60 Differential diagnosis of food allergy In a meta-analysis of studies evaluating the prevalence of FA, up to 35% of individuals reporting a reaction to food

believe they have FA, whereas studies confirming FA by oral food challenge suggest a much lower prevalence of about 3.5%. Much of this discrepancy is due to a misclassification of adverse reactions to foods that are not allergic in origin, for example lactose intolerance causing bloating, abdominal pain, and diarrhea after consuming milk products. Many causes of reactions to foods are not allergic in origin. In the differential diagnosis of FAs, allergic disorders from other causes, such as drugs, as well as disorders that are not immunologic in nature, must be considered. The patients medical history is vital in excluding these alternative diagnoses. Recognize the early signs and symptoms of an allergic reaction. Keep in mind that cutaneous, gastrointestinal, and respiratory symptoms are the most common clinical manifestations of food allergy. Conditions to consider in the differential diagnosis of food allergies include the following:

Differential diagnosis of food allergy

1. Acute allergic reactions initially attributed to a food may be triggered by other allergens (for example, medications, insect stings). 2. In children with AD, eczematous flares erroneously attributed to foods are sometimes precipitated by irritants, humidity, temperature fluctuations, and bacterial infections of the skin (for example, Staphylococcus aureus). 3. Chronic GI symptoms may result from reflux, infection, anatomical disorders, metabolic abnormalities (for example, lactose intolerance), and other causes. 4. Chemical effects and irritant effects of foods may mimic allergic reactions. For example, gustatory rhinitis may occur from hot or spicy foods due to neurologic responses to temperature or capsaicin. 5. Tart foods may trigger an erythematous band on the skin of the cheek along the distribution of the auriculotemporal nerve in persons with gustatory flushing syndrome. 6. Food poisoning due to bacterial toxins, such as toxigenic E. coli, or scombroid poisoning caused by spoiled dark-meat fish, such as tuna and mahi-mahi, can mimic an allergic reaction. Food poisoning is defined as an illness caused by the consumption of food or water contaminated with bacteria and/or their toxins, or with parasites, viruses, or chemicals. The symptoms, varying in degree and combination, include abdominal pain, vomiting, diarrhea, and headache; more serious cases can result in life-threatening neurologic, hepatic, and renal syndromes leading to permanent disability or death. 7. For persons with EGIDs, alternative diagnoses such as parasite infections, gastroesophageal reflux disease, systemic eosinophilic disorders, and vasculitis should be considered. 8. Behavioral and mental disorders may result in food aversion (for example, anorexia nervosa, bulimia, and Munchausen syndrome by proxy). 9. Pharmacologic effects of chemicals that occur in foods (for example, tryptamine in tomatoes) and food additives may mimic some allergic symptoms of the skin and GI tract 10. Auriculotemporal syndrome

11. Esophagitis The most common cause of esophagitis is gastroesophageal reflux disease (GERD). (See Epidemiology.) Other important, but less common, types of esophagitis include infectious esophagitis (in patients who are immunocompromised), radiation esophagitis, and esophagitis from direct erosive effects of ingested medication or corrosive agents 12. Factitious disorder 13. Food poisoning 14. Acute gastritis 15. Chronic gastritis 16. Bacterial gastroenteritis 17. Viral gastroenteritis 18. Gastroesophageal reflux disease 19. Giardiasis Giardiasis is a major diarrheal disease found throughout the world. The flagellate protozoan Giardia intestinalis (previously known as G lamblia), its causative agent, is the most commonly identified intestinal parasite in the United States and the most common protozoal intestinal parasite isolated worldwide. Infection is more common in children than in adults 20. Hiatal hernia A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. Although the existence of hiatal hernia has been described in earlier medical literature, it has come under scrutiny only in the last century or so because of its association with gastroesophageal reflux disease (GERD) and its complications. There is also an association between obesity and the presence of hiatal hernia. By far, most hiatal hernias are asymptomatic and are discovered incidentally. On rare occasion, a life-threatening complication, such as gastric volvulus or strangulation, may present acutely 21. Inflammatory bowel disease 22. Intestinal motility disorders 23. Irritable bowel syndrome 24. Lactose intolerance Lactose intolerance is a common disorder and is due to the inability to digest lactose into its constituents, glucose and galactose, secondary to low levels of lactase enzyme in the brush border of the duodenum.Lactase deficiency is the most common form of disaccharidase deficiency. Enzyme levels are highest shortly after birth and decline with aging, despite a continued intake of lactose. Within the animal world, nonhuman mammals usually lose the ability to digest lactose as they reach adulthood. Some populations of the human species, including those of Asian, South American, and African descent, have a propensity for developing lactase deficiency. By contrast, races descended from northern Europe or from the northwestern Indian subcontinent are likely to retain the ability to absorb lactose into adulthood 25. Trichosporon infections 26. Urethral diverticula 27. Urticaria Urticaria (hives) is a vascular reaction of the skin marked by the transient appearance of smooth, slightly elevated patches (wheals) that are erythematous and that are often attended by severe pruritus. Individual lesions resolve without scarring in several hours. Most cases of urticaria are self-limited and of short duration; the eruption rarely lasts more than several days, it but may be recurrent over weeks. Chronic urticaria is defined as urticaria with recurrent episodes lasting longer than 6 weeks). 28. VIPomas VIPomas are neuroendocrine tumors that secrete vasoactive intestinal polypeptide (VIP) autonomously.VIPomas arise from the pancreas in 90% of cases,

