Idiopathic eosinophilic gastrointestinal diseases in adults

Clinical significance of direct fast scarlet staining on the diagnosis of eosinophilic colitis: A comparative study focusing on the eosinophil degranulation in colonic mucosal tissue

This study aimed to validate the DFS (direct fast scarlet) staining in the diagnosis of EC (eosinophilic colitis). The study included 50 patients with EC and 60 with control colons. Among the 60 control samples, 39 and 21 were collected from the ascending and descending colons, respectively. We compared the median number of eosinophils and frequency of eosinophil degranulation by HE (hematoxylin and eosin) and DFS staining between the EC and control groups. In the right hemi-colon, eosinophil count by HE was useful in distinguishing between EC and control (41.5 vs. 26.0 cells/HPF, p < 0.001), but the ideal cutoff value is 27.5 cells/HPF (high-power field). However, this method is not useful in the left hemi-colon (12.5 vs. 13.0 cells/HPF, p = 0.990). The presence of degranulation by DFS allows us to distinguish between the groups even in the left hemi-colon (58% vs. 5%, p < 0.001). DFS staining also enabled a more accurate determination of degranulation than HE. According to the current standard to diagnose EC (count by HE staining ≥20 cells/HPF), mucosal sampling from left hemi-colon is problematic since the number of eosinophils could not be increased even in EC. Determination of degranulated eosinophils by DFS may potentiate the diagnostic performance even in such conditions.

Eosinophilic gastroenteritis with abdominal pain and ascites: A case report

BACKGROUND

Eosinophilic gastroenteritis (EGE) is a rare disease that presents many unspecific gastroenterological symptoms. The disease includes three types depending on the depth of eosinophil infiltration in the gastrointestinal tract. The serosal type is the most rare, presenting as ascites.

CASE SUMMARY

A 34-year-old man presented with abdominal pain, diarrhea without bloody stool, or nausea. Laboratory test results revealed a peripheral blood eosinophil count (4.85 × 10⁹/L), which was remarkedly elevated. Computed tomography scan demonstrated extensive intestinal wall edema thickening in the duodenum, jejunum, ascending colon and transverse colon; multiple exudative effusion surrounding the intestinal tract, and ascites in the abdominal cavity. A series of examinations excluded eosinophil elevation in secondary diseases. Endoscopic multipoint biopsy detected eosinophilic infiltration in the mucous layer of the transverse colon, with ≥ 50 eosinophils/high power field. All symptoms vanished after a few days of steroid therapy and ascites disappeared within 2 wk.

CONCLUSION

EGE should be considered in patients with abdominal pain, ascites, and eosinophilia. Multiple point biopsies are essential for diagnosis.

Upper Gastrointestinal Bleed in a Young Male- A Rare Presentation of Eosinophilic Gastroenteritis

Eosinophilic gastroenteritis (EGE) is a rare idiopathic disease affecting multiple organs (stomach and small intestine) of the digestive tract. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract disease. The prevalence of this condition is ranging from 8 and 28 per 100,000. We present a rare presentation of EGE manifesting as upper GI bleeding.  A 28-year-old male with PMH of EGE, duodenal ulcers, and stricture presented to the hospital with the chief complaints of three episodes of dizziness and melena over one day. His home medications included prednisone, montelukast, and pantoprazole. On admission, he was found to be tachycardic (150) while other vital signs were stable. Physical examination revealed cold, pale and clammy skin but was otherwise normal on examination. Initial labs showed hemoglobin (hgb) of 9.3. His hospital course was complicated with 1 episode of large volume hematemesis >1.5 L and brief loss of consciousness for which a code rapid response was called. On day 2, the hgb dropped to 5.7 and the patient received a blood transfusion. Emergent endoscopy (EGD) revealed high-grade duodenal stenosis, severe pyloroduodenal deformity and a duodenal ulcer with the visible vessel. Two clips were deployed blindly. Epinephrine could not be injected due to hard and fibrotic tissue around duodenal stenosis. The Interventional Radiology team was consulted and emergent angiography was done which revealed active bleeding from a branch of the gastric artery. Embolization was done and hemostasis was achieved successfully. He needed 5 units of PRBC transfusion in total. He was treated with pantoprazole twice a day intravenously since admission. For his known duodenal stricture, the surgical team was consulted. No acute surgical intervention was recommended. On discharge, he was sent home with pantoprazole 40 mg twice a day, slow tapering of prednisone and close follow up with gastroenterology, surgery, and primary care doctor within 1 week. The purpose of this case report is to increase awareness about this clinical condition among medical professionals.

