Eosinophilic gastroenteritis: Difference between revisions

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{{SK}} ''Eosinophilic esophagitis; eosinophilic gastritis; Eosinophilic enteritis; Eosinophilic colitis; Eosinophilic proctocolitis, Eosinophilic gastrointestinal disorders''
==Overview==
==Overview==
'''Eosinophilic gastroenteritis''' (EG) is a rare and heterogeneous condition characterized by patchy or diffuse [[eosinophilic]] infiltration of the [[gastrointestinal]] (GI) tissue, first described by Kaijser in 1937.<ref name="Zur">Kaijser R. Zur Kenntnis der allergischen Affektionen des Verdauugskanals vom Standpunkt des Chirurgen aus. Arch Klin Chir 1937; 188:36–64.</ref><ref>{{cite journal |author=Whitaker I, Gulati A, McDaid J, Bugajska-Carr U, Arends M |title=Eosinophilic gastroenteritis presenting as obstructive jaundice |journal=European journal of gastroenterology & hepatology |volume=16 |issue=4 |pages=407-9 |year=2004 |pmid=15028974}}</ref> Presentation may vary depending on the location as well as depth and extent of bowel wall involvement and usually runs a chronic relapsing course. It can be classified into mucosal, muscular and serosal types based on the depth of involvement.<ref name="klein">{{cite journal |author=Klein N, Hargrove R, Sleisenger M, Jeffries G |title=Eosinophilic gastroenteritis |journal=Medicine (Baltimore) |volume=49 |issue=4 |pages=299-319 |year=1970 |pmid=5426746}}</ref><ref>{{cite journal |author=Treiber, Treiber |title=Eosinophilic Gastroenteritis |journal= |volume= |issue= |pages= |year=2007 |pmid=17428742}}</ref> Any part of the GI tract can be affected, and isolated biliary tract involvement has also been reported.<ref>{{cite journal |author=Polyak S, Smith T, Mertz H |title=Eosinophilic gastroenteritis causing pancreatitis and pancreaticobiliary ductal dilation |journal=Dig. Dis. Sci. |volume=47 |issue=5 |pages=1091-5 |year=2002 |pmid=12018905}}</ref><ref>{{cite journal |author=Christopher V, Thompson M, Hughes S |title=Eosinophilic gastroenteritis mimicking pancreatic cancer |journal=Postgraduate medical journal |volume=78 |issue=922 |pages=498-9 |year=2002 |pmid=12185230}}</ref> The [[stomach]] is the [[Organ (anatomy)|organ]] most commonly affected, followed by the [[small intestine]] and the [[Colon (anatomy)|colon]].<ref>{{cite journal |author=Naylor A |title=Eosinophilic gastroenteritis |journal=Scottish medical journal |volume=35 |issue=6 |pages=163-5 |year=1990 |pmid=2077646}}</ref><ref>{{cite journal |author=Jimenez-Saenz M, Villar-Rodriguez J, Torres Y, Carmona I, Salas-Herrero E, Gonzalez-Vilches J, Herrerias-Gutierrez J |title=Biliary tract disease: a rare manifestation of eosinophilic gastroenteritis |journal=Dig. Dis. Sci. |volume=48 |issue=3 |pages=624-7 |year=2003 |pmid=12757181}}</ref>
Eosinophilic gastroenteritis is a rare, heterogenous disorder characterized by localized patchy or diffuse [[eosinophilic]] infiltration of the [[gastrointestinal tract]].<ref name="baig">{{cite journal| author=Baig MA, Qadir A, Rasheed J| title=A review of eosinophilic gastroenteritis. | journal=J Natl Med Assoc | year= 2006 | volume= 98 | issue= 10 | pages= 1616-9 | pmid=17052051 | doi= | pmc=2569760 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17052051  }} </ref> Most of the data available in the literature are based on few documented case reports/case series. The presentation of eosinophilic gastroenteritis may vary depending on the location, depth and extent of [[bowel]] wall involvement.<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref><ref name="baig">{{cite journal |author=Baig M, Qadir A, Rasheed J |title=A review of eosinophilic gastroenteritis |journal=Journal of the National Medical Association |volume=98 |issue=10 |pages=1616-9 |year=2006 |pmid=17052051}}</ref><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref> The cause of eosinophilic gastroenteritis is idiopathic although there is a significant association with [[allergy]].<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref><ref name="baig">{{cite journal |author=Baig M, Qadir A, Rasheed J |title=A review of eosinophilic gastroenteritis |journal=Journal of the National Medical Association |volume=98 |issue=10 |pages=1616-9 |year=2006 |pmid=17052051}}</ref> Non-specific gastrointestinal symptoms such as  episodic [[abdominal pain]], [[vomiting]] and [[diarrhea]] are common. Eosinophilic gastroenteritis is a diagnosis of exclusion and other causes of [[Gastrointestinal tract|GIT]] symptoms with gastrointestinal tissue [[eosinophilia]] must be ruled out.<ref name="pmid26054822" /> Biopsy of the [[Gastrointestinal tract|GIT]] is the primary diagnostic modality. The mainstay of treatment is [[Corticosteroids|corticosteroid]] therapy. Majority of patients respond well to treatment but the disease may run a chronic relapsing course.<ref name="klein">{{cite journal| author=Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH| title=Eosinophilic gastroenteritis. | journal=Medicine (Baltimore) | year= 1970 | volume= 49 | issue= 4 | pages= 299-319 | pmid=5426746 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5426746  }} </ref><ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref>


==Historical Perspective==
==Historical Perspective==
The first description of eosinophilic gastroenteritis was by Kaijser et al. in 1937, and it was described as an [[allergic]] disease of the [[gut]].<ref name="pmid15028974">{{cite journal| author=Whitaker IS, Gulati A, McDaid JO, Bugajska-Carr U, Arends MJ| title=Eosinophilic gastroenteritis presenting as obstructive jaundice. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 4 | pages= 407-9 | pmid=15028974 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15028974  }} </ref><ref name="pmid28299223">{{cite journal| author=Shetty V, Daniel KE, Kesavan A| title=Hematemesis as Initial Presentation in a 10-Week-Old Infant with Eosinophilic Gastroenteritis. | journal=Case Rep Pediatr | year= 2017 | volume= 2017 | issue=  | pages= 2391417 | pmid=28299223 | doi=10.1155/2017/2391417 | pmc=5337357 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28299223  }} </ref> Klein et al. subsequently classified it into three types (predominant mucosal, muscular, and subserosal layer disease) based on the depth of eosinophilic infiltration.<ref name="pmid5426746">{{cite journal| author=Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH| title=Eosinophilic gastroenteritis. | journal=Medicine (Baltimore) | year= 1970 | volume= 49 | issue= 4 | pages= 299-319 | pmid=5426746 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5426746  }} </ref>


==Classification==
==Classification==
Eosinophilic gastroenteritis can be subdivided into three groups according to the Klein classification:<ref name="klein" /><ref name="talley">{{cite journal| author=Talley NJ, Shorter RG, Phillips SF, Zinsmeister AR| title=Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues. | journal=Gut | year= 1990 | volume= 31 | issue= 1 | pages= 54-8 | pmid= 2318432 | doi= | pmc=1378340 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2318432  }} </ref><ref name="baig">{{cite journal| author=Baig MA, Qadir A, Rasheed J| title=A review of eosinophilic gastroenteritis. | journal=J Natl Med Assoc | year= 2006 | volume= 98 | issue= 10 | pages= 1616-9 | pmid=17052051 | doi= | pmc=2569760 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17052051  }} </ref><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref><ref name="pmid26054822" />
*'''Mucosal eosinophilic gastroenteritis'''
#Most common subtype of eosinophilic gastroenteritis.
#Mucosal infiltration by [[eosinophils]], and/or presence of mucosal [[edema]] on [[Barium|barium studies]].
#Absent histological evidence of muscle infiltration.
#No evidence of [[gastrointestinal obstruction]] or eosinophilic [[ascites]].
*'''Muscular eosinophilic gastroenteritis'''


==Pathophysiology==
#Documentation of complete/incomplete [[bowel obstruction]], and/or infiltration of the [[tunica muscularis]] by [[eosinophils]].
Peripheral blood [[eosinophilia]] and elevated [[serum]] [[IgE]] are usual but not universal. The damage to the [[gastrointestinal tract]] wall is caused by eosinophilic [[Infiltration (medical)|infiltration]] and [[degranulation]]<ref>{{cite journal |author=Tan A, Kruimel J, Naber T |title=Eosinophilic gastroenteritis treated with non-enteric-coated budesonide tablets |journal=European journal of gastroenterology & hepatology |volume=13 |issue=4 |pages=425-7 |year=2001 |pmid=11338074}}</ref>.  
#No evidence of eosinophilic [[ascites]].


