Eosinophilic colitis

Current and Novel Therapies for Eosinophilic Gastrointestinal Diseases

Eosinophilic gastrointestinal diseases (EGIDs) are an emerging group of pathological entities characterized by an eosinophil-predominant infiltration of different tracts of the gut in the absence of secondary causes of eosinophilia. According to the specific tract of the gut involved, EGIDs can be classified into eosinophilic esophagitis (EoE), eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The epidemiology of EGIDs is evolving rapidly. EoE, once considered a rare disease, now has an incidence and prevalence of 7.7 new cases per 100,000 inhabitants per years and 34.4 cases per 100,000 inhabitants per year, respectively. Fewer data are available regarding non-EoE EGIDs, whose prevalence are estimated to range between 2.1 and 17.6 in 100,000 individuals, depending on age, sex, and ethnicity. Diagnosis requires the presence of suggestive symptoms, endoscopic biopsies showing abnormal values of eosinophils infiltrating the gut, and exclusion of secondary causes of eosinophilia. EoE typically presents with dysphagia and episodes of food bolus impactions, while EoG, EoN, and EoC may all present with abdominal pain and diarrhea, with or without other non-specific symptoms. In addition, although different EGIDs are currently classified as different entities, there may be overlap between different diseases in the same patient. Despite EGIDs being relatively novel pathological entities, the research on possible treatments is rapidly growing. In this regard, several randomized controlled trials are currently ongoing to investigate novel molecules, including ad-hoc steroid formulations, immunosuppressants, and mostly monoclonal antibodies that target the specific molecular mediators of EGIDs. This narrative review provides an up-to-date overview of available and investigational drugs for different EGIDs.

Treatment of primary eosinophilic colitis using immunoglobulin/histamine complex

Primary eosinophilic colitis (PEC) is a primary eosinophilic gastrointestinal disorder, and immunoglobulin/histamine complex (IHC) may be an effective therapeutic for PEC. IHC has a nonallergen-specific antinociceptive effect in the treatment of histamine-mediated pain.

Clinical Characteristics and Outcomes of Eosinophilic Colitis in Patients With Cancer

BACKGROUND

Eosinophilic colitis (EoC) is a rare form of eosinophilic gastrointestinal disease characterized by diffuse eosinophilic infiltration in the deep lamina propria of colonic mucosa. The pathophysiology is unclear, but EoC has been associated with multiple known risk factors.

AIM

The aim of this study was to characterize the clinical characteristics and disease course of patients with EoC at a major cancer center.

MATERIAL AND METHODS

We retrospectively reviewed colonic samples obtained between January 2000 and December 2018 from our institutional database and included cases with significant colonic eosinophilia. Baseline clinical data and EoC-related clinical course and outcomes were documented.

RESULTS

Forty-one patients were included. One fourth had coexisting autoimmune conditions. Seventy-eight percent had a cancer diagnosis. Half the patients received chemotherapy, with a median duration of 180 days between chemotherapy and EoC onset. Symptoms were present in 76% of patients. Diarrhea was more prevalent in patients who received chemotherapy (85% vs. 42%). Median duration of EoC symptoms was 30 days in patients with cancer and 240 days in those without cancer (P=0.03). Most patients (88%) had normal colonoscopy findings. Fifteen percent of patients required hospitalization. All-cause mortality was 37%, mostly related to underlying malignancy and organ failure.

CONCLUSIONS

EoC in cancer patients appears to have more diarrhea-predominant symptoms, particularly in patients receiving chemotherapy, but a shorter disease duration compared with patients without cancer. Hospitalization can be required for serious cases. Treatment may be reserved for patients requiring symptom management, as most patients with EoC have good clinical outcomes regardless of treatment.

Eosinophilic Colitis that Presented with Subepithelial Tumor-like Lesions

Eosinophilic colitis is a rare disease that is characterized by eosinophilic infiltration in the colon wall in symptomatic patients. Thus far, the epidemiology and pathophysiology of eosinophilic colitis have not been well defined, but the hypersensitivity response is likely to play a role in its pathogenesis. The clinical presentation of eosinophilic colitis is usually nonspecific and depends on the layer of the intestinal wall affected by the eosinophilic infiltrate. Eosinophilic colitis is diagnosed generally by exclusion, i.e., after all other causes of eosinophilic infiltration have been excluded. Although there is no consensus over its diagnostic criteria, the laboratory results and radiology and endoscopy findings can provide important diagnostic evidence. This paper reports a case of eosinophilic colitis presenting as subepithelial tumor-like lesions in a 41-year-old man with the chief complaints of abdominal pain and loose stools. The patient had no diseases and no food or drug allergies in his medical history. In general, the endoscopic findings of eosinophilic colitis can vary from a normal mucosa to frank ulcerations. In this case, however, endoscopy revealed subepithelial tumor-like lesions. The colon biopsy showed eosinophilic infiltration in the lamina propria. The patient was treated with steroids, and his symptoms regressed with no signs of relapse.