Non-IgE Mediated Food Allergy

Food allergies, defined as an immune response to food proteins, affect as many as 8% of young children and 2% of adults in western countries, and their prevalence appears to be rising like all allergic diseases. In addition to well-recognized urticaria and anaphylaxis triggered by IgE antibody- mediated immune responses, there is an increasing recognition of cell-mediated disorders, such as eosinophilic esophagitis and food protein-induced enterocolitis. Non-IgE-Mediated gastrointestinal food allergies are a heterogeneous group of food allergies in which there is an immune reaction against food but the primary pathogenesis is not a production of IgE and activation of mast cells and basophils. Those diseases tend to affect mainly the gastrointestinal tract and can present as acute (FPIES) or chronic reaction, such as Eosinophilic Esophagitis (EoE), Food Protein-Induced Allergic Proctocolitis (FPIAP). The role of food allergy in Non-EoE gastrointestinal Eosinophilic disorders (Non- EoE EGID) is poorly understood. In some diseases like EoE, T cell seems to play a major role in initiating the immunological reaction against food, however, in FPIES and FPIAP, the mechanism of sensitization is not clear. Diagnosis requires food challenges and/or endoscopies in most of the patients, as there are no validated biomarkers that can be used for monitoring or diagnosis of Non-IgE mediated food allergies. The treatment of Non-IgE food allergy is dependent on diet (FPIES, and EoE) and/or use of drugs (i.e. steroids, PPI) in EoE and Non-EoE EGID. Non-IgE mediated food allergies are being being investigated.

A Prospective Study on the Prevalence, Extent of Disease and Outcome of Eosinophilic Gastroenteritis in Patients Presenting with Lower Abdominal Symptoms

Background/Aims

The epidemiology of eosinophilic gastroenteritis remains unclear. We aim to determine the prevalence of eosinophilic gastroenteritis in patients with lower abdominal symptoms.

Methods

In a prospective study, colonoscopy was performed on 2,469 consecutive patients. Biopsies were taken from the terminal ileum and ascending, transverse, descending and sigmoid colon in all patients.

Results

Sixty-four of the 2,469 patients (2.6%) had eosinophilic gastroenteritis. Only five of the 64 patients (7.8%) with eosinophilic gastroenteritis had endoscopic mucosal abnormalities during colonoscopy. Six of these 64 patients (9.4%) had severe disease at presentation, and seven of these 64 patients (10.9%) required systemic steroid treatment. An elevated absolute peripheral eosinophil count was independently associated with severe disease at presentation (4/6 [66.7%] vs 3/58 [5.2%], p=0.005; odds ratio [OR], 25.320; 95% confidence interval [CI], 2.628 to 243.910), and severe disease at the time of presentation was independently associated with the use of systemic steroid treatment (6/7 [85.7%] vs 0/57 [0%], p=0.008; OR, 18.021; 95% CI, 2.163 to 150.152).

Conclusions

The prevalence of eosinophilic gastroenteritis is common, and patients usually present normal-appearing mucosa on colonoscopy. Those with severe disease at presentation usually have a raised absolute peripheral eosinophil count and should be commenced on systemic steroids as an initial therapy.

Expanding and characterizing esophageal epithelial cells obtained from children with eosinophilic esophagitis

BACKGROUND

The role of epithelial cells in eosinophilic esophagitis (EoE) is not well understood. In this study, our aim was to isolate, culture, and expand esophageal epithelial cells obtained from patients with or without EoE and characterize differences observed over time in culture.

METHODS

Biopsies were obtained at the time of endoscopy from children with EoE or suspected to have EoE. We established patient-derived esophageal epithelial cell (PDEEC) lines utilizing conditional reprogramming methods. We determined integrin profiles, gene expression, MHC class II expression, and reactivity to antigen stimulation.

RESULTS

The PDEECs were found to maintain their phenotype over several passages. There were differences in integrin profiles and gene expression levels in EoE-Active compared to normal controls and EoE-Remission patients. Once stimulated with antigens, PDEECs express MHC class II molecules on their surface, and when co-cultured with autologous T-cells, there is increased IL-6 and TNF-α secretion in EoE-Active patients vs. controls.

CONCLUSION

We are able to isolate, culture, and expand esophageal epithelial cells from pediatric patients with and without EoE. Once stimulated with antigens, these cells express MHC class II molecules and behave as non-professional antigen-presenting cells. This method will help us in developing an ex vivo, individualized, patient-specific model for diagnostic testing for causative antigens.