As a part of [[Immune system|host defense]] mechanism, [[eosinophil]] is normally present in gastrointestinal [[mucosa]], though finding in deeper [[tissue]] is almost always [[Pathology (disambiguation)|pathologic]]
*'''Subserosal eosinophilic gastroenteritis'''
<ref>{{cite journal |author=Blackshaw A, Levison D |title=Eosinophilic infiltrates of the gastrointestinal tract |journal=J. Clin. Pathol. |volume=39 |issue=1 |pages=1-7 |year=1986 |pmid=2869055}}</ref>.
What triggers such dense infiltration in EG is not clear. It is possible that different [[pathogenesis|pathogenetic]] mechanisms of disease is involved in several subgroups of patients. Food [[allergy]] and variable [[IgE]] response to food substances has been observed in some patients which implies role of [[Hypersensitivity|hypersensitive]] response in pathogenesis. Many patients indeed have history of other [[atopy|atopic]] conditions like [[eczema]], [[asthma]] etc.


Eosinophil recruitment into inflammatory tissue is a complex process, regulated by a number of [[inflammatory]] [[cytokines]]. In EG [[cytokines]] [[IL-3]], [[IL-5]] and granulocyte macrophage colony stimulating factor ([[GM-CSF]]) may be behind the recruitement and activation. They have been observed [[immunohistochemistry|immunohistochemically]] in diseased intestinal wall
#Eosinophilic infiltration of the [[gut]]
<ref>{{cite journal |author=Desreumaux P, Bloget F, Seguy D, Capron M, Cortot A, Colombel J, Janin A |title=Interleukin 3, granulocyte-macrophage colony-stimulating factor, and interleukin 5 in eosinophilic gastroenteritis |journal=Gastroenterology |volume=110 |issue=3 |pages=768-74 |year=1996 |pmid=8608886}}</ref>.
#Presence of eosinophilic [[ascites]] (may occasionally progress to an eosinophilic [[pleural effusion]])
In addition [[CCL11|eotaxin]] has been shown to have an integral role in regulating the homing of eosinophils into the [[lamina propria]] of stomach and small intestine
<ref>{{cite journal |author=Mishra A, Hogan S, Brandt E, Rothenberg M |title=An etiological role for aeroallergens and eosinophils in experimental esophagitis |journal=J. Clin. Invest. |volume=107 |issue=1 |pages=83-90 |year=2001 |pmid=11134183}}</ref>.
In the allergic subtype of disease, it is thought that food [[allergens]] cross the intestinal mucosa and trigger an inflammatory response that includes [[mast cell]] degranulation and recruitment of eosinophils
<ref>{{cite journal |author=Pérez-Millán A, Martín-Lorente J, López-Morante A, Yuguero L, Sáez-Royuela F |title=Subserosal eosinophilic gastroenteritis treated efficaciously with sodium cromoglycate |journal=Dig. Dis. Sci. |volume=42 |issue=2 |pages=342-4 |year=1997 |pmid=9052516}}</ref>.


==Causes==
==Causes==
The cause of eosinophilic gastroenteritis is unknown.<ref name="baig">{{cite journal| author=Baig MA, Qadir A, Rasheed J| title=A review of eosinophilic gastroenteritis. | journal=J Natl Med Assoc | year= 2006 | volume= 98 | issue= 10 | pages= 1616-9 | pmid=17052051 | doi= | pmc=2569760 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17052051  }} </ref>
==Risk Factors==
*[[Allergy]]: A study conducted in 40 patients with eosinophilic gastroenteritis demonstrated a history of [[allergy]] in half of the patients.<ref name="talley" /> Food intolerance or [[allergy]] is more commonly seen in mucosal eosinophilic gastroenteritis, affecting over 50% of patients with mucosal disease according to a study.<ref name="talley" />
==Pathophysiology==
===Pathogenesis===
*Eosinophilic gastroenteritis is a rare disease with poorly understood pathophysiology.
*Eosinophils are normally seen in the entire [[GIT]] (except in the [[esophagus]]) of healthy individuals.<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref>
*In patients with eosinophilic gastroenteritis, there is varying degrees of increased eosinophilic infiltration of the [[Gastrointestinal tract|GIT]] (in the absence of other known causes of tissue [[eosinophilia]]).<ref name="pmid28299223">{{cite journal| author=Shetty V, Daniel KE, Kesavan A| title=Hematemesis as Initial Presentation in a 10-Week-Old Infant with Eosinophilic Gastroenteritis. | journal=Case Rep Pediatr | year= 2017 | volume= 2017 | issue=  | pages= 2391417 | pmid=28299223 | doi=10.1155/2017/2391417 | pmc=5337357 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28299223  }} </ref><ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref>
*Any part of the [[Gastrointestinal tract|GIT]] from the [[esophagus]] to the [[colon]] can be affected. Occasionally, eosinophilic gastroenteritis affects the entire [[gastrointestinal tract]].<ref name="talley" /> The [[stomach]] and proximal [[small intestine]] are most commonly affected, while the [[colon]] is usually the least affected part of the [[Gastrointestinal tract|GIT]].<ref name="pmid28299223" /><ref name="talley" /><ref name="pmid26054822" />
*The etiology of the excessive eosinophilic infiltration of the [[Gastrointestinal tract|GIT]] is not clear. Destruction of the [[Gastrointestinal tract|GIT]] [[epithelium]] caused by the release of eosinophilic basic protein and activated degranulating [[eosinophils]] has been proposed.<ref name="talley" /><ref name="pmid 11338074">{{cite journal| author=Tan AC, Kruimel JW, Naber TH| title=Eosinophilic gastroenteritis treated with non-enteric-coated budesonide tablets. | journal=Eur J Gastroenterol Hepatol | year= 2001 | volume= 13 | issue= 4 | pages= 425-7 | pmid= 11338074 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11338074  }} </ref>
*Inflammatory mediators such as [[TH2-cells|Th-2]] [[cytokines]] ([[IL-3]], [[IL-5]], [[GM-CSF]] and [[IL-13]]), [[monocyte]] generating [[chemokines]] such as [[Interleukin 8|IL-8]], [[monocyte]] chemotactic proteins, [[mast cells]], [[granulocytes]], [[eosinophils]], and eosinophilic mediators such as eotaxin have been strongly implicated.<ref name="pmid28299223" /><ref name="pmid26054822" /><ref name="baig" />
*The inflammatory mediators associated with the pathogenesis of eosinophilic gastroenteritis have well established roles in the pathogenesis of [[allergy]] and [[asthma]]. A significant number of patients with eosinophilic gastroenteritis have also been documented to have [[allergies]]/allergy-related disorders, suggesting a [[hypersensitivity reaction]] is involved in the pathogenesis of eosinophilic gastroenteritis.<ref name="pmid28299223" /><ref name="baig" />


