Eosinophilic colitis

Diagnosing eosinophilic colitis: histopathological pattern or nosological entity?

Reports of  "eosinophilic colitis"-raised colonic mucosal eosinophil density in patients with lower gastrointestinal symptoms-have increased markedly over the last fifteen years, though it remains a rarity. There is no consensus over its diagnosis and management, and uncertainty is compounded by the use of the same term to describe an idiopathic increase in colonic eosinophils and an eosinophilic inflammatory reaction to known aetiological agents such as parasites or drugs. In patients with histologically proven colonic eosinophilia, it is important to seek out underlying causes and careful clinicopathological correlation is advised. Because of the variability of eosinophil density in the normal colon, it is recommended that histological reports of colonic eosinophilia include a quantitative morphometric assessment of eosinophil density, preferably across several sites. Few reported cases of "eosinophilic colitis" meet these criteria. As no correlation has been shown between colonic eosinophil density and symptoms in older children or adults, it is suggested that treatment should be directed towards alleviation of symptoms and response to treatment assessed clinically rather than by histological estimates of intramucosal eosinophils.

Eosinophilic-Crohn overlap colitis and review of the literature

Eosinophilic colitis is an idiopathic inflammation of the alimentary canal and is characterized by infiltration of the intestinal wall by eosinophils, massive submucosal edema, and peripheral eosinophilia. However, the presence of eosinophils in a colon biopsy requires thorough searching for secondary causes and eosinophilic colitis remains a diagnosis of exclusion. A 67-year-old male patient underwent a diagnostic ileocolonoscopy because of recurrent episodes of diarrhea for the last six months. Colonoscopy revealed a normal terminal ileum while in the entire colon an erythematous mucosa with very slight edema on a continuous pattern that was more pronounced in the left colon. The laboratory workup demonstrated eosinophils slightly elevated, biochemical tests were unremarkable and further clinical and laboratory workup was unremarkable. Histology showed overlapping findings of eosinophilic colitis and Crohn's colitis. Patient started on mesalazine 2.4 with very good results. A review of the literature shows that the spectrum of eosinophil involvement in inflammatory bowel disease as well as in eosinophilic colitis is largely varying, including also some exceptional cases that parallel the case described herein.

[Drug-induced enterocolitis]

Drug-induced enterocolitis is a frequent but underdiagnosed disease. Gross and microscopic features are often non-specific, except for particular cases. Drug-induced enterocolitis is usually a diagnosis of exclusion. In this article we describe the pathologic features and causes of various cases of drug-induced enterocolitis.

Classification of eosinophilic gastrointestinal diseases

Diagnosis of eosinophilic gastrointestinal diseases is based on morphological evaluation with regard to localization and density of eosinophil infiltration of the mucosa and/or deeper parts of the oesophagus, stomach, and bowel in biopsy or resection specimens. As with eosinophils in any tissue, in the majority of diseases they are probably a sequel of acute inflammation and do not indicate any specific disease. Eosinophil morphology includes intact cells with bilobated nuclei and eosinophil granules in the cytoplasm and extracellular tissue following activation/degranulation. There is no fixed number of eosinophils that can be used as a cut-off criterion to define disease. Associated histopathological features observed in eosinophilic gastrointestinal disease depend on the site of manifestation and primary disease. Eosinophils are typically increased in allergy-associated colitis in adults and allergic proctocolitis in infants, eosinophilic gastroenteritis and eosinophilic oesophagitis. Their presence can also suggest a drug-induced eosinophilia or the presence of a parasitic infection. In general, eosinophils are increased in inflammatory bowel disease (IBD). They are seen in reflux oesophagitis, coeliac disease, and microscopic and infectious colitis. Eosinophils may be a feature of polyarteriitis nodosa and Churg-Strauss syndrome, and can accompany connective-tissue disease as well as malignant lymphomas and adenocarcinomas of gastrointestinal mucosa.

