How is the FRD→ARE→IRE sequence used in diagnosis?

• A. Start with antibiotics, then diet, then immunosuppression
• B. Begin with a diet trial (FRD); if no response, trial antibiotics (ARE); if still no response, escalate to immunosuppressants and biopsy (IRE/IBD)
• C. Do surgery first
• D. Use only histopathology

Answer: (B)

This sequence is a stepwise, therapeutic trial approach that classifies chronic enteropathy by how the patient responds to treatments, guiding diagnosis and management. Start with a diet trial because many GI disturbances are driven by food, allergies, or sensitivities. A response here—often with a hydrolyzed or novel-protein diet—indicates a diet-responsive enteropathy and avoids more invasive testing.

If there is no improvement with the diet, move to antibiotics. A positive response suggests antibiotic-responsive enteropathy, where microbial factors or dysbiosis contribute to the symptoms. This helps narrow the cause without immediately jumping to aggressive therapies.

If the patient still doesn’t respond, escalate to immunosuppressants and consider biopsy. A lack of response after diet and antibiotics points toward immune-mediated disease, such as inflammatory bowel disease, where immunosuppressive therapy is warranted and histopathology from biopsy can confirm the diagnosis and guide long-term management.

In short, the best approach uses a diet trial first to identify diet-responsive cases, then an antibiotic trial for microbial-responsive cases, and only then immunosuppression with biopsy for suspected immune-mediated disease.