==Differentiating {{PAGENAME}} from Other Diseases==
==Differentiating {{PAGENAME}} from Other Diseases==
Diseases with peripheral [[eosinophilia]] and gastrointestinal symptoms should be differentiated from eosinophilic gastroenteritis. It is also important to consider eosinophilic gastroenteritis in the differential diagnosis of unexplained gastrointestinal symptoms (even when peripheral [[eosinophilia]] is not present). Most diseases that can manifest with gastrointestinal symptoms and peripheral [[eosinophilia]] are easily differentiated from eosinophilic gastroenteritis via detailed history taking, laboratory investigations,  and histologic examination of endoscopic biopsies.<ref name="baig" /><ref name="pmid26054822" /> Some of these diseases include:<ref name="baig" /><ref name="pmid26054822" /><ref name="pmid7572911">{{cite journal| author=Matsushita M, Hajiro K, Morita Y, Takakuwa H, Suzaki T| title=Eosinophilic gastroenteritis involving the entire digestive tract. | journal=Am J Gastroenterol | year= 1995 | volume= 90 | issue= 10 | pages= 1868-70 | pmid=7572911 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7572911  }} </ref><ref name="pmid15492606">{{cite journal| author=Barbie DA, Mangi AA, Lauwers GY| title=Eosinophilic gastroenteritis associated with systemic lupus erythematosus. | journal=J Clin Gastroenterol | year= 2004 | volume= 38 | issue= 10 | pages= 883-6 | pmid=15492606 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15492606  }} </ref>
*[[Intestinal parasites|Intestinal parasitic infections]]: [[Stool examination]] for [[ova]] and [[parasites]] can be utilized for diagnosis.
*[[Inflammatory bowel disease|Inflammatory bowel disease (IBD)]]: Biopsy can easily distinguish [[Inflammatory bowel disease|IBD]] from eosinophilic gastroenteritis.
*[[Hypereosinophilic syndrome]]: It usually presents with markedly elevated peripheral [[eosinophilia]] (>1500 cells/μL) for more than six consecutive months. Eosinophilic gastroenteritis is observed in association with eosinophilic infiltration of other organ systems. The organs that are commonly affected in [[hypereosinophilic syndrome]] are the [[lungs]], [[skin]], [[GIT]], [[kidneys]], [[heart]] and [[brain]].
*[[Helicobacter pylori]] infecton: This is not a common cause of tissue [[eosinophilia]]. [[Histology]] of gastric biopsies using [[silver staining]] can rule out [[Helicobacter pylori]] infection.
*[[Vasculitides|Vasculitic disorders]] such as [[Churg-Strauss syndrome|churg-strauss syndrome]] and [[polyarteritis nodosa]]: Eosinophilic infiltration of small [[blood vessels]] in the [[GIT]] is seen. [[Autoantibodies]] are usually present and markers of [[inflammation]] are elevated.
*[[Connective tissue disorders]] such as [[scleroderma]], [[polymyositis]], [[dermatomyositis]], [[systemic lupus erythematosus]].
*[[Celiac disease]]: [[Serology]] and [[biopsy]] can differentiate it from eosinophilic gastroenteritis.
*[[Drugs]]: Some medications have been documented to cause eosinophilic infiltration of the [[GIT]]. Examples of such medications include [[gold compounds]], [[rifampicin]], [[clofazimine]], [[gemfibrozil]], [[azathioprine]], [[enalapril]], [[naproxen]] and other [[NSAIDS]], [[interferon]], [[tacrolimus]], etc.<ref name="pmid12118924">{{cite journal| author=Shakeer VK, Devi SR, Chettupuzha AP, Mustafa CP, Sandesh K, Kumar SK et al.| title=Carbamazepine-induced eosinophilic enteritis. | journal=Indian J Gastroenterol | year= 2002 | volume= 21 | issue= 3 | pages= 114-5 | pmid=12118924 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12118924  }} </ref><ref name="pmid7968003">{{cite journal| author=Lange P, Oun H, Fuller S, Turney JH| title=Eosinophilic colitis due to rifampicin. | journal=Lancet | year= 1994 | volume= 344 | issue= 8932 | pages= 1296-7 | pmid=7968003 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7968003  }} </ref><ref name="pmid16340639">{{cite journal| author=Jiménez-Sáenz M, González-Cámpora R, Linares-Santiago E, Herrerías-Gutiérrez JM| title=Bleeding colonic ulcer and eosinophilic colitis: a rare complication of nonsteroidal anti-inflammatory drugs. | journal=J Clin Gastroenterol | year= 2006 | volume= 40 | issue= 1 | pages= 84-5 | pmid=16340639 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16340639  }} </ref><ref name="pmid2220886">{{cite journal| author=Bridges AJ, Marshall JB, Diaz-Arias AA| title=Acute eosinophilic colitis and hypersensitivity reaction associated with naproxen therapy. | journal=Am J Med | year= 1990 | volume= 89 | issue= 4 | pages= 526-7 | pmid=2220886 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2220886  }} </ref><ref name="pmid10905364">{{cite journal| author=Kakumitsu S, Shijo H, Akiyoshi N, Seo M, Okada M| title=Eosinophilic enteritis observed during alpha-interferon therapy for chronic hepatitis C. | journal=J Gastroenterol | year= 2000 | volume= 35 | issue= 7 | pages= 548-51 | pmid=10905364 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10905364  }} </ref><ref name="pmid10963515">{{cite journal| author=Lee JY, Medellin MV, Tumpkin C| title=Allergic reaction to gemfibrozil manifesting as eosinophilic gastroenteritis. | journal=South Med J | year= 2000 | volume= 93 | issue= 8 | pages= 807-8 | pmid=10963515 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10963515  }} </ref><ref name="pmid8470652">{{cite journal| author=Ravi S, Holubka J, Veneri R, Youn K, Khatib R| title=Clofazimine-induced eosinophilic gastroenteritis in AIDS. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 4 | pages= 612-3 | pmid=8470652 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8470652  }} </ref><ref name="pmid11468446">{{cite journal| author=Barak N, Hart J, Sitrin MD| title=Enalapril-induced eosinophilic gastroenteritis. | journal=J Clin Gastroenterol | year= 2001 | volume= 33 | issue= 2 | pages= 157-8 | pmid=11468446 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11468446  }} </ref><ref name="pmid16911498">{{cite journal| author=Saeed SA, Integlia MJ, Pleskow RG, Calenda KA, Rohrer RJ, Dayal Y et al.| title=Tacrolimus-associated eosinophilic gastroenterocolitis in pediatric liver transplant recipients: role of potential food allergies in pathogenesis. | journal=Pediatr Transplant | year= 2006 | volume= 10 | issue= 6 | pages= 730-5 | pmid=16911498 | doi=10.1111/j.1399-3046.2006.00538.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16911498  }} </ref>


==Epidemiology and Demographics==
==Epidemiology and Demographics==
Epidemiology may differ between studies, as number of cases are small, with approximately 300 EG cases reported in published literature.
===Incidence===
The estimated incidence of eosinophilic gastroenteritis is approximately 1-20 per 100,000 patients.<ref name="pmid28299223">{{cite journal| author=Shetty V, Daniel KE, Kesavan A| title=Hematemesis as Initial Presentation in a 10-Week-Old Infant with Eosinophilic Gastroenteritis. | journal=Case Rep Pediatr | year= 2017 | volume= 2017 | issue=  | pages= 2391417 | pmid=28299223 | doi=10.1155/2017/2391417 | pmc=5337357 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28299223  }} </ref><ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref> It is a rare disease with approximately 300 reported cases in published literature.<ref name="baig" />


EG can present at any age and across all races, with a slightly higher incidence in males<ref>{{cite book | last = Guandalini | first = Stefano | title = Essential Pediatric Gastroenterology and Nutrition | publisher = McGraw-Hill Professional | location = City | year = 2004 | isbn = 0071416307 }} Page 210.</ref>. Earlier studies showed higher incidence in the third to fifth decades of life.<ref name="Zur"/><ref name="klein"/>
===Age===
Eosinophilic gastroenteritis can present at any age.<ref name="baig">{{cite journal| author=Baig MA, Qadir A, Rasheed J| title=A review of eosinophilic gastroenteritis. | journal=J Natl Med Assoc | year= 2006 | volume= 98 | issue= 10 | pages= 1616-9 | pmid=17052051 | doi= | pmc=2569760 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17052051  }} </ref> However, a higher incidence has been observed in the third to fifth decade of life.<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref><ref name="klein" /> In pediatric patients with eosinophilic gastroenteritis, the [[esophagus]] is usually the involved organ ([[eosinophilic esophagitis]]).<ref name="pmid28299223" /> The youngest documented pediatric case of eosinophilic gastroenteritis occurred in a full-term 10month old infant.<ref name="pmid28299223" />


==Risk Factors==
===Sex===
There is a slightly higher incidence in adult males.<ref name="baig" />
 
===Race===
Eosinophilic gastroenteritis has been documented in all races.<ref>{{cite book | last = Guandalini | first = Stefano | title = Essential Pediatric Gastroenterology and Nutrition | publisher = McGraw-Hill Professional | location = City | year = 2004 | isbn = 0071416307 }} Page 210.</ref> However, most of the cases reported occurred in Caucasians.<ref name="baig" />


==Screening==
==Screening==
There is no screening guideline for eosinophilic gastroenteritis.