Massive hemorrhagic ascites: A rare presentation of eosinophilic gastroenteritis

According to Klein’s classification system, the symptomatology of eosinophilic gastroenteritis (EG), a rare disease, differs based on the affected tissue layer. Patients with subserosal EG often have peritoneal effusion. Hemorrhagic ascites due to EG is extremely rare and has not been reported in the literature. Here, we report a 57-year-old woman with EG and massive hemorrhagic ascites. Laboratory investigations showed elevated peripheral eosinophils with significant eosinophilia (65.6%). Ultrasonography showed massive abdominal ascites. Abdominal paracentesis revealed hemorrhagic peritoneal fluid and microscopy showed predominant eosinophils. Upper gastrointestinal endoscopy revealed erosions, exudates, and mucosal rings in the duodenal mucosa; histological examination indicated eosinophilic infiltration. EG presenting with hemorrhagic ascites was diagnosed by histologic examination of eosinophilic infiltration. She was empirically treated with ketotifen 1 mg bid po with rapid resolution of ascites and a remarkable decline in peripheral eosinophil counts. Clinicians should consider the differential diagnosis of unexplained hemorrhagic ascites.

Eosinophilic gastrointestinal diseases beyond eosinophilic esophagitis

OBJECTIVE

Eosinophilic gastrointestinal diseases (EGIDs) are a rare group of disorders that can have varied clinical presentations dependent on the involved segment within the gastrointestinal tract. Eosinophilic gastritis presents with abdominal pain or vomiting, eosinophilic gastroenteritis presents with diarrhea and anemia or hypoalbuminemia, and eosinophilic colitis can present with diarrhea or bloody stools. These nonspecific symptoms remain poorly understood in their relation to the underlying pathogenesis, but a significant percentage of patients have atopy. In this review, we discuss the current literature on EGIDs to promote a practical approach to diagnosis and care.

DATA SOURCES

Review of published literature.

STUDY SELECTIONS

Clinically relevant literature from 1900 through 2018 was obtained from a PubMed search. Those that addressed prevalence, diagnosis, clinical manifestations, natural history, and treatment of EGIDs were reviewed and are summarized in this article.

RESULTS

Of the 485 articles found in the search, most of which were case reports, 71 were selected for review. The natural history of EGIDs is based primarily on case series and small numbers of patients, making therapeutic decisions difficult. Treatment remains limited to dietary restriction that is not effective in many patients and topical or systemic corticosteroids whose long-term use is to be avoided if possible.

CONCLUSION

With the seeming increase in all types of EGIDs, phenotypic descriptions are emerging that will likely promote better understanding of the pathogenesis and identification of novel therapeutic targets.

Eosinophilic gastroenteritis presenting as upper gastrointestinal hematoma and ulcers after endoscopic biopsy: A case report and literature review

RATIONALE

Eosinphilic gastroenteritis (EG) is a gastrointestinal disorder characterized by eosinophilic infiltration with various manifestations. The diagnosis is usually confirmed by an endoscopic biopsy, which is considered a safe and routine procedure for the majority.

PATIENT CONCERNS

We report a 54-year-old male who was presented with intermittent periumbilical pain and melena, and only revealed verrucous gastritis by endoscopy.

DIAGNOSES

The patient's condition worsened two days after the endoscopic biopsy, and another endoscopy found hematoma and ulcers in upper gastrointestinal tract. He was diagnosed with EG by the pathological analysis of biopsy specimen.

INTERVENTIONS

Oral methylprednisolone and Montelukast were prescribed.

OUTCOMES

The patient got remission after initiation of the treatment.

LESSONS

This case highlights an extremely rare but potentially severe complication of endoscopic biopsies in patients with EG. Physicians should be cautious with hematoma or ulceration, and consider it in such patients who undergo this procedure.

Diagnosis of eosinophilic gastroenteritis is easily missed

AIM

To analyze the clinical characteristics of eosinophilic gastroenteritis (EGE) and to investigate the situations of missed diagnosis of EGE.