Eosinophilic colitis in adults

Eosinophilic colitis (EoC) is a pathological entity associated with abnormal infiltration of colonic mucosa by eosinophilic polynuclear cells (Eo). This is a relatively common pathology in infants and children under 2 years old, but is more rare and has been less studied in adults. EoC can be classified as primary or secondary. Primary EoC is, in the majority of cases, related to an allergic reaction, either IgE-mediated and capable of causing an anaphylactic-type food allergy, or not mediated by IgE and capable of giving rise to food enteropathy. The symptoms for adults with EoC are variable and non-specific, diarrhoea and abdominal pain being the most common signs. There is no histological consensus for the diagnosis of EoC. The presence of over 40 Eo per high-power field (×400) in at least two different colonic segments could be suggested as the criterion for the diagnosis. In adults with primary EoC, skin tests are of limited value and the response to a restrictive diet is less effective than in young children, given that IgE or non-IgE-mediated allergic reactions are rarely identified and EoC generally require medical treatment. There is no consensus on the treatment of EoC, but the potential efficacy of corticosteroids and budesonide has been demonstrated in the vast majority of cases studied.

Eosinophilic colitis: A clinical review

Eosinophilic colitis is a rare entity characterized by the presence of a high eosinophilic infiltrate into the colonic wall in symptomatic patients, more often presenting with abdominal pain or diarrhea. These characteristics distinguish eosinophilic colitis from primary colonic eosinophilia, in which patients are asymptomatic. Primary colonic eosinophilia does not need any therapy, while eosinophilic colitis requires a strict treatment, similar to that of the more codified chronic intestinal inflammatory diseases. To date the lack of codified guidelines regarding the diagnostic criteria and the eosinophil threshold values for each colonic segment are the main diagnostic challenge for eosinophilic colitis. In addition, eosinophilic colitis is a diagnosis of exclusion, once all other causes of colonic eosinophilia (food allergens, infections, drugs, etc.) have been excluded. Several treatment options are available for eosinophilic colitis, although the evidence for most of them is limited to case reports and small case series. We examine the epidemiology, etiology, pathophysiology, diagnostic criteria and therapeutic options of eosinophilic colitis reporting recent evidence from the current literature.

Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review

Eosinophilic gastrointestinal disorders, including eosinophilic esophagitis, gastroenteritis, and colitis, refer to a spectrum of clinical diseases that present with variable degrees of infiltration of the gastrointestinal tract by eosinophils in the absence of other known causes of tissue eosinophilia. Clinical symptoms and laboratory findings are usually non-specific and may or may not be accompanied by peripheral blood eosinophilia. The extent of eosinophilic infiltration of the gastrointestinal wall varies from mucosal to transmural and serosal involvement. Diagnosis requires presence of gastrointestinal symptoms, demonstration of gastrointestinal eosinophilia by biopsy, and exclusion of other known causes of tissue eosinophilia. Many studies have pointed toward the eosinophil as the major offender; however, the exact functional role of the eosinophil in the pathogenesis of eosinophilic gastrointestinal disorders remains unclear. The roles of T-helper-2 cytokines and other mediators, such as eotaxin-1 and interleukin-5, have gained significant importance in the pathobiology of eosinophilic gastrointestinal disorders. Current understanding of treatment is based on case reports and a few case series, as there is a lack of large prospective studies. Steroids are currently the mainstay of therapy, but the roles of other drugs such as leukotriene inhibitors, mast cell stabilizers, interleukin-5 inhibitors, and anti-immunoglobulin E, along with other targets in the immune pathway, are currently being explored.

Eosinophilic colitis is a sporadic self-limited disease of middle-aged people: a population-based study

AIM

Eosinophilic colitis (EC) is a rare manifestation of eosinophilic gastrointestinal disorders. Due to its rarity, little information is available on its natural history.

METHOD

From the single population-based pathology database of the Calgary Health Region (comprising a population of 1.28 million in 2008), cases of EC during the period 1996-2008 were identified. Medical records of all adults diagnosed with EC were identified and the pathology reviewed. The patients were then contacted for follow-up using a standardized questionnaire.