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
===Natural History===
===Natural History===
Eosinophilic gastroenteritis is an idiopathic disease. A history of [[allergy]]/allergy-related disorders have been documented in a significant number of patients with the disease.<ref name="baig" />
===Complications===
Complications of eosinophilic gastroenteritis can include the following:<ref name="talley" /><ref name="pmid15028974">{{cite journal| author=Whitaker IS, Gulati A, McDaid JO, Bugajska-Carr U, Arends MJ| title=Eosinophilic gastroenteritis presenting as obstructive jaundice. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 4 | pages= 407-9 | pmid=15028974 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15028974  }} </ref><ref name="pmid 12757181">{{cite journal| author=Jimenez-Saenz M, Villar-Rodriguez JL, Torres Y, Carmona I, Salas-Herrero E, Gonzalez-Vilches J et al.| title=Biliary tract disease: a rare manifestation of eosinophilic gastroenteritis. | journal=Dig Dis Sci | year= 2003 | volume= 48 | issue= 3 | pages= 624-7 | pmid= 12757181 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12757181  }} </ref><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref><ref name="pmid26054822" /><ref name="pmid16525206">{{cite journal| author=Lyngbaek S, Adamsen S, Aru A, Bergenfeldt M| title=Recurrent acute pancreatitis due to eosinophilic gastroenteritis. Case report and literature review. | journal=JOP | year= 2006 | volume= 7 | issue= 2 | pages= 211-7 | pmid=16525206 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525206  }} </ref>


===Complications===
*[[Gastric outlet obstruction]]: Pyloric outlet obstruction has been documented in patients with muscular eosinophilic gastroenteritis, and surgical intervention is often required in severe cases.
*Esophageal narrowing/[[strictures]]: Seen when there is esophageal involvement.
*[[Biliary tract diseases resident survival guide|Biliary tract disease]] such as [[biliary tract]] [[fibrosis]] and [[Obstruction of bile duct|obstruction]].
*[[Intestinal perforation]]
*[[Intussusception]]
*[[Acute pancreatitis]]


===Prognosis===
===Prognosis===
The prognosis is good with treatment but relapses are common, which may necessitate chronic low dose steroid therapy for maintenance of remission.<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref> If eosinophilic gastroenteritis is left untreated, patients may develop severe [[malabsorption]] and [[malnutrition]]. Spontaneous remission can also occur.<ref name="baig" />


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
[[Image:CT gastroent.jpg|left|thumb|Spiral CT showing ascites and concentric thickening of colon and ileum in EG]]
Talley et al.<ref name="talley">{{cite journal |author=Talley N, Shorter R, Phillips S, Zinsmeister A |title=Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues |journal=Gut |volume=31 |issue=1 |pages=54-8 |year=1990 |pmid=2318432}}</ref> suggested 3 diagnostic criteria which is still widely used:
#the presence of gastrointestinal symptoms,
#[[histology|histological]] demonstration of eosinophilic infiltration in one or more areas of the gastrointestinal tract or presence of high eosinophil count in [[ascitic]] fluid (latter usually indicates subserosal variety),
#no evidence of parasitic or extraintestinal disease.


[[Hypereosinophilia]], the hallmark of allergic response, may be absent in up to 20% of patients, but [[hypoalbuminaemia]] and other abnormalities suggestive of malabsorption may be present.
===History and Symptoms===
====History====
It is important to obtain the following history from the patient:<ref name="talley" />


[[CT scan]] may show nodular and irregular thickening of the folds in the distal stomach and proximal small bowel, but these findings can also be present in other conditions like [[Crohn's disease]] and [[lymphoma]].
*Presenting symptoms
*Duration of symptoms
*History of [[allergy]]: A history of [[food allergy]]/intolerance, [[drug allergy]], allergy-related conditions such as [[Seasonal allergy|seasonal allergies]], [[atopy]], [[asthma]], and [[nasal polyps]] should be obtained.


The [[endoscopic]] appearance in eosinophilic gastroenteritis is nonspecific; it includes erythematous, friable, nodular, and occasional ulcerative changes<ref name="chen">{{cite journal |author=Chen M, Chu C, Lin S, Shih S, Wang T |title=Eosinophilic gastroenteritis: clinical experience with 15 patients |journal=World J. Gastroenterol. |volume=9 |issue=12 |pages=2813-6 |year=2003 |pmid=14669340}}</ref>.
====Symptoms====
Sometimes diffuse inflammation results in complete loss of [[villi]], involvement of multiple layers, [[submucosal]] [[oedema]] and [[fibrosis]].<ref>{{cite journal |author=Johnstone J, Morson B |title=Eosinophilic gastroenteritis |journal=Histopathology |volume=2 |issue=5 |pages=335-48 |year=1978 |pmid=363591}}</ref><ref>{{cite journal |author=Katz A, Goldman H, Grand R |title=Gastric mucosal biopsy in eosinophilic (allergic) gastroenteritis |journal=Gastroenterology |volume=73 |issue=4 Pt 1 |pages=705-9 |year=1977 |pmid=892374}}</ref>
Eosinophilic gastroenteritis can present with several nonspecific gastrointestinal symptoms. The manifestations often depend on the site affected in the [[Gastrointestinal tract|GIT]], and the involved layer of the gastrointestinal wall.<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref><ref name="baig">{{cite journal |author=Baig M, Qadir A, Rasheed J |title=A review of eosinophilic gastroenteritis |journal=Journal of the National Medical Association |volume=98 |issue=10 |pages=1616-9 |year=2006 |pmid=17052051}}</ref><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref> The following are the gastrointestinal symptoms seen in eosinophilic gastroenteritis:<ref name="talley" /><ref name="pmid 11338074" /><ref name="pmid28299223" /><ref name="baig" /><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref><ref name="pmid22036223">{{cite journal| author=Tien FM, Wu JF, Jeng YM, Hsu HY, Ni YH, Chang MH et al.| title=Clinical features and treatment responses of children with eosinophilic gastroenteritis. | journal=Pediatr Neonatol | year= 2011 | volume= 52 | issue= 5 | pages= 272-8 | pmid=22036223 | doi=10.1016/j.pedneo.2011.06.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22036223  }} </ref><ref name="pmid15028974">{{cite journal| author=Whitaker IS, Gulati A, McDaid JO, Bugajska-Carr U, Arends MJ| title=Eosinophilic gastroenteritis presenting as obstructive jaundice. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 4 | pages= 407-9 | pmid=15028974 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15028974  }} </ref>


Definitive diagnosis involves [[histology|histological]] evidence of eosinophilic infiltration in biopsy slides. [[Microscopy]] reveals >20 eosinophils per [[High Power Field|high power field]]<ref name="talley"/><ref name="baig"/>. Infiltration is often patchy , can be missed and [[laparoscopy|laparoscopic]] full thickness biopsy may be required.
'''Common symptoms'''


[[Radionuclide|Radio isotope]] scan using [[Tc-99m]] HMPAO-labeled [[leukocyte]] [[single photon emission computed tomography|SPECT]] may be useful in assessing the extent of disease and response to treatment but has little value in diagnosis, as the scan does not help differentiating EG from other causes of inflammation<ref>{{cite journal |author=Lee K, Hahm K, Kim Y, Kim J, Cho S, Jie H, Park C, Yim H |title=The usefulness of Tc-99m HMPAO labeled WBC SPECT in eosinophilic gastroenteritis |journal=Clinical nuclear medicine |volume=22 |issue=8 |pages=536-41 |year=1997 |pmid=9262899}}</ref><ref>{{cite journal |author=Imai E, Kaminaga T, Kawasugi K, Yokokawa T, Furui S |title=The usefulness of 99mTc-hexamethylpropyleneamineoxime white blood cell scintigraphy in a patient with eosinophilic gastroenteritis |journal=Annals of nuclear medicine |volume=17 |issue=7 |pages=601-3 |year=2003 |pmid=14651361}}</ref>.
*Episodic [[abdominal pain]]
*[[Nausea]]
*[[Vomiting]]
*[[Diarrhea]]
*[[Poor appetite]]
*[[Weight loss]]
*[[Steatorrhea]]
*[[Hematochezia]]
*[[Bloating|Abdominal bloating]] and [[ascites]]: Seen more often in patients with subserosal disease.