METHODS

First, the clinical characteristics of 20 EGE patients who were treated at our hospital were retrospectively summarized. Second, 159 patients who underwent gastroscopy and 211 patients who underwent colonoscopy were enrolled. The pathological diagnosis showed only chronic inflammation in their medical records. The biopsy slides of these patients were reevaluated to determine the number of infiltrating eosinophils in order to assess the probability of a missed diagnosis of EGE. Finally, 122 patients who experienced refractory upper gastrointestinal symptoms for at least one month were recruited. At least 6 biopsy specimens were obtained by gastroscopy, and the number of eosinophils that had infiltrated was evaluated. Those who met the pathological diagnostic criteria of EGE underwent further examination to confirm the diagnosis of EGE. The probability of a missed diagnosis of EGE was prospectively investigated.

RESULTS

Among the 20 patients with EGE, mucosal EGE was found in 15 patients, muscular EGE was found in 3 patients and serosal EGE was found in 2 patients. Abdominal pain was the most common symptom. The number of peripheral blood eosinophils was elevated in all 20 patients, all of whom were sensitive to corticosteroids. Second, among the 159 patients who underwent gastroscopy, 7 (4.40%) patients met the criteria for pathological EGE (eosinophil count ≥ 25/HPF). Among the 211 patients who underwent colonoscopy, 9 (4.27%) patients met the criteria for pathological EGE (eosinophil count ≥ 30/HPF). No patients with eosinophil infiltration were diagnosed with EGE in clinical practice before or after endoscopy. Although these patients did not undergo further examination to exclude other diseases that can also lead to gastrointestinal eosinophil infiltration, these might be the cases where the diagnosis of EGE was missed. Finally, among the 122 patients with refractory upper gastrointestinal symptoms, eosinophil infiltration was seen in 7 patients (5.74%). The diagnosis of EGE was confirmed in all 7 patients after the exclusion of other diseases that can also lead to gastrointestinal eosinophil infiltration. A positive correlation was observed between the duration of the symptoms and the risk of EGE (r = 0.18, P < 0.01). The patients whose symptoms persisted longer than 6 mo more readily developed EGE. None of the patients were considered to have EGE by their physicians before endoscopy.

CONCLUSION

Although EGE is a rare inflammatory disorder, it is easily misdiagnosed. When a long history of abdominal symptoms fails to improve after conventional therapy, EGE should be considered.

Eosinophil infiltration in the upper gastrointestinal tract of patients with bronchial asthma

BACKGROUND

Eosinophilic esophagitis (EoE) is related to allergic diseases such as bronchial asthma (BA), atopic dermatitis, and allergic rhinitis. The aim of this study was to examine the eosinophil infiltration in the upper gastrointestinal (GI) tract in patients with BA using esophagogastroduodenoscopy.

METHODS

Patients with BA who had upper GI tract symptoms were enrolled. Patients who received systemically administered steroids were excluded. Eosinophil infiltrations in the esophagus, stomach, and duodenum were examined with regard to the endoscopic findings and pathological findings of biopsy specimens (UMIN000010132).

RESULTS

Ninety patients were enrolled from October in 2012 to September in 2014. Thirty-six were male, 54 were female, and the mean age was 57.5 years. Eighty-one (90%) used inhaled corticosteroids. Fourteen patients (15.6%) had reflux esophagitis, 8 of whom had grade A and 6 had grade B. No patient with EoE was observed. One female patient who had marked eosinophil infiltration in the esophagus, stomach, and duodenum was diagnosed as having eosinophilic gastroenteritis, but endoscopy showed only mucosal edema in the antrum. Another female patient who had marked eosinophil infiltration in the esophagus, stomach, and duodenum was diagnosed as having eosinophilic granulomatosis with polyangiitis, and endoscopy showed erosions in the antrum and the duodenum. Three patients had eosinophil infiltration in the stomach, but none of them had severe symptoms.

CONCLUSIONS

Patients with asthma who had upper gastrointestinal symptoms rarely had eosinophilic gastrointestinal disorders. Biopsy specimens are of high importance in the diagnosis of eosinophilic gastrointestinal disorders even if there is no remarkable endoscopic finding.

Eosinophilic Gastroenteritis: An Underdiagnosed Condition

BACKGROUND

Eosinophilic gastroenteritis (EOGE) is a rare idiopathic disease characterized by eosinophil-predominant inflammation of the stomach and/or intestines. Our aims are to determine the epidemiology, clinical features and outcomes of EOGE cases in a tertiary-care hospital.

METHODS

Retrospective cohort study of patients with gastrointestinal eosinophilic infiltration from 2004 through 2014. All relevant specimens were reviewed by an expert pathologist. Significant eosinophilic infiltrate was defined as >25 eosinophils/HPF in the stomach or small intestine and >50 eosinophils/HPF in the colon.