Eosinophilic enteritis: CT features

We report CT features of four cases of Eosinophilic enteritis. The disease involves the jejunum in one case, the ileum in two cases, and the colon in the remaining case. Two cases demonstrate a predominantly mucosal type of eosinophilic enteritis, while the other two cases demonstrate a predominantly subserosal type. CT findings include bowel wall thickening in four cases, bowel fold thickening in two cases, layering of the bowel wall in two cases, luminal narrowing without obstruction in three cases, an intra-luminal granuloma mimicking a huge polyp in one case, an extra-luminal irregular granuloma markedly enhancing and slightly necrosing in one case, mesenteric lymphadenopathy with peripheral rim-like enhancement and marked necrosis in one case and ascites in one case. CT findings are more characteristic of an inflammatory disease rather than of a tumor, and these findings are helpful for assessing the extent and location of the disease. Moreover, combined with its typical clinical manifestations, CT findings may lead to the correct diagnosis.

Eosinophilic colitis

Eosinophilic colitis is a rare chronic inflammatory bowel condition of unknown etiology. We report a case of cecal volvulus causing obstruction in a patient with eosinophilic colitis. A 48-year-old lady presented with abdominal pain, constipation, and abdominal distension. Clinically and radiologically, she was diagnosed to have cecal volvulus. Preoperative colonoscopic reduction failed. At laparotomy, a right hemicolectomy with primary anastomosis was undertaken. Histology of the resected specimen showed diffuse eosinophilic infiltration suggesting eosinophilic colitis. To the best of our knowledge, this association has been never reported.

Los granulocitos eosinófilos: de residentes habituales de la mucosa gastrointestinal normal a protagonistas agresivos de la gastroenteritis eosinofílica

Because of their biological affinity for normal gastrointestinal (GI) mucosa, eosinophilic granulocytes are "normal residents" in the mucosa. This physiological GI eosinophilia translates into a state of "permanent normal inflammation", which means that the mucosa's local immune system is constantly confronted by dietary proteins and indigenous microorganisms. This eosinophilic infiltration of the GI mucosa is increased, reactively, in the course of local inflammatory processes, collagenosis, infections (especially helminthic infections), vasculitis, neoplasms and IgE-dependent allergic reactions to food. Lastly, GI eosinophilia that is clearly aggressive, both because of its intensity and its persistence, is what characterizes eosinophilic gastroenteritis. In the present article, we summarize the ethiopathogenic and clinico-epidemiological features of this process, as well as its position within the field of immunopathologic food intolerance.

Histologic study of colonic mucosa in patients with chronic diarrhea and normal colonoscopic findings

BACKGROUND

There are controversies about the importance of biopsies of normal colon mucosa in the investigation of patients with chronic diarrhea.

STUDY

Colonic and terminal ileum biopsies of 167 patients were reviewed. In 5 patients, used as controls, colonoscopy was done due to family history of colon cancer.

RESULTS

The 5 patients without symptoms had no histologic abnormalities. The histologic findings in 162 patients with chronic diarrhea were as follows: 110 patients (67.9%) with normal histology, microscopic colitis not otherwise specified, and isolated small granulomas; 17 (10.5%) patients had findings of borderline diagnostic significance, including possible collagenous colitis, some features of lymphocytic colitis and melanosis coli; and 35 (21.6%) patients, with diagnostic significant histologic findings as collagenous colitis, lymphocytic colitis, minimal change microscopic colitis, eosinophilic colitis, pericrypt eosinophilic enterocolitis, intestinal spirochetosis, schistosomiasis, and Crohn's disease. Of the 52 patients with either borderline or significant diagnostic abnormalities, in 8 (15.4%) the diagnosis was done only with a proximal study (ascending, transverse, or descending colons).

CONCLUSIONS

Histologic lesions of possible diagnostic value could exist in 32.1% of chronic diarrhea patients with normal colonoscopy, which can justify, in certain cases, mucosa biopsies, which might contribute for a more precise etiologic diagnosis; also, the distribution of these histologic changes has pointed out the importance of having all colon segments biopsied.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare gastrointestinal (GI) disorder of undetermined cause characterized by infiltration of eosinophils in the GI tract. Eosinophils accumulate in tissues and may release highly cytotoxic granular proteins, which cause severe tissue damage characteristic of eosinophilic gastroenteritis. Eotaxin may play a role in the recruitment of eosinophils into tissue in combination with chemoattractants and cytokines, including interleukin 3 and 5 and granulocyte-macrophage colony-stimulating factor. Food allergy, especially in children, can be a triggering factor, and an amino acid-based diet may be helpful. Accumulation of eosinophils in the gut is a common feature in food-induced GI disorders that can be regulated through a complex molecular network involving Th2 cells, various cytokines, and chemokines. Eosinophilic gastroenteritis has a wide spectrum of clinical presentation depending on the site of involvement. It may be confused with irritable bowel syndrome or dyspepsia and, rarely, mimics pancreatitis or appendicitis. Diagnosis is important and is usually made by a pathologist. Eosinophilic gastroenteritis is a treatable disease; patients generally respond to steroid therapy, although relapse is common. Non-enteric-coated budesonide, a locally acting corticosteroid with little risk of adrenal suppression, may be substituted, although more experience is needed. Promising new drugs for eosinophilic gastroenteritis include montelukast, a selective leukotriene receptor antagonist, and suplaplast tosilate, a selective Th2 cytokine inhibitor with inhibitory effects on allergy-induced eosinophilic infiltration and IgE production. Although it is likely a separate disease, more experience has accumulated, and an elimination or specific amino acid-based diet appears to be helpful in treatment.