RESULTS

Seven cases of EC (four in women) were identified, with a median follow-up of 45 (23-79) months. The median age at diagnosis was 42 (22-70) years. Symptoms at diagnosis were abdominal pain (86%), nonbloody diarrhoea (57%), bloody diarrhoea (29%) and significant (>10%) weight loss (29%). Three patients gave a history of allergic reactions to drugs and four reported allergy to cows' milk. Endoscopic findings were nonspecific, ranging from oedema to small aphthous ulceration. An eosinophilic infiltrate was identified in the lamina propria in the initial colonic biopsy in all patients. Over the longer term, three patients experienced spontaneous resolution without treatment. Two continued to have mild diarrhoea and abdominal cramps but did not require medical therapy. Two patients required medical treatment by 5-aminosalicylic acid, with one requiring prednisone and azathioprine maintenance therapy.

CONCLUSION

Eosinophilic colitis is a rare mostly self-limiting disease affecting middle-aged adults. It usually has a mild clinical course and drug treatment is not usually necessary. When required, drug treatment follows the standard medication for other inflammatory bowel disease.

CT imaging features of eosinophilic colitis in children

BACKGROUND

Eosinophilic colitis (EC) is a gastrointestinal disease of undetermined etiology whose clinical features overlap with those of the inflammatory bowel diseases. To the best of our knowledge, the CT imaging features of EC have not been described in children.

OBJECTIVE

To report and analyze the clinical, imaging and histological findings in seven children with EC.

MATERIALS AND METHODS

Children with EC were identified in a pediatric pathology database, and those with CT imaging within 2 months of diagnosis were included, totaling seven children. Clinical, imaging and pathological features were reviewed and analyzed.

RESULTS

The most common presenting symptoms were abdominal pain, bloody diarrhea and rectal bleeding. EC was characterized as a dense and predominantly eosinophilic inflammatory infiltrate in the lamina propria or epithelium without granulomas. CT scans were abnormal in six children (86%), demonstrating colonic wall thickening, predominantly cecal, in five (71%), mild to moderate terminal ileal thickening in two (29%), and pneumatosis in one (14%). Right colonic involvement was greater than terminal ileal involvement.

CONCLUSION

CT imaging findings in children with EC include right colonic wall thickening of variable extent downstream and absent or mild involvement of the terminal ileum. EC should be considered in the differential diagnosis in children presenting with abdominal pain and bloody diarrhea.

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 colitis: epidemiology, clinical features, and current management

Primary eosinophilic gastrointestinal disorders (EGIDs) represent a spectrum of inflammatory gastrointestinal disorders in which eosinophils infiltrate the gut in the absence of known causes for such tissue eosinophilia. EGIDs can be subgrouped as eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis (EC). The least frequent manifestation of EGIDs is EC. EC is a heterogeneous entity with a bimodal age distribution, presenting with either an acute self-limited bloody diarrhea in otherwise healthy infants or as a more chronic relapsing colitis in young adults. The pathophysiology of primary EC appears related to altered hypersensitivity, principally as a food allergy in infants and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. In adults, symptoms include diarrhea, abdominal pain, and weight loss. Endoscopic changes are generally modest, featuring edema and patchy granularity. Although standardized criteria are not yet established, the diagnosis of EC depends on histopathology that identifies an excess of eosinophils. Therapeutic approaches are based on case reports and small case series, as prospective randomized controlled trials are lacking. Eosinophilic colitis in infants is a rather benign, frequently food-related entity and dietary elimination of the aggressor often resolves the disorder within days. Adolescent or older patients require more aggressive medical management including: glucocorticoids, anti-histamines, leukotriene receptors antagonists as well as novel approaches employing biologics that target interleukin-5 (IL-5) and IgE. This review article summarizes the current knowledge of EC, its epidemiology, clinical manifestations, diagnosis, and treatment.

Histopathologic diagnosis of eosinophilic conditions in the gastrointestinal tract

Eosinophils, a constitutive component of the columnar-lined gastrointestinal tract, play an essential role in allergic responses and parasitic infections. The tissue density of these cells also increases in a variety of conditions of uncertain etiology. With the exception of the esophageal squamous epithelium, in which no eosinophils are normally present, the population of normal eosinophils in the remainder of the luminal gut is poorly defined. Therefore, histopathologists must rely on their subjective judgment to determine when a diagnosis of eosinophilic gastritis, enteritis, or colitis should be rendered. Eosinophilic esophagitis is currently the best defined and most studied eosinophilic condition of the digestive tract; therefore, the confidence in accurate diagnosis is increasing. In contrast, the characteristic clinicopathologic features of eosinophilic conditions affecting other parts of the digestive tract remain somewhat elusive. This review was designed to present pathologists with simple and practical information for the biopsy-based histopathologic diagnosis of eosinophilic esophagitis, gastritis, enteritis, and colitis. It was prepared by critically reviewing more than 200 articles on the topic, along with incorporating evidence accumulated through our own collective experience. We anticipate that by increasing pathologists' confidence in reporting these abnormal but often nameless eosinophilic infiltrates, we can help better define and characterize their significance.

