Saudi Journal of Medicine and Medical Sciences

CASE REPORT
Year
: 2014  |  Volume : 2  |  Issue : 3  |  Page : 213--215

Eosinophilic gastroenteritis: A case report with review of the literature


Abdulla I Al-Musa, Muhammed M Pallippath, Anas M Hussameddin, Abdulaziz A Al-Quorain 
 Department of Internal Medicine, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia

Correspondence Address:
Muhammed M Pallippath
Department of Internal Medicine, King Fahd Hospital of the University, P.O. Box 40006, Al-Khobar 31952
Saudi Arabia

Abstract

Eosinophilic gastroenteritis (EG) is a heterogenous disorder affecting adults, and is characterized by the presence of eosinophilic infiltration in the gastrointestinal tract. The clinical features of EG are related to the layers and extent of bowel involved from the esophagus to the colon. The diagnosis is typically confirmed by biopsy, which should reveal 20-25 eosinophils per high-power field on microscopic examination. We report a 38-year-old man who presented with a 2-month history of dyspeptic symptoms. On examination, he was found to have only moderate ascites. The investigations revealed peripheral eosinophilia with markedly elevated eosinophils (95%) in the ascitic fluid. The imaging studies showed diffuse concentric bowel wall thickening involving the entire small bowel. The diagnosis was confirmed by biopsy from the antrum of the stomach. The patient was managed with steroids.



How to cite this article:
Al-Musa AI, Pallippath MM, Hussameddin AM, Al-Quorain AA. Eosinophilic gastroenteritis: A case report with review of the literature.Saudi J Med Med Sci 2014;2:213-215


How to cite this URL:
Al-Musa AI, Pallippath MM, Hussameddin AM, Al-Quorain AA. Eosinophilic gastroenteritis: A case report with review of the literature. Saudi J Med Med Sci [serial online] 2014 [cited 2019 Jun 19 ];2:213-215
Available from: http://www.sjmms.net/text.asp?2014/2/3/213/142575


Full Text

 INTRODUCTION



Eosinophilic gastroenteritis (EG) is a heterogeneous disorder affecting children and adults, and is characterized by the presence of an intense eosinophilic infiltrate on histopathology of one or multiple segments from the esophagus to the rectum. [1] In EG, the eosinophilic infiltration of the gastrointestinal tract is frequently confined to specific layers of the gut wall. The diagnosis of EG is rare, with an approximate incidence of 1/100,000. [2] EG is most commonly diagnosed between the second and sixth decades of life, and rarely in infants. [3],[4]

 CASE REPORT



A 38-year-old man in apparent good health presented to the gastroenterology clinic with a 2-month history of dyspeptic symptoms, nausea and pyrosis. He lost about 20 kg of weight. He denied any history of vomiting, fever, joint pains, gastrointestinal bleeding or other symptoms. He was also noticed to have gradual distention of his abdomen. Past medical history revealed no previous hospitalizations, history of asthma, allergic rhinitis, atopic dermatitis and food allergy.

Physical examination revealed a well-appearing young gentleman, not pale or jaundiced. His abdomen was distended with moderate ascites. He had no peritoneal signs and no focal areas of tenderness on deep palpation. There was no organomegaly or masses.

 LABORATORY AND IMAGING STUDIES



The patient's complete blood count revealed an elevated white blood cell (WBC) count of 18000/mL (normal 4500-11,000/mL), with marked eosinophilia of 40% and an absolute esosinophil count of 7200/mL (normal 0-1% and <350/mL, respectively). Peripheral blood smear revealed marked mature eosinophilis, liver function test showed normal total protein of 7.8 g/dh (normal 6-8 g/dh) and low albumin 2.8 g/dL (normal 3.5-5 g/dL). Stool culture and microscopy for ova and parasites were negative. Fecal occult blood was negative. Fluid obtained from the peritoneal cavity was yellow in color, with a WBC count of 3700/mL, red blood cell count of 820/mL, markedly elevated eosinophils (95%) and polmorpho-nuclear cells (5%). Analysis of asctic fluid revealed a lactate dehydrogenase level of 144 u/L, protein level of 5.5 g/dL, albumin level of 2.6 g/dL and glucose level of 80 mg/dL. Cytological examination of the fluid was negative for malignancy and the acid fast bacilli culture was negative.

 COMPUTERIZED TOMOGRAPHY IMAGING



Computerized tomography (CT) imaging of the abdomen with contrast demonstrated a moderate amount of ascites and diffuse concentric bowel wall thickening involving the entire small bowel while the large bowel was normal. No obstruction was seen and no other abnormalities were found. There was no lymphadenopathy. The heart and lung imaging was normal.