When eosinophilic gastroenteritis is observed in association with eosinophilic infiltration of other organ systems, the diagnosis of [[idiopathic]] [[hypereosinophilic syndrome]] should be considered<ref>{{cite journal |author=Matsushita M, Hajiro K, Morita Y, Takakuwa H, Suzaki T |title=Eosinophilic gastroenteritis involving the entire digestive tract |journal=Am. J. Gastroenterol. |volume=90 |issue=10 |pages=1868-70 |year=1995 |pmid=7572911}}</ref>.


===History and Symptoms===
 
EG typically presents with a combination of chronic nonspecific GI symptoms which include [[abdominal]] pain, [[nausea]], vomiting, [[diarrhea]], [[weight loss]], and abdominal distension. Approximately 80% have symptoms for several years<ref>{{cite journal |author=Christopher V, Thompson M, Hughes S |title=Eosinophilic gastroenteritis mimicking pancreatic cancer |journal=Postgraduate medical journal |volume=78 |issue=922 |pages=498-9 |year=2002 |pmid=12185230}}</ref>; a high degree of clinical suspicion is often required to establish the diagnosis, as the disease is extremely rare. Occasionally, the disease may manifest itself as an acute abdomen or bowel obstruction<ref>{{cite journal |author=Shweiki E, West J, Klena J, Kelley S, Colley A, Bross R, Tyler W |title=Eosinophilic gastroenteritis presenting as an obstructing cecal mass--a case report and review of the literature |journal=Am. J. Gastroenterol. |volume=94 |issue=12 |pages=3644-5 |year=1999 |pmid=10606337}}</ref><ref>{{cite journal |author=Tran D, Salloum L, Tshibaka C, Moser R |title=Eosinophilic gastroenteritis mimicking acute appendicitis |journal=The American surgeon |volume=66 |issue=10 |pages=990-2 |year=2000 |pmid=11261632}}</ref>.
'''Uncommon symptoms'''
* '''[[Mucosal]] EG''' (25-100%)is the commonest variety,<ref name="baig">{{cite journal |author=Baig M, Qadir A, Rasheed J |title=A review of eosinophilic gastroenteritis |journal=Journal of the National Medical Association |volume=98 |issue=10 |pages=1616-9 |year=2006 |pmid=17052051}}</ref><ref>{{cite journal |author=Lee C, Changchien C, Chen P, Lin D, Sheen I, Wang C, Tai D, Sheen-Chen S, Chen W, Wu C |title=Eosinophilic gastroenteritis: 10 years experience |journal=Am. J. Gastroenterol. |volume=88 |issue=1 |pages=70-4 |year=1993 |pmid=8420276}}</ref> which presents with features of [[malabsorption]] and [[protein losing enteropathy]]. Failure to thrive and [[anaemia]] may also be present. [[Lower gastrointestinal bleeding]] may imply colonic involvement.
 
*'''Muscular EG''' (13-70%) present with obstruction of gastric outlet or small intestine; sometimes as an obstructing [[Cecum|caecal]] mass or [[intussusception]].
*[[Dysphagia]]: This has been documented in patients with esophageal involvement.
*'''[[Serous membrane|Subserosal]]''' '''EG''' (4.5 % to 9 % in Japan and 13 % in the USA)<ref>{{cite journal |author=Miyamoto T, Shibata T, Matsuura S, Kagesawa M, Ishizawa Y, Tamiya K |title=Eosinophilic gastroenteritis with ileus and ascites |journal=Intern. Med. |volume=35 |issue=10 |pages=779-82 |year=1996 |pmid=8933185}})</ref>presents with ascites which is usually exudative in nature, abundant peripheral eosinophilia, and has favourable responses to [[corticosteroids]].
*[[Hematemesis]]
*Other documented features are [[Cholangitis]], [[pancreatitis]]<ref>{{cite journal |author=Lyngbaek S, Adamsen S, Aru A, Bergenfeldt M |title=Recurrent acute pancreatitis due to eosinophilic gastroenteritis. Case report and literature review |journal=JOP |volume=7 |issue=2 |pages=211-7 |year=2006 |pmid=16525206}}</ref>, eosinophilic [[splenitis]], acute [[appendicitis]] and giant refractory [[duodenal ulcer]].
*[[Jaundice]]


===Physical Examination===
===Physical Examination===
The physical examination findings in eosinophilic gastroenteritis are non-specific, and are mostly dependent on the site and depth of [[bowel]] involvement. The following findings may be present:<ref name="pmid26054822" /><ref name="pmid22036223">{{cite journal| author=Tien FM, Wu JF, Jeng YM, Hsu HY, Ni YH, Chang MH et al.| title=Clinical features and treatment responses of children with eosinophilic gastroenteritis. | journal=Pediatr Neonatol | year= 2011 | volume= 52 | issue= 5 | pages= 272-8 | pmid=22036223 | doi=10.1016/j.pedneo.2011.06.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22036223  }} </ref>
====HEENT====
*[[Anemia]]
====Gastrointestinal system====
*[[Abdominal tenderness]]
*[[Ascites]]
*[[Hematochezia]] on [[rectal exam]]
====Skin====
Eczema may be seen in patients with atopy.


===Laboratory Findings===
===Laboratory Findings===
The following laboratory findings can be seen:<ref name="talley" /><ref name="pmid26054822" />
*[[Complete blood count|CBC]]: Peripheral blood [[eosinophilia]] is often seen, but it may be absent in >20% of affected patients. Patients with subserosal disease often have a higher eosinophil count. [[Anemia]] can also be present ([[iron deficiency anemia]] is a frequent finding).
*Elevated [[serum]] [[IgE]] is a common finding.
*Elevated [[Erythrocyte sedimentation rate|ESR]]: This can be moderately elevated in 25% of patients with eosinophilic gastroenteritis.
*[[Hypoalbuminemia]]: This can occur as a result of severe [[malabsorption]] and [[protein losing enteropathy]].
*Fecal fat test: Mild-moderate [[steatorrhea]] is sometimes seen.
*Stool α-1 antitrypsin clearance: For assessment of fecal protein loss.
*[[Allergy testing]]: Tests such as [[Skin allergy testing|skin-prick]] and [[RAST blood test|RAST]] testing may be done when specific food and environmental [[allergies]] are strongly suspected as triggers for the disease.
===Microscopic Findings===
Eosinophilic gastroenteritis is a diagnosis of exclusion. There are no well standardized pathologic criteria for making a diagnosis of eosinophilic gastroenteritis. There are three widely utilized diagnostic criteria:<ref name="pmid26054822" /><ref name="talley">{{cite journal |author=Talley N, Shorter R, Phillips S, Zinsmeister A |title=Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues |journal=Gut |volume=31 |issue=1 |pages=54-8 |year=1990 |pmid=2318432}}</ref>
#Presence of gastrointestinal symptoms
#[[Biopsy]] demonstrating eosinophilic infiltration of one or more areas of the [[Gastrointestinal tract|GIT]] (from the [[esophagus]] to [[colon]])
#Exclusion of other causes of tissue [[eosinophilia]].
====Biopsy====
*[[Biopsy]] is widely used for making a diagnosis. In the absence of other causes of tissue [[eosinophilia]], eosinophilic infiltration of the [[Gastrointestinal tract|GIT]] on [[biopsy]] and/or the presence of eosinophilic [[ascitic]] fluid in a patient with gastrointestinal symptoms is diagnostic for eosinophilic gastroenteritis.<ref name="pmid28299223" />
*Eosinophilic infiltration of the [[gastrointestinal tract]] is seen on [[histology]] following [[endoscopic]]/surgical biopsies. Abnormal eosinophilic infiltration of the [[Gastrointestinal tract|GIT]] can be defined as the presence of diffuse or multifocal [[eosinophils]] ≥20 per high power field.<ref name="talley" /><ref name="pmid26054822" />
*The diagnosis can occasionally be missed, especially in patients with the localized patchy infiltration. Multiple [[biopsy]] samples throughout the [[Gastrointestinal tract|GIT]] (including visually normal areas) should be taken.<ref name="pmid26054822" />
[[File:Presentation1.jpg|center|Endoscopic [[biopsy]] of [[ileum]] showing distinct eosinophilic infiltration|1000x1000px|thumb]]
====Paracentesis====
*In cases of suspected eosinophilic ascites, it is important to perform a diagnostic [[paracentesis]].<ref name="pmid26054822" />