The usefulness of Tc-99m HMPAO labeled WBC SPECT in eosinophilic gastroenteritis

Tc-99m HMPAO labeled WBC SPECT was performed in 5 patients with eosinophilic gastroenteritis before and after successful medical therapy. The imaging findings were graded according to the following imaging scheme; grade 0, no uptake; grade 1, uptake < bone marrow; grade 2, uptake < liver; grade 3, uptake > liver. In no patient was the diagnosis made radiologically or with colonoscopy. The sites of involvement were identified with Tc-99m HMPAO WBC imaging in all patients before treatment and the radionuclide imaging studies were all negative after therapy.

Deposits of eosinophil granule proteins in eosinophilic cholecystitis and eosinophilic colitis associated with hypereosinophilic syndrome

A case of hypereosinophilic syndrome with eosinophilic colitis, eosinophilic cholecystitis, and increased serum levels of interleukin-5 (IL-5) and soluble interleukin-2 receptor (sIL-2R) is reported. Immunohistochemical studies of cholecystectomy and colon biopsy specimens with monoclonal antibodies, which are specific for activated eosinophils, secreted eosinophil cationic protein (ECP) and for major basic protein (MBP), demonstrated the presence of numerous activated eosinophils, secretion of ECP, and deposition of MBP in areas of tissue damage. These findings suggest that in eosinophilic cholecystitis and eosinophilic colitis, activated eosinophils infiltrate and degranulate in each tissue, releasing eosinophil granule proteins that produce tissue damage.

A case of Churg-Strauss syndrome: tissue diagnosis established by sigmoidoscopic rectal biopsy

A case is presented of Churg-Strauss syndrome in a young man in whom the definitive diagnostic procedure was a full thickness sigmoidoscopic rectal biopsy, with submucosal sampling. Gastrointestinal changes in Churg-Strauss syndrome, a rare systemic illness characterised by asthma, blood and tissue eosinophilia, vasculitis, and granulomatous inflammation are common but poorly reported. The endoscopic and histopathological features of a case are described and emphasise the potential value of a limited sigmoidoscopy in establishing the diagnosis, when lower gastrointestinal symptoms are present.

Eosinophilic gastro-enteritis associated with protein-losing enteropathy and protein C deficiency

Reported below is a case of eosinophilic gastro-enteritis involving the colon, stomach and duodenum in a patient who was also found to have marked hypoalbuminaemia and protein C deficiency due to severe protein-losing enteropathy. The most recent literature is reviewed and the challenging differential diagnosis of the disease is discussed.

Radiographic manifestations of eosinophilic gastroenteritis

Eosinophilic gastroenteritis (EG) is a rare inflammatory disease of unknown etiology, characterized by focal or diffuse eosinophilic infiltration of the gastrointestinal tract. Although little over 250 cases of EG have been reported in the literature, EG is probably more common than reports in the literature would indicate. A retrospective review of 25 patients with EG along with a review of the literature was done to identify clinical, laboratory, radiographic, and therapeutic features. An allergic disorder was present in 14 (56%) and a peripheral eosinophilia was present in 24 (96%) of our patients. The most common radiographic manifestations of the stomach and small bowel included stenosis and fold thickening, respectively. Thirteen patients had esophageal involvement, with the esophageal stricture being the most common abnormality found in these patients. Steroids produced a good therapeutic result in most patients; the remaining patients responded to cromolyn and/or surgery.