RESULTS

Three hundred and sixty-one charts were reviewed and 13 EOGE cases were identified, including nine adults and four pediatric cases. The majority (78 %) of adult cases were females. Clinical presentation was variable; most patients (62 %) had abdominal pain, followed by diarrhea (31 %) and nausea/vomiting (31 %). Atopy and food allergies were present in 54 and 38 % of patients, respectively. Weight loss and failure to thrive were present only in pediatric cases (50 vs 0 %; P = .01). Most EOGE cases (69 %) had peripheral eosinophilia, which was more prominent in patients with ascites compared to patients without ascites (37.3 ± 25.4 vs 9.3 ± 5.4 %; P = .01). Among patients who had long-term follow-up; 30 % had spontaneous remission, 60 % responded to steroids and/or restriction diet, and 10 % had refractory disease.

CONCLUSION

EOGE is an underdiagnosed condition. In contrast to eosinophilic esophagitis; the disease might be female-predominant in adults. High index of clinical suspicion is required for diagnosis. Further studies about the long-term outcomes and the efficacy of restriction diet in adult patients are required.

Characterizing the inflammatory response in esophageal mucosal biopsies in children with eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is an emerging allergic, IgE- and non-IgE (Th2 cell)-mediated disease. There are major gaps in the understanding of the basic mechanisms that drive the persistence of EoE. We investigated whether esophageal biopsies from children with EoE demonstrate an inflammatory response that is distinct from normal controls. We prospectively enrolled 84 patients, of whom 77 were included in our analysis, aged 4-17 years (12.8±3.8 years; 81% males). Five esophageal biopsies were collected from each patient at the time of endoscopy. Intramucosal lymphocytes were isolated, phenotyped and stimulated with phorbol 12-myristate 13-acetate/ionomycin to measure their potential to produce cytokines via flow cytometry. We also performed cytokine arrays on 72-h biopsy culture supernatants. CD8(+) T cells, compared with CD4(+) T cells, synthesized more TNF-α and interferon (IFN)-γ after mitogen stimulation in the EoE-New/Active vs EoE-Remission group (P=0.0098; P=0.02) and controls (P=0.0008; P=0.03). Culture supernatants taken from explant esophageal tissue contained 13 analytes that distinguished EoE-New/Active from EoE-Remission and Controls. Principal component analysis and cluster analysis based on these analytes distinctly separated EoE-New/Active from EoE-Remission and Controls. In summary, we have identified a previously unappreciated role for CD8(+) T lymphocytes with potential to produce TNF-α and IFN-γ in EoE. Our results suggest that CD8(+) T cells have a role in the persistence or progression of EoE. We have also identified a panel of analytes produced by intact esophageal biopsies that differentiates EoE-New/Active from EoE-Remission and controls. Our results suggest that esophageal epithelial cells may have specific immune effector functions in EoE that control the type and amplitude of inflammation.

Wheat allergy: diagnosis and management

Triticum aestivum (bread wheat) is the most widely grown crop worldwide. In genetically predisposed individuals, wheat can cause specific immune responses. A food allergy to wheat is characterized by T helper type 2 activation which can result in immunoglobulin E (IgE) and non-IgE mediated reactions. IgE mediated reactions are immediate, are characterized by the presence of wheat-specific IgE antibodies, and can be life-threatening. Non-IgE mediated reactions are characterized by chronic eosinophilic and lymphocytic infiltration of the gastrointestinal tract. IgE mediated responses to wheat can be related to wheat ingestion (food allergy) or wheat inhalation (respiratory allergy). A food allergy to wheat is more common in children and can be associated with a severe reaction such as anaphylaxis and wheat-dependent, exercise-induced anaphylaxis. An inhalation induced IgE mediated wheat allergy can cause baker’s asthma or rhinitis, which are common occupational diseases in workers who have significant repetitive exposure to wheat flour, such as bakers. Non-IgE mediated food allergy reactions to wheat are mainly eosinophilic esophagitis (EoE) or eosinophilic gastritis (EG), which are both characterized by chronic eosinophilic inflammation. EG is a systemic disease, and is associated with severe inflammation that requires oral steroids to resolve. EoE is a less severe disease, which can lead to complications in feeding intolerance and fibrosis. In both EoE and EG, wheat allergy diagnosis is based on both an elimination diet preceded by a tissue biopsy obtained by esophagogastroduodenoscopy in order to show the effectiveness of the diet. Diagnosis of IgE mediated wheat allergy is based on the medical history, the detection of specific IgE to wheat, and oral food challenges. Currently, the main treatment of a wheat allergy is based on avoidance of wheat altogether. However, in the near future immunotherapy may represent a valid way to treat IgE mediated reactions to wheat.