===Imaging Findings===
===Imaging Findings===
[[Imaging studies|Radiological studies]] are of limited diagnostic value in patients with eosinophilic gastroenteritis. The findings on imaging are often variable and non-specific. [[Imaging studies]] may reveal the following:<ref name="pmid28299223" /><ref name="chen">{{cite journal| author=Chen MJ, Chu CH, Lin SC, Shih SC, Wang TE| title=Eosinophilic gastroenteritis: clinical experience with 15 patients. | journal=World J Gastroenterol | year= 2003 | volume= 9 | issue= 12 | pages= 2813-6 | pmid=14669340 | doi= | pmc=4612059 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14669340  }} </ref><ref name="talley" /><ref name="pmid14651361">{{cite journal| author=Imai E, Kaminaga T, Kawasugi K, Yokokawa T, Furui S| title=The usefulness of 99mTc-hexamethylpropyleneamineoxime white blood cell scintigraphy in a patient with eosinophilic gastroenteritis. | journal=Ann Nucl Med | year= 2003 | volume= 17 | issue= 7 | pages= 601-3 | pmid=14651361 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14651361  }} </ref><ref name="pmid9262899">{{cite journal| author=Lee KJ, Hahm KB, Kim YS, Kim JH, Cho SW, Jie H et al.| title=The usefulness of Tc-99m HMPAO labeled WBC SPECT in eosinophilic gastroenteritis. | journal=Clin Nucl Med | year= 1997 | volume= 22 | issue= 8 | pages= 536-41 | pmid=9262899 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9262899  }} </ref>
====Ultrasonography====
*Presence of [[Bowel|bowe]]<nowiki/>l thickening/folds, [[ascites]] and [[peritoneal]] nodules.
*Response to therapy
====CT scan====
*Prominent nodular, irregular folds/thickening of the [[stomach]] and [[intestines]] (similar findings can be seen in other diseases such as [[Crohn's disease|Crohn’s disease]] and [[lymphoma]]).
*[[Ascites]]
====Barium studies====
*Antral stenosis and mucosal irregularity of the [[stomach]]. A [[string sign]] appearance can be seen on [[Barium|barium studies]] when complications such as [[gastric outlet obstruction]] occur.
*Thickened mucosal folds of the [[small intestine]] due to [[edema]].


===Other Diagnostic Studies===
====Endoscopy====
 
*Normal appearance of the [[Gastrointestinal tract|GIT]].
*Gross findings such as gastric [[pseudopolyps]].
*Other non-specific findings such as mucosal [[erythema]], friability, and fine [[granularity]] in the [[stomach]] may be seen. Mucosal [[ulcerations]]/erosions, thickening of gastric mucosal folds and mucosal nodules or whitish specks are sometimes seen.
 
====Tc-99m hexamethylpropyleneamine oxime(HMPAO) scintigraphy scanning====
 
*Radionuclide scan using [[Tc-99m]] HMPAO-labeled [[leukocyte]] [[single photon emission computed tomography|SPECT]] may be useful for assessing the extent of disease and the response to treatment
*It cannot differentiate eosinophilic gastroenteritis from other causes of [[Gastrointestinal tract|GIT]] [[inflammation]], hence, it is not a diagnostic test.


==Treatment==
==Treatment==
There is no guidelines/definitive consensus for the management of eosinophilic gastroenteritis, and the treatment is usually based on the severity of the disease. [[Steroids]] are widely recognized as the mainstay of treatment for eosinophilic gastroenteritis. Chronic [[Relapse|relapses]] frequently occur and continued maintenance on low dose [[steroid]] therapy may be necessary.<ref name="pmid26054822">{{cite journal| author=Uppal V, Kreiger P, Kutsch E| title=Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review. | journal=Clin Rev Allergy Immunol | year= 2016 | volume= 50 | issue= 2 | pages= 175-88 | pmid=26054822 | doi=10.1007/s12016-015-8489-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26054822  }} </ref><ref name="pmid8420276">{{cite journal| author=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS et al.| title=Eosinophilic gastroenteritis: 10 years experience. | journal=Am J Gastroenterol | year= 1993 | volume= 88 | issue= 1 | pages= 70-4 | pmid=8420276 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8420276  }} </ref>
===Medical Therapy===
===Medical Therapy===
Corticosteroids are the mainstay of therapy with a 90% response rate in some studies. Appropriate duration of steroid treatment is unknown and relapse often necessitates long term treatment. Various steroid sparing agents e.g. [[sodium cromoglycate]] (a stabilizer of mast cell [[cell membrane|membranes]]), [[ketotifen]] (an [[antihistamine]]), and [[montelukast]] (a selective, competitive [[Leukotriene antagonist|leukotriene receptor antagonist]]) have been proposed, centering around an allergic hypothesis, with mixed results<ref>{{cite journal |author=Barbie D, Mangi A, Lauwers G |title=Eosinophilic gastroenteritis associated with systemic lupus erythematosus |journal=J. Clin. Gastroenterol. |volume=38 |issue=10 |pages=883-6 |year=2004 |pmid=15492606}}</ref>. An elimination diet may be successful if a limited number of food allergies are identified<ref>{{cite journal |author=Katz A, Twarog F, Zeiger R, Falchuk Z |title=Milk-sensitive and eosinophilic gastroenteropathy: similar clinical features with contrasting mechanisms and clinical course |journal=J. Allergy Clin. Immunol. |volume=74 |issue=1 |pages=72-8 |year=1984 |pmid=6547462}}</ref><ref name="chen"/>.
The medical management of eosinophilic gastroenteritis entails the following:<ref name="talley" /><ref name="pmid26054822" /><ref name="pmid6547462">{{cite journal| author=Katz AJ, Twarog FJ, Zeiger RS, Falchuk ZM| title=Milk-sensitive and eosinophilic gastroenteropathy: similar clinical features with contrasting mechanisms and clinical course. | journal=J Allergy Clin Immunol | year= 1984 | volume= 74 | issue= 1 | pages= 72-8 | pmid=6547462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6547462 }} </ref><ref name="chen" /><ref name="pmid28299223" /><ref name="pmid28279648">{{cite journal| author=Yanagimoto Y, Taniuchi S, Ishizaki Y, Nakano K, Hosaka N, Kaneko K| title=Eosinophilic gastroenteritis caused by eating hens' eggs: A case report. | journal=Allergol Int | year= 2017 | volume=  | issue=  | pages=  | pmid=28279648 | doi=10.1016/j.alit.2017.02.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28279648  }} </ref>


===Surgery===
'''Preferred therapy'''


===Prevention===
*[[Corticosteroids]]: This is the mainstay of therapy for eosinophilic gastroenteritis. A dramatic response to [[Corticosteroid medications|corticosteroid therapy]] is commonly seen in patients with subserosal disease. A 90% response rate to [[Corticosteroid medications|corticosteroid therapy]] has been documented in some studies.
*Dietary modification
 
#Elimination of identified food [[allergies]] from the diet.
#Introduction of elemental diets.
 
'''Alternate therapy'''


== Other gastrointestinal conditions associated with allergy ==
These medications can be used alone or in combination with [[steroids]] for treatment and/or maintenance therapy.
*[[Ketotifen]]
*[[Cromolyn|Cromolyn sodium]]
*[[Montelukast]]: Either used alone or in combination with steroids as a steroid-sparing agent. Some patients treated with montelukast alone did not have a relapse.<ref name="pmid22036223">{{cite journal| author=Tien FM, Wu JF, Jeng YM, Hsu HY, Ni YH, Chang MH et al.| title=Clinical features and treatment responses of children with eosinophilic gastroenteritis. | journal=Pediatr Neonatol | year= 2011 | volume= 52 | issue= 5 | pages= 272-8 | pmid=22036223 | doi=10.1016/j.pedneo.2011.06.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22036223  }} </ref>
*Suplatast tosilate<ref name="pmid11344364">{{cite journal| author=Shirai T, Hashimoto D, Suzuki K, Osawa S, Aonahata M, Chida K et al.| title=Successful treatment of eosinophilic gastroenteritis with suplatast tosilate. | journal=J Allergy Clin Immunol | year= 2001 | volume= 107 | issue= 5 | pages= 924-5 | pmid=11344364 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11344364  }} </ref>
*Biologic medications such as [[omalizumab]], [[reslizumab]], and [[mepolizumab]].


