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ALIMENTARY AGONY: ALLERGY AND THE GUT SIDNEY T. BOGARDUS, JR., and SUMNER C. KRAFT* Background Broaching the issue of a patient's potential food allergy with a physician colleague often provokes a roll of the eyes and a shrug of the shoulders; these people are crazy, the gestures seem to imply, and I have better (and easier) things on which to spend my time. Although most people know of the occurrence of serious or even fatal reactions to foods such as peanuts, the general issue more frequently raises skeptical eyebrows; many people view the topic with deep suspicion, as one filled with shoddy science, bogus claims, and muddy thinking—perhaps even outright quackery. Much has been written about adverse reactions to foods in humans, but the literature often has appeared confusing, contradictory, and of dubious quality. Food allergy is viewed by many physicians as a subject overly affected by health faddism and the popular press, symptomatic primarily of an exaggerated sense of the influence of one's environment—perhaps similar to controversial syndromes such as so-called environmental illness or multiple chemical sensitivity. Most of us, in fact, have had patients come to the office with a complaint attributed to some type of food. We hear about rashes ifwe are dermatologists , wheezing if we are pulmonologists, belching, bloating, and diarrhea ifwe are gastroenterologists, or (horrors!) all of the above ifwe are generalists . Often the link with food is clear and definite in the mind ofthe patient; sometimes the link is vaguer, and requires a bit of sleuthing to discern. It is far rarer to have a patient come to the office, at least in our experience, with one of the above complaints and to discover a potential link with food that the patient has not already guessed. The major question often remaining after eliciting the history is whether the link with food is real or *Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637-1463. Correspondence: Sidney T. Bogardus,Jr., Yale University School of Medicine, Room IE-61, SHM New Haven CT 06520.© 1995 by The University of Chicago. All rights reserved. 0031-5982/95/3804-0934101.00 394 Sidney T. Bogardus, Jr., and Sumner C. Kraft ¦ Alimentary Agony spurious, and how to go about approaching this question. This is the real problem; if we are fortunate enough to have a good allergist within shouting distance, we might avail ourselves of his or her expertise, but most of us will have to forge ahead on our own, at least part of the way. In this brief (and certainly not exhaustive) essay, we will try to explore the issues of food allergy: its scope, varieties, evaluation, treatment, and some of the more recent advances in the field. Since we are clinicians, we approach the subject from that perspective; it is a clinical problem, and we are interested in what can be done about it. Although we do not attempt to develop any coherent set of recommendations, we hope to clarify the issue so that the physician confronting a potential diagnostic dilemma (e.g., can I make a diagnosis of food allergy when I don't really know if it truly exists?) will understand the problem conceptually. Scope ofFood Allergy The subject of food allergy is difficult to discuss because of a lack of standard terminology, and hence we will begin with a definition of terms. In the popular sense, the term "food allergy" may be taken to include any of the multitude of adverse reactions to food, whether or not these represent true "allergy" or not (Table 1). In fact, as we shall see, the vast majority of "food allergies" in the popular sense are not truly allergies at all. Throughout this essay, we will use terms in accordance with the recommendations of the American Academy of Allergy and Immunology [I]. Thus, the term "adverse reaction to food" refers to any abnormal response to ingested food. The terms "food allergy" and "food hypersensitivity" are synonymous and refer to an immunologically mediated reaction to ingested food; whereas "food anaphylaxis" refers to the classic IgE-mediated immediate hypersensitivity response. All other reactions generally are considered to be non-immunologic...


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