Eosinophilic colitis: an update on pathophysiology and treatment

BACKGROUND

Primary eosinophilic gastrointestinal disorders, a spectrum of inflammatory conditions, occurs when eosinophils selectively infiltrate the gut in the absence of known causes for such tissue eosinophilia. These may be classified into eosinophilic esophagitis, eosinophilic gastroenteritis and eosinophilic colitis (EC). This review focuses on EC: its pathogenesis, epidemiology, clinical presentation, diagnosis and current approach to treatment.

SOURCES OF DATA

A literature review published in English was performed using Pubmed, Ovid, Google scholar search engines with the following keywords: eosinophilic gastrointestinal disorder, EC, eosinophils, colitis and gastrointestinal.

AREAS OF AGREEMENT

The basis for primary EC appears related to increased sensitivity to allergens, principally as a food allergy in infants and a T lymphocyte-mediated event in adults. Endoscopic changes are generally modest, featuring edema and patchy granularity.

AREAS OF CONTROVERSY

Clear clinical and pathological diagnostic criteria of EC and its management strategy.

GROWING POINTS

Intestinal involvement of EC is primarily mucosal, presenting as a mild self-limited proctitis in infants and self-limited colitis in young adults. Therapeutic approaches based on case reports tend to use either elimination diets to avoid a presumed allergen; agents traditionally used in inflammatory disease or targeted drugs like anti-histamines or leukotriene receptor antagonists.

AREAS TIMELY FOR DEVELOPING RESEARCH

Prospective randomized controlled trials addressing the disease natural history, possible preventive methods and effective medical approach and long-term prognosis are required.

Eosinophilic digestive diseases: eosinophilic esophagitis, gastroenteritis, and colitis

Eosinophilic digestive diseases (EDD) are relatively rare disorders associated with increased gastrointestinal eosinophilic infiltrates without any underlying primary etiology. The pathophysiology of EDD is unclear, but is suspected to be related to a hypersensitivity reaction given its correlation with other atopic disorders and clinical response to corticosteroid therapy. Given the overall relative increase of various atopic conditions, it is important for clinicians to understand the presentation and diagnosis and treatment options available. We present here a review of EDD, including the proposed pathophysiology, diagnosis and current treatment options for these disorders.

Eosinophilic colitis

Eosinophilic colitis (EC) is a rare form of primary eosinophilic gastrointestinal disease with a bimodal peak of prevalence in neonates and young adults. EC remains a little understood condition in contrast to the increasingly recognized eosinophilic esophagitis. Clinical presentation of EC is highly variable according to mucosal, transmural, or serosal predominance of inflammation. EC has a broad differential diagnosis because colon tissue eosinophilia often occurs in parasitic infection, drug-induced allergic reactions, inflammatory bowel disease, and various connective tissue disorders, which require thorough searching for secondary causes that may be specifically treated with antibiotics or dietary and drug elimination. Like eosinophilic gastrointestinal disease involving other segments of the gastrointestinal tract, EC responds very well to steroids that may be spared by using antihistamines, leukotriene inhibitors and biologics.

Abdominal pain in an adult with Type 2 diabetes: A case report

Introduction

Chronic abdominal pain (CAP) may be a manifestation of diseases involving many intra-abdominal organs. Beside diseases affecting subjects without diabetes mellitus, diabetic patients may have CAP due to diabetes-related complications like neuritis, motor diseases of the gastrointestinal tract and autonomic dysfunction. Atherosclerosis is 2–4 times more common in patients with diabetes and affects mainly carotid, coronary, iliac and lower limb arteries as well as aorta. Another less common complication is chronic mesenteric ischemia (CMI, intestinal angina), caused by atherosclerotic obstruction of the celiac artery and its branches and results in episodic or constant intestinal hypoperfusion.

Case presentation

We present a case of a diabetic patient with CMI in whom the diagnosis was delayed by almost 5 years. The dominant symptoms were crampy abdominal postprandial pain, anorexia, changes in bowel habits and cachexia. Conventional angiography revealed significant stenosis of the celiac artery and complete obstruction of the inferior mesenteric artery. Noteworthy, no significant stenoses in carotids or limbs' arteries were found. Revascularization resulted in clinical improvement 1 week post-intervention.

Conclusion

CAP in patients with diabetes may be due to CMI. The typical presentation is crampy postprandial abdominal pain in a heavy smoker male patient with long-standing diabetes, accompanied by anorexia, changes in bowel habits and mild to moderate weight loss. At least two of the three main splanchnic arteries must be significantly occluded in order CMI to be symptomatic. The diagnostic procedure of choice is conventional angiography and revascularization of the occluded arteries is the radical treatment.