Eosinophilic Esophagitis and Gastroenteritis

Eosinophilic gastrointestinal disease (EGID) can be classified as eosinophilic esophagitis (EoE) when the eosinophilia is limited to the esophagus or as eosinophilic gastritis (EG) if it is limited to the gastric tract, eosinophilic colitis (EC) if it is limited to the colon, and eosinophilic gastroenteritis (EGE) if the eosinophilia involves one or more parts of the gastrointestinal tract. EoE is by far the most common EGID. It is a well-defined chronic atopic disease due to a T helper type 2 (Th2) inflammation triggered often by food allergens. EoE diagnosis is done if an esophageal biopsy shows at least 15 eosinophils per high power field (eos/hpf). Globally accepted long-term therapies for EoE are the use of swallowed inhaled steroids or food antigen avoidance. The treatment of EoE is done not only to control symptoms but also to prevent complications such as esophageal stricture and food impaction. EGE cause non-specific gastrointestinal (GI) symptoms and are diagnosed if esophagogastroduodenoscopy (EGD)/colonoscopy show eosinophilia in one or more parts of the GI tract. They are rare diseases with an unclear pathogenesis, and they are poorly defined in terms of diagnostic criteria and treatment. Before initiating treatment of any EGE, it is imperative to conduct a differential diagnosis to exclude other causes of hypereosinophilia with GI localization. EGE are often poorly responsive to therapy and there is no commonly accepted long-term treatment. EG has many characteristics similar to EoE, including the fact that it is often due to a food allergen-driven Th2 inflammation; transcriptome analysis however shows that it is more a systemic disease and has a different gene signature than EoE. EC is a benign form of delayed food allergy in infant and is instead a difficult-to-treat severe inflammatory condition in older children and adults. EC in the latter groups can be a manifestation of drug allergy or autoimmune disease. Overall EGE, EC, and EG are rare and are a diagnosis of exclusion until more common causes of eosinophilia have been excluded.

Efficacy of Dietary Treatment for Inducing Disease Remission in Eosinophilic Gastroenteritis

OBJECTIVES

Various dietary interventions have been used to treat patients with eosinophilic gastroenteritis (EGE). Concrete evidence as to the effectiveness of such treatments in inducing disease remission is, however, lacking. The aim of the study was to systematically review the efficacy of dietary therapies in inducing EGE remission.

METHODS

We performed a systematic search for the MEDLINE, EMBASE, and SCOPUS libraries for studies investigating the efficacy of dietary interventions (in both histological and symptomatic remission) for children and adults with EGE and colitis.

RESULTS

The search yielded 490 references; 30 were included in the review, with most of these references being "low-quality" individual cases or short case series. No significant publication bias was found. Elemental diets in children were linked to 75.8% of clinical improvement, but few of these patients underwent a histological evaluation. Allergy-testing results have been used scarcely in EGE. Empiric elimination of allergy-associated foods was the most commonly used option. The variable results in terms of symptom relief, however, were scarcely accompanied by histological confirmation. Clinical and methodological heterogeneity hindered the performance of quantitative summaries for the efficacy of dietary therapies in inducing disease remission.

CONCLUSIONS

Symptomatic improvements reported for dietary treatment in EGE by most of the available literature are questionable because of the lack of objective evaluation of clinical changes and the very limited assessment of histological remission. Because of the relative lack of well-designed, high-quality studies, the unequivocal use of dietary treatment for patients with EGE and colitis cannot be supported. Further research should be undertaken.

Histologic eosinophilic gastritis is a systemic disorder associated with blood and extragastric eosinophilia, TH2 immunity, and a unique gastric transcriptome

BACKGROUND

The definition of eosinophilic gastritis (EG) is currently limited to histologic EG based on the tissue eosinophil count.

OBJECTIVE

We aimed to provide additional fundamental information about the molecular, histopathologic, and clinical characteristics of EG.

METHODS

Genome-wide transcript profiles and histologic features of gastric biopsy specimens, as well as blood eosinophil counts, were analyzed in patients with EG and control subjects (n = 15 each).