Eosinophilic gastroenteritis presenting with colitis and cholangitis

Eosinophilic gastroenteritis (EG) is a rare condition that most commonly affects the stomach and intestine. Large bowel involvement has also been described. We report a case of EG presenting with colitis and cholangitis. This is the first case of associated cholangitis demonstrated radiologically and histologically. Simultaneous biliary and gastrointestinal tract involvement suggest a common link between EG and hypereosinophilic syndrome (HES). However, HES requires high peripheral hypereosinophilia and several organs including gastrointestinal tract, lung, heart, infiltrated with eosinophils. The patient's condition improved with corticosteroids.

Eosinophilic enterocolitis diagnosed by means of technetium-99m albumin scintigraphy and treated with budesonide (CIR)

A patient with a 15 year history of diarrhoea of unknown origin is described. Scintigraphy with technetium-99m labelled albumin suggested albumin loss at the terminal ileum and caecum; subsequent colonoscopic biopsies of these macroscopically normal looking areas showed abundant infiltration with eosinophils. A diagnosis of eosinophilic enterocolitis was made. Treatment with prednisolone had good results, but had to be stopped because of severe side effects. Oral cromoglycate and mesalazine were not effective. Budesonide (CIR), a new topically active corticosteroid with very little systemic effects, was at least as effective as prednisolone without producing side effects.

Localized eosinophilic gastroenteritis with necrotizing granulomas presenting as acute abdomen

Eosinophilic gastroenteritis is a condition of unknown aetiology that has been frequently reported involving the stomach and bowel. The colon is rarely cited as a site for the condition. We report a patient suffering from allergic symptoms (asthma, atopic dermatitis, elevated serum IgE levels) who presented with colonic perforation due to eosinophilic colitis with necrotizing granulomas.

Collagenous colitis, eosinophilic colitis, and neutropenic colitis

Neutropenic colitis is a complication of the treatment of hematologic malignancies and, less commonly, of other disease entities. The septic, inflammatory process has a predilection for the terminal ileum and right colon. While the pathogenesis is not clear, mucosal injury caused by several different mechanisms and local opportunistic infection play significant roles. An association has been recognized between neutropenic colitis and sepsis caused by C. septicum. Patients present with fever, diarrhea, and acute abdominal pain and tenderness often localized in the right lower quadrant. Sonography and CT are helpful in demonstrating colonic wall thickening and pericolic fluid. Peritoneal lavage has been used to exclude perforation in these critically ill patients. Although there has been debate about whether medical or operative management is best, the optimal initial therapy includes supportive care with gastric decompression, fluid and blood product replacement, and broad-spectrum antibiotics. The indications for surgery include continued intestinal bleeding despite correction of coagulopathy and pancytopenia, free intraperitoneal air, and uncontrolled sepsis. At operation, a right colectomy with ileostomy and mucous fistula or, in selected patients, primary anastomosis is the procedure of choice. Timely return of functioning neutrophils and the eventual prognosis of the primary disease are crucial to the overall success or failure of treatment of neutropenic colitis.

Colitis caused by food allergy in infants

Thirteen infants with eosinophilic colitis caused by food allergy were reviewed after five to 10 years. By the age of 5 years most foods were tolerated. The colon was normal in the one child re-examined. There was an atopic association, but no family history of classical inflammatory bowel disease. Allergic colitis is a temporary disorder of early childhood.

Near fatal eosinophilic gastroenteritis responding to oral sodium chromoglycate

Eosinophilic gastroenteritis (EG) is an uncommon disorder, characterised by cramping abdominal pain, diarrhoea and vomiting and histologically by eosinophilic infiltration of bowel wall. We present a patient who developed EG during the course of a systemic, necrotising vasculitis, who became critically ill after failure of treatment with corticosteroids and cytotoxic drugs and responded only to oral sodium chromoglycate.

Eosinophilic gastroenteritis presenting in an adolescent with isolated colonic involvement

Eosinophilic gastroenteritis most commonly involves the stomach and proximal small intestine with eosinophilic inflammation of either the mucosa, submucosa or serosa. The patient reported here had isolated eosinophilic colitis. The initial presentation with iron deficiency anaemia owing to occult gastrointestinal blood loss emphasises the need to evaluate the entire gastrointestinal tract in patients with eosinophilic gastroenteritis.