*[[Eosinophilic esophagitis]]
===Surgical Therapy===
*Eosinophilic [[ascites]]
There are no indications for surgery in the primary management of eosinophilic gastroenteritis. However, surgical management may be required when complications such as intestinal perforation or severe [[gastric outlet obstruction]] occur.
*[[Coeliac disease]]
*[[Protein losing enteropathy]] from intolerance to cow's milk protein
*Infantile formula protein intolerance


== See also ==
===Prevention===
[[Allergy]]<br />
There are no guidelines for the prevention of eosinophilic gastroenteritis. Elimination of identified triggers such as food [[allergies]] may be beneficial.<ref name="pmid28279648" />
[[Gastroenteritis]]<br />
[[Malabsorption]]


==References==
==References==

Latest revision as of 12:32, 1 January 2021

Eosinophilic gastroenteritis
H&E Stain: Dense Eosinophilic infiltration of gastro-duodenal wall
ICD-10 K52.8
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Fatimo Biobaku M.B.B.S [2]

Synonyms and keywords: Eosinophilic esophagitis; eosinophilic gastritis; Eosinophilic enteritis; Eosinophilic colitis; Eosinophilic proctocolitis, Eosinophilic gastrointestinal disorders

Overview

Eosinophilic gastroenteritis is a rare, heterogenous disorder characterized by localized patchy or diffuse eosinophilic infiltration of the gastrointestinal tract.[1] Most of the data available in the literature are based on few documented case reports/case series. The presentation of eosinophilic gastroenteritis may vary depending on the location, depth and extent of bowel wall involvement.[2][1][3] The cause of eosinophilic gastroenteritis is idiopathic although there is a significant association with allergy.[2][1] Non-specific gastrointestinal symptoms such as episodic abdominal pain, vomiting and diarrhea are common. Eosinophilic gastroenteritis is a diagnosis of exclusion and other causes of GIT symptoms with gastrointestinal tissue eosinophilia must be ruled out.[2] Biopsy of the GIT is the primary diagnostic modality. The mainstay of treatment is corticosteroid therapy. Majority of patients respond well to treatment but the disease may run a chronic relapsing course.[4][2]

Historical Perspective

The first description of eosinophilic gastroenteritis was by Kaijser et al. in 1937, and it was described as an allergic disease of the gut.[5][6] Klein et al. subsequently classified it into three types (predominant mucosal, muscular, and subserosal layer disease) based on the depth of eosinophilic infiltration.[7]

Classification

Eosinophilic gastroenteritis can be subdivided into three groups according to the Klein classification:[4][8][1][3][2]

  • Mucosal eosinophilic gastroenteritis
  1. Most common subtype of eosinophilic gastroenteritis.
  2. Mucosal infiltration by eosinophils, and/or presence of mucosal edema on barium studies.
  3. Absent histological evidence of muscle infiltration.
  4. No evidence of gastrointestinal obstruction or eosinophilic ascites.
  • Muscular eosinophilic gastroenteritis
  1. Documentation of complete/incomplete bowel obstruction, and/or infiltration of the tunica muscularis by eosinophils.
  2. No evidence of eosinophilic ascites.
  • Subserosal eosinophilic gastroenteritis
  1. Eosinophilic infiltration of the gut
  2. Presence of eosinophilic ascites (may occasionally progress to an eosinophilic pleural effusion)

Causes

The cause of eosinophilic gastroenteritis is unknown.[1]

Risk Factors

  • Allergy: A study conducted in 40 patients with eosinophilic gastroenteritis demonstrated a history of allergy in half of the patients.[8] Food intolerance or allergy is more commonly seen in mucosal eosinophilic gastroenteritis, affecting over 50% of patients with mucosal disease according to a study.[8]

Pathophysiology

Pathogenesis

  • Eosinophilic gastroenteritis is a rare disease with poorly understood pathophysiology.
  • Eosinophils are normally seen in the entire GIT (except in the esophagus) of healthy individuals.[2]
  • In patients with eosinophilic gastroenteritis, there is varying degrees of increased eosinophilic infiltration of the GIT (in the absence of other known causes of tissue eosinophilia).[6][2]
  • Any part of the GIT from the esophagus to the colon can be affected. Occasionally, eosinophilic gastroenteritis affects the entire gastrointestinal tract.[8] The stomach and proximal small intestine are most commonly affected, while the colon is usually the least affected part of the GIT.[6][8][2]
  • The etiology of the excessive eosinophilic infiltration of the GIT is not clear. Destruction of the GIT epithelium caused by the release of eosinophilic basic protein and activated degranulating eosinophils has been proposed.[8][9]
  • Inflammatory mediators such as Th-2 cytokines (IL-3, IL-5, GM-CSF and IL-13), monocyte generating chemokines such as IL-8, monocyte chemotactic proteins, mast cells, granulocytes, eosinophils, and eosinophilic mediators such as eotaxin have been strongly implicated.[6][2][1]
  • The inflammatory mediators associated with the pathogenesis of eosinophilic gastroenteritis have well established roles in the pathogenesis of allergy and asthma. A significant number of patients with eosinophilic gastroenteritis have also been documented to have allergies/allergy-related disorders, suggesting a hypersensitivity reaction is involved in the pathogenesis of eosinophilic gastroenteritis.[6][1]

Differentiating Eosinophilic gastroenteritis from Other Diseases

Diseases with peripheral eosinophilia and gastrointestinal symptoms should be differentiated from eosinophilic gastroenteritis. It is also important to consider eosinophilic gastroenteritis in the differential diagnosis of unexplained gastrointestinal symptoms (even when peripheral eosinophilia is not present). Most diseases that can manifest with gastrointestinal symptoms and peripheral eosinophilia are easily differentiated from eosinophilic gastroenteritis via detailed history taking, laboratory investigations, and histologic examination of endoscopic biopsies.[1][2] Some of these diseases include:[1][2][10][11]

Epidemiology and Demographics

Incidence

The estimated incidence of eosinophilic gastroenteritis is approximately 1-20 per 100,000 patients.[6][2] It is a rare disease with approximately 300 reported cases in published literature.[1]

Age

Eosinophilic gastroenteritis can present at any age.[1] However, a higher incidence has been observed in the third to fifth decade of life.[2][4] In pediatric patients with eosinophilic gastroenteritis, the esophagus is usually the involved organ (eosinophilic esophagitis).[6] The youngest documented pediatric case of eosinophilic gastroenteritis occurred in a full-term 10month old infant.[6]

Sex

There is a slightly higher incidence in adult males.[1]

Race

Eosinophilic gastroenteritis has been documented in all races.[21] However, most of the cases reported occurred in Caucasians.[1]

Screening

There is no screening guideline for eosinophilic gastroenteritis.

Natural History, Complications, and Prognosis

Natural History

Eosinophilic gastroenteritis is an idiopathic disease. A history of allergy/allergy-related disorders have been documented in a significant number of patients with the disease.[1]

Complications

Complications of eosinophilic gastroenteritis can include the following:[8][5][22][3][2][23]

Prognosis

The prognosis is good with treatment but relapses are common, which may necessitate chronic low dose steroid therapy for maintenance of remission.[2][3] If eosinophilic gastroenteritis is left untreated, patients may develop severe malabsorption and malnutrition. Spontaneous remission can also occur.[1]

Diagnosis

History and Symptoms

History

It is important to obtain the following history from the patient:[8]

Symptoms

Eosinophilic gastroenteritis can present with several nonspecific gastrointestinal symptoms. The manifestations often depend on the site affected in the GIT, and the involved layer of the gastrointestinal wall.[2][1][3] The following are the gastrointestinal symptoms seen in eosinophilic gastroenteritis:[8][9][6][1][3][24][5]

Common symptoms


Uncommon symptoms

Physical Examination

The physical examination findings in eosinophilic gastroenteritis are non-specific, and are mostly dependent on the site and depth of bowel involvement. The following findings may be present:[2][24]

HEENT

Gastrointestinal system

Skin

Eczema may be seen in patients with atopy.