RESULTS

The peak gastric antrum eosinophil count was 283 ± 164 eosinophils/×400 high-power field in patients with EG and 11 ± 9 eosinophils/×400 high-power field in control subjects (P = 6.1 × 10(-7)). Patients with EG (87%) had coexisting eosinophilic inflammation in multiple gastrointestinal segments; the esophagus represented the most common secondary site. Increased peripheral blood eosinophil counts (patients with EG: 1.09 ± 0.88 × 10(3)/μL vs control subjects: 0.09 ± 0.08 10(3)/μL, P = .0027) positively correlated with peak gastric eosinophil counts (Pearson r(2) = .8102, P < .0001). MIB-1(+) (proliferating), CD117(+) (mast cells), and FOXP3(+) (regulatory T cells, activated T cells, or both) cell counts were increased in patients with EG. Transcript profiling revealed changes in 8% of the genome in gastric tissue from patients with EG. Only 7% of this EG transcriptome overlapped with the eosinophilic esophagitis transcriptome. Significantly increased IL4, IL5, IL13, IL17, CCL26, and mast cell-specific transcripts and decreased IL33 transcripts were observed.

CONCLUSION

EG is a systemic disorder involving profound blood and gastrointestinal tract eosinophilia, TH2 immunity, and a conserved gastric transcriptome markedly distinct from the eosinophilic esophagitis transcriptome. The data herein define germane cellular and molecular pathways of EG and provide a basis for improving diagnosis and treatment.

Case-control study of association of eosinophilic gastrointestinal disorders with Helicobacter pylori infection in Japan

Recent studies have suggested that decrease in Helicobacter pylori infection may predispose to allergic diseases. However, there are few reports of the relationships of eosinophilic gastrointestinal disorders (EGIDs), especially eosinophilic gastroenteritis (EGE), with H. pylori infection. We investigated the possible influence of H. pylori infection on EGIDs in Japanese patients. We performed a case-control study to investigate the prevalence of H. pylori infection in patients with EGIDs. Eighteen with eosinophilic esophagitis (EoE) and 22 with EGE were enrolled. For each patient, 3 age- and gender-matched normal controls (n = 120) were randomly selected from a population who received a medical check-up between April 2010 and December 2011 at the Shimane Institute of Health Science. The mean ages of the EoE and EGE patients were 50.9 ± 17 and 49.2 ± 20 years, respectively. Males were more frequently seen in the EoE group, while there was no significant gender difference in regard to EGE. Of the patients with EoE, 22.3% were infected with H. pylori, as compared to 55.5% of their age- and sex-matched normal controls. The odds ratio for EoE patients to have an H. pylori infection was 0.22 (p<0.05). In addition, 22.7% of the patients with EGE and 48.5% of their matched controls were infected with H. pylori, with odds ratio for EGE patients to have an H. pylori infection shown to be 0.31 (p<0.05). In conclusion, the prevalence of H. pylori infection was significantly lower in EGE and EoE patients in Japan as compared to normal control subjects.

Clinical characteristics of Japanese patients with eosinophilic esophagitis and eosinophilic gastroenteritis

BACKGROUND

The clinical characteristics of Japanese patients with eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE) have not been fully clarified. For understanding the pathogenesis as well as providing support for accurate diagnosis, precise information regarding clinical characteristics of these diseases is important.

METHODS

A questionnaire-based survey of EoE and EGE was conducted in 1,078 teaching hospitals. Clinical data of patients with confirmed EoE or EGE diagnosed from 2004 to 2009 were collected.

RESULT

Clinical data from 26 patients with EoE and 144 patients with EGE were collected. The mean ages of patients in both groups were in the 40s. Those with EoE frequently complained of dysphagia and heartburn, and had characteristic endoscopic features such as longitudinal furrows and multiple concentric rings in the esophagus, while only 34% had peripheral eosinophilia. Patients with EGE frequently complained of abdominal pain and diarrhea, and approximately 80% of them have peripheral eosinophilia. They did not have characteristic endoscopic features helpful for diagnosis. Computed tomography (CT) findings and the presence of peripheral eosinophilia were diagnostic for EGE. EGE patients with a small intestinal involvement showed the highest peripheral eosinophil counts. Glucocorticoid administration was the most widely used treatment for these diseases and its effect was favorable for at least induction of remission.

CONCLUSION

EGE is more prevalent than EoE in Japan. Patients with EGE have abdominal pain and diarrhea, high peripheral eosinophil counts, and gastrointestinal wall thickening identifiable by CT findings, while EoE is characterized by dysphagia and characteristic endoscopic features.