but they may also be found in periganglionic tissue or at other sites, including the colon, bronchus, adrenal glands, and liver, especially in children 29. Vocal cord dysfunction Vocal cord dysfunction (VCD), also commonly known as paradoxical vocal fold motion, can be characterized as an abnormal adduction of the vocal cords during the respiratory cycle (especially during the inspiratory phase) that produces airflow obstruction at the level of the larynx 30. Wasp stings 31. Whipple disease Whipple disease is a systemic disease most likely caused by a grampositive bacterium, Tropheryma whippelii. Although the first descriptions of the disorder described a malabsorption syndrome with small intestine involvement, the disease also affects the joints, CNS, and cardiovascular system. Because fewer than 1000 reported cases have been described, clinical experience with this disorder is sparse. 32. Anorexia Nervosa Anorexia nervosa (AN) is a psychiatric disorder with severe physiologic consequences, characterized by the inability or refusal to maintain a minimally normal weight. Patients have a profoundly disturbed body image as well as an intense fear of weight gain despite being moderately to severely underweight 33. Bulimia Bulimia nervosa is an eating disorder delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR).[1] The word bulimia is derived from the Greek words bous (ox) and limos (hunger), indicating a state of excessive hunger. Among the eating disorders, bulimia nervosa and anorexia nervosa are far more common in young females, while binge-eating disorder, the most common eating disorder overall, is more common in adults. 34. Celiac Sprue Celiac sprue, also known as celiac disease or gluten-sensitive enteropathy, is a chronic disease of the digestive tract that interferes with the digestion and absorption of food nutrients. People with celiac sprue cannot tolerate gliadin, the alcohol-soluble fraction of gluten. Gluten is a protein commonly found in wheat, rye, and barley. Most patients with celiac disease tolerate oats, but they should be monitored closely. When people with celiac sprue ingest gliadin, the mucosa of their intestines is damaged by an immunologically mediated inflammatory response, resulting in maldigestion and malabsorption. Patients with celiac disease can present with failure to thrive and diarrhea (the classical form). However, some patients have only subtle symptoms (atypical celiac disease) or are asymptomatic (silent celiac disease). 35. Clostridium Difficile Colitis 36. Constipation 37. Diverticulitis Diverticula are small mucosal herniations protruding through the intestinal layers and the smooth muscle along the natural openings created by the vasa recta or nutrient vessels in the wall of the colon. These herniations create small pouches lined solely by mucosa. Diverticula can occur anywhere in the gastrointestinal tract but are usually observed in the colon. The sigmoid colon has the highest intraluminal pressures and is most commonly affected. Diverticulosis is defined as the condition of having uninflamed diverticula. The cause of diverticulosis is not yet conclusive, but it appears to be associated with a low-fiber diet, constipation, and obesity. 38. Dumping Syndrome The stomach serves as the receptive and storage site of ingested food. The primary functions of the stomach are to act as a reservoir, to initiate the digestive process, and to release its contents downstream into the duodenum in a controlled fashion. The capacity of the stomach in adults is

approximately 1.5-2 liters, and its location in the abdomen allows for considerable distensibility. Gastric motility is regulated by the enteric nervous system, which is influenced by extrinsic innervation and by circulating hormones. Alterations in gastric anatomy after surgery or interference in its extrinsic innervation (vagotomy) may have profound effects on gastric emptying. These effects, for convenience, have been termed postgastrectomy syndromes. Postgastrectomy syndromes include small capacity, dumping, bile gastritis, afferent loop syndrome, efferent loop syndrome, anemia, and metabolic bone disease. Postgastrectomy syndromes are iatrogenic conditions which may arise from partial gastrectomies, independent of whether the gastric surgery was initially done for peptic ulcer disease, cancer, or for weight loss (bariatric). The surgical procedures include Billroth-I, Billroth-II, and Roux-en-Y 39. Esophageal Motility Disorders 40. Esophageal Spasm 41. Esophageal Stricture 42. Esophagitis 43. Factitious Disorder 44. Gastritis, Acute 45. Gastritis, Chronic 46. Gastroenteritis, Bacterial 47. Gastroenteritis, Viral 48. Gastroesophageal Reflux Disease Gastroesophageal reflux is a normal physiologic phenomenon experienced intermittently by most people, particularly after a meal. Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit, causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis). 49. Giardiasis 50. Hiatal Hernia 51. Inflammatory Bowel Disease Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The 2 major types of IBD are ulcerative colitis (UC), which is limited to the colon, and Crohn disease (CD), which can involve any segment of the gastrointestinal (GI) tract from the mouth to the anus, involves skip lesions, and is transmural (see the images below). There is a genetic predisposition for IBD (see Etiology), and patients with this condition are more prone to the development of malignancy. 52. Intestinal Motility Disorders The phrase intestinal motility disorders applies to abnormal intestinal contractions, such as spasms and intestinal paralysis. This phrase is used to describe a variety of disorders in which the gut has lost its ability to coordinate muscular activity because of endogenous or exogenous causes 53. Irritable Bowel Syndrome 54. Lactose Intolerance 55. Trichosporon Infections 56. Urethral Diverticula 57. Urticaria 58. Vocal Cord Dysfunction 59. Wasp Stings 60. Whipple Disease