Laboratory Findings

The following laboratory findings can be seen:[8][2]

  • CBC: Peripheral blood eosinophilia is often seen, but it may be absent in >20% of affected patients. Patients with subserosal disease often have a higher eosinophil count. Anemia can also be present (iron deficiency anemia is a frequent finding).
  • Elevated serum IgE is a common finding.
  • Elevated ESR: This can be moderately elevated in 25% of patients with eosinophilic gastroenteritis.
  • Hypoalbuminemia: This can occur as a result of severe malabsorption and protein losing enteropathy.
  • Fecal fat test: Mild-moderate steatorrhea is sometimes seen.
  • Stool α-1 antitrypsin clearance: For assessment of fecal protein loss.
  • Allergy testing: Tests such as skin-prick and RAST testing may be done when specific food and environmental allergies are strongly suspected as triggers for the disease.

Microscopic Findings

Eosinophilic gastroenteritis is a diagnosis of exclusion. There are no well standardized pathologic criteria for making a diagnosis of eosinophilic gastroenteritis. There are three widely utilized diagnostic criteria:[2][8]

  1. Presence of gastrointestinal symptoms
  2. Biopsy demonstrating eosinophilic infiltration of one or more areas of the GIT (from the esophagus to colon)
  3. Exclusion of other causes of tissue eosinophilia.

Biopsy

  • Biopsy is widely used for making a diagnosis. In the absence of other causes of tissue eosinophilia, eosinophilic infiltration of the GIT on biopsy and/or the presence of eosinophilic ascitic fluid in a patient with gastrointestinal symptoms is diagnostic for eosinophilic gastroenteritis.[6]
  • The diagnosis can occasionally be missed, especially in patients with the localized patchy infiltration. Multiple biopsy samples throughout the GIT (including visually normal areas) should be taken.[2]
Endoscopic biopsy of ileum showing distinct eosinophilic infiltration

Paracentesis

  • In cases of suspected eosinophilic ascites, it is important to perform a diagnostic paracentesis.[2]

Imaging Findings

Radiological studies are of limited diagnostic value in patients with eosinophilic gastroenteritis. The findings on imaging are often variable and non-specific. Imaging studies may reveal the following:[6][25][8][26][27]

Ultrasonography

CT scan

Barium studies

Endoscopy

  • Normal appearance of the GIT.
  • Gross findings such as gastric pseudopolyps.
  • Other non-specific findings such as mucosal erythema, friability, and fine granularity in the stomach may be seen. Mucosal ulcerations/erosions, thickening of gastric mucosal folds and mucosal nodules or whitish specks are sometimes seen.

Tc-99m hexamethylpropyleneamine oxime(HMPAO) scintigraphy scanning

  • Radionuclide scan using Tc-99m HMPAO-labeled leukocyte SPECT may be useful for assessing the extent of disease and the response to treatment
  • It cannot differentiate eosinophilic gastroenteritis from other causes of GIT inflammation, hence, it is not a diagnostic test.

Treatment

There is no guidelines/definitive consensus for the management of eosinophilic gastroenteritis, and the treatment is usually based on the severity of the disease. Steroids are widely recognized as the mainstay of treatment for eosinophilic gastroenteritis. Chronic relapses frequently occur and continued maintenance on low dose steroid therapy may be necessary.[2][3]

Medical Therapy

The medical management of eosinophilic gastroenteritis entails the following:[8][2][28][25][6][29]

Preferred therapy

  1. Elimination of identified food allergies from the diet.
  2. Introduction of elemental diets.

Alternate therapy

These medications can be used alone or in combination with steroids for treatment and/or maintenance therapy.

Surgical Therapy

There are no indications for surgery in the primary management of eosinophilic gastroenteritis. However, surgical management may be required when complications such as intestinal perforation or severe gastric outlet obstruction occur.

Prevention

There are no guidelines for the prevention of eosinophilic gastroenteritis. Elimination of identified triggers such as food allergies may be beneficial.[29]

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 Baig MA, Qadir A, Rasheed J (2006). "A review of eosinophilic gastroenteritis". J Natl Med Assoc. 98 (10): 1616–9. PMC 2569760. PMID 17052051.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 Uppal V, Kreiger P, Kutsch E (2016). "Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review". Clin Rev Allergy Immunol. 50 (2): 175–88. doi:10.1007/s12016-015-8489-4. PMID 26054822.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS; et al. (1993). "Eosinophilic gastroenteritis: 10 years experience". Am J Gastroenterol. 88 (1): 70–4. PMID 8420276.
  4. 4.0 4.1 4.2 Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH (1970). "Eosinophilic gastroenteritis". Medicine (Baltimore). 49 (4): 299–319. PMID 5426746.
  5. 5.0 5.1 5.2 Whitaker IS, Gulati A, McDaid JO, Bugajska-Carr U, Arends MJ (2004). "Eosinophilic gastroenteritis presenting as obstructive jaundice". Eur J Gastroenterol Hepatol. 16 (4): 407–9. PMID 15028974.
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 Shetty V, Daniel KE, Kesavan A (2017). "Hematemesis as Initial Presentation in a 10-Week-Old Infant with Eosinophilic Gastroenteritis". Case Rep Pediatr. 2017: 2391417. doi:10.1155/2017/2391417. PMC 5337357. PMID 28299223.
  7. Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH (1970). "Eosinophilic gastroenteritis". Medicine (Baltimore). 49 (4): 299–319. PMID 5426746.
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 Talley NJ, Shorter RG, Phillips SF, Zinsmeister AR (1990). "Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues". Gut. 31 (1): 54–8. PMC 1378340. PMID 2318432  2318432 Check |pmid= value (help).
  9. 9.0 9.1 Tan AC, Kruimel JW, Naber TH (2001). "Eosinophilic gastroenteritis treated with non-enteric-coated budesonide tablets". Eur J Gastroenterol Hepatol. 13 (4): 425–7. PMID 11338074  11338074 Check |pmid= value (help).
  10. Matsushita M, Hajiro K, Morita Y, Takakuwa H, Suzaki T (1995). "Eosinophilic gastroenteritis involving the entire digestive tract". Am J Gastroenterol. 90 (10): 1868–70. PMID 7572911.
  11. Barbie DA, Mangi AA, Lauwers GY (2004). "Eosinophilic gastroenteritis associated with systemic lupus erythematosus". J Clin Gastroenterol. 38 (10): 883–6. PMID 15492606.
  12. Shakeer VK, Devi SR, Chettupuzha AP, Mustafa CP, Sandesh K, Kumar SK; et al. (2002). "Carbamazepine-induced eosinophilic enteritis". Indian J Gastroenterol. 21 (3): 114–5. PMID 12118924.
  13. Lange P, Oun H, Fuller S, Turney JH (1994). "Eosinophilic colitis due to rifampicin". Lancet. 344 (8932): 1296–7. PMID 7968003.
  14. Jiménez-Sáenz M, González-Cámpora R, Linares-Santiago E, Herrerías-Gutiérrez JM (2006). "Bleeding colonic ulcer and eosinophilic colitis: a rare complication of nonsteroidal anti-inflammatory drugs". J Clin Gastroenterol. 40 (1): 84–5. PMID 16340639.
  15. Bridges AJ, Marshall JB, Diaz-Arias AA (1990). "Acute eosinophilic colitis and hypersensitivity reaction associated with naproxen therapy". Am J Med. 89 (4): 526–7. PMID 2220886.
  16. Kakumitsu S, Shijo H, Akiyoshi N, Seo M, Okada M (2000). "Eosinophilic enteritis observed during alpha-interferon therapy for chronic hepatitis C." J Gastroenterol. 35 (7): 548–51. PMID 10905364.
  17. Lee JY, Medellin MV, Tumpkin C (2000). "Allergic reaction to gemfibrozil manifesting as eosinophilic gastroenteritis". South Med J. 93 (8): 807–8. PMID 10963515.
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