCFC involves supervised gradual ingestion of the suspected food disguised in another food (or hidden in capsules). A food similar in taste and appearance but without the allergen is used as a placebo control. The feeding (potential allergen vs placebo) is randomized so that both the patient and the observer are unaware of the contents of the challenge at the time of the feeding and observation. Feeding of the allergen and placebo may be separated by hours or days.
    • This type of challenge is designed to reduce both patient and observer bias and subjective attitudes during the procedure.
    • This procedure is considered the criterion standard for diagnosing food allergy, and is used especially in research investigations. Currently, it is the only completely objective method for determining the validity of the history of an adverse reaction to a food.

More on Food Allergies

Overview: Food Allergies
Differential Diagnoses & Workup: Food Allergies
Treatment & Medication: Food Allergies
Follow-up: Food Allergies
References
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Further Reading

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Keywords

food allergies, food allergy, adverse immunologic reactions to foods, allergic reactions to foods, food hypersensitivity, food intolerance, food allergy test, food allergy symptoms, food allergy rash, food allergy treatment, allergy foods, adverse food reactions, lactose intolerance, bacterial food poisoning, peanut allergy, protein-induced enterocolitis syndrome, proctocolitis, food hypersensitivity, allergen exposure, anaphylactic reactions, food-induced anaphylactic reaction, oral allergy syndrome, dietary protein enterocolitis, food-induced asthma, food-induced pulmonary hemosiderosis, Heiner syndrome, egg allergy, milk allergy, peanut allergy, soy allergy, fish allergy, shellfish allergy, tree nut allergy, wheat allergy, celiac disease, childhood food allergy, lactose intolerant

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Contributor Information and Disclosures

Author

Scott H Sicherer, MD, Associate Professor of Pediatrics, Mount Sinai School of Medicine of New York University
Scott H Sicherer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
Disclosure: Genentech Consulting fee Consulting

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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