The patient was subjected to eosophago-gastro-duodenoscopy (EGD), which showed hyperemic mucosa at the antrum and the first part of the duodenum suggestive of gastroduodenitis, with no erosions or ulcerations [Figure 1]. The biopsy revealed diffuse infiltration of eosinophils and multifocal chronic inflammatory infiltrates in the antrum and duodenum. Colonoscopy revealed normal mucosa. But, a biopsy of the colonic mucosa showed diffuse eosinophilic infiltrate suggestive of acute eosinophilic colitis [Figure 2]. Diagnostic laparoscopy was performed to exclude infectious or inflammatory causes of ascites, which showed turbid ascitic fluid of about 1 L with marked inflamed and edematous stomach and the entire small bowel. The examination of ascitic fluid showed abundant WBC counts, which were predominantly eosinophils; cytology, culture and smear tests for acid fast bacilli in fluid were negative.{Figure 1}{Figure 2}

 DISCUSSION



EG represents one member of a family of diseases that includes eosinophilic esophagitis, gastritis, enteritis and colitis, collectively referred to as eosinophilic gastrointestinal disorders (EGIDs). [5] The clinical features of EG are related to the layer(s) and the extent of the bowel involved, with eosinophilic infiltration (mucosa muscle and/or subserosa). [6] Eosinophilic mucosal infiltration produces non-specific symptoms, which depend on the organ(s) involved. The entire gastrointestinal tract from the esophagus to the colon, including the bile ducts, can be affected. [7],[8] The diagnosis of mucosal EG is typically confirmed by endoscopic biopsies, which should reveal ≥20-25 eosinophils per high-power field on microscopic examination. [7],[9] Upper gastrointestinal endoscopy with biopsy of the stomach and small intestine is diagnostic in at least 80% of the patients. [7],[9] Eosinophilic infiltration of the muscle layer of the gastrointestinal tract results in thickened, rigid gut and symptoms of intestinal obstruction such as nausea, vomiting and abdominal distention. [7],[6] Pseudoachalasia, esophageal stricture, perforation or obstruction of the gastric outlet, small bowel or, rarely, the colon can occur depending on the site of infiltration. [6],[7],[8],[9],[10],[11] The diagnosis of muscle layer disease is typically made after resection of the small bowel for obstruction. In less-acute presentations, barium studies may reveal irregular luminal narrowing, especially in the distal antrum and in the proximal small bowel. These findings can mimic those induced by cancer, lymphoma or other malignancies. Endoscopic biopsies should be performed; however but they are often non-diagnostic due to the lack of mucosal involvement. In these cases, laparoscopic full-thickness biopsy is usually necessary to exclude malignancy. [12] Patients with subserosal EG may present with isolated ascites or ascites in combination with symptoms characteristic of mucosal or muscular EG. The diagnostic feature is marked eosinophilia, up to 88% in the asctic fluid. [6] Patients in this subgroup may have an allergic history and peripheral eosinophil count as high as 8000 cells/μL. An eosinophilic pleural effusion may also be present. [13] The biopsies of the mucosal layers taken during gastroscopy and colonoscopy often fail to diagnose EG. Laparotomy or laparoscopy is often required to confirm the diagnosis in such cases. The role of food allergy as a stimulus to EG has not been clearly defined for eosinophilic esophagitis. However, several reports have described an allergic response to food allergens with improvement in disease activity with allergen avoidance, with an elemental or elimination diet. [2],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

Our patient presented with symptoms of dyspepsia, nausea and distended abdomen. The endoscopic biopsies from the stomach, duodenum and colon showed diffuse infiltration of eosinophils. The CT scan revealed diffuse concentric bowel wall thickening involving the entire small bowel and the ascitic fluid showed markedly elevated eosinophils suggestive of EG. Infectious, malignant and autoimmune diseases were excluded.

Treatment with steroid is the mainstay in the management of EG, which will usually lead to dramatic clinical improvement. The duration of treatment is controversial. Surgical intervention may sometimes be required for patients with obstructive complications or when performing a full-thickness intestinal biopsy to establish the diagnosis. [15] Using an elimination diet has no role in the therapy of EG. In general, the long-term prognosis for this disease is good. Our patient was managed with steroid, which was tapered gradually after 2 weeks with excellent response. [16] His symptoms improved, WBC count was back to normal after 1 month and his ascites disappeared.

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