A case of eosinophilic gastrointestinal disorders presenting with chronic diarrhea and abdominal pain

Eosinophilic gastrointestinal disorders (EGID) are rare conditions characterized by eosinophilic infiltration of the bowel wall and gastrointestinal symptoms. These disorders can present with various manifestations, depending on the specific site of the affected gastrointestinal tract and specific layer of the affected gastrointestinal wall. The pathogenesis and etiology of EGID remain unclear. The present case report describes a 76-year-old woman who presented with chronic diarrhea and lower abdominal pain. The patient was successfully treated with corticosteroid and restriction of some food allergens. One needs to consider these rare disorders during the differential diagnosis of unexplained gastrointestinal symptoms, especially when they are associated with peripheral eosinophilia.

A case of postpartum eosinophilic gastroenteritis and review of the literature

Eosinophilic gastroenteritis (EG) is a rare disease of unknown etiology that can involve any area of the gastrointestinal (GI) tract. It can be classified into three major types: predominantly mucosal, muscularis, or subserosal form. Diagnosis of EG is confirmed after the exclusion of other disorders having similar features, such as parasitic infection, carcinoma, allergy, and autoimmune conditions such as Churg-Strauss disease. Correct diagnosis hinges on the presence of eosinophilic infiltration of one or more areas of the GI tract, without extraintestinal involvement. We present the case of a 30-year-old female with symptoms of EG 26 days after delivery. After corticosteroid and montelukast treatment for 2 weeks, all symptoms and objective clinical findings disappeared. Although numerous cases of this disorder have been described, to our knowledge this is the first case of postpartum EG. This case highlights the need to include this entity in the differential diagnosis of postpartum GI disorders.

Eosinophilic gastrointestinal disorders (EGID) with peripheral eosinophilia: a retrospective review at Mayo Clinic

BACKGROUND AND AIMS

Hypereosinophilic syndrome (HES) is defined by significant eosinophilia (>1,500 eos/μl), which often leads to end-organ damage/dysfunction. It is unclear if the presence of significant peripheral eosinophilia (>1,500 eos/μl) indicates a more aggressive form of eosinophilic gastrointestinal disorder (EGID).

METHODS

A database query of the Mayo Clinic Rochester electronic records (1995-2008) was performed using several search terms for eosinophilic gastrointestinal disease, and 161 records were reviewed. Patients under 18 years age, those without Mayo-reviewed pathology specimens, those with eosinophilic esophagitis only, and/or those with evidence of secondary etiologies for GI eosinophilia were excluded. A total of 39 were found to have primary EGID. We compared individuals with biopsy-proven primary EGID based on whether they had significant peripheral eosinophilia (≥1,500 eos/μl) (group A) or not (group B).

RESULTS

Group A tended to have more atopy (A: 12/15; B: 11/24; p = 0.03) and more extensive segmental involvement of the GI tract (p = 0.001). None with available studies had evidence of cardiac (A: 7/15; B: 6/24) or bone marrow (A: 10/15; B: 6/24) involvement. The two thromboembolic events in group A after diagnosis did not translate to significantly greater risk (HR = infinity, p = 0.13; group A vs. B). Doses of initial (A: 40 mg/day; B: 55 mg/day; p = 0.17) and maintenance prednisone (A; 8.75 mg/day; B: 7.5 mg/day; p > 0.90) were similar. Group A was significantly more likely to need maintenance prednisone (77 vs. 8%, p = 0.001), with a median treatment duration of 52 weeks. Recurrence of symptoms (and peripheral eosinophilia) during prednisone taper was common in both groups. Prednisone-sparing agents (hydroxyurea, imatinib mesylate, interferon (IFN)-α2b, anti-interleukin (IL-5) monoclonal antibody) were more commonly used in group A (73 vs. 8%; p < 0.0001).

CONCLUSIONS

EGID with peripheral eosinophilia ≥1,500/μl is associated with atopy, greater GI segmental involvement, and uncertain risk of thrombosis. The common use of long-term steroids and variable responsiveness to nonsteroidal agents, particularly in group A, underscores the need for targeted therapies.

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 gastroenteritis]

BACKGROUND

Eosinophilic gastroenteritis is a disease that presents with nonspecific symptoms such as abdominal pain, nausea and diarrhoea. We here present an overview of the disease with an emphasis on practical management.

MATERIAL AND METHODS

The basis for the review is literature retrieved through a search in PubMed and on our own experience treating patients with this disease. A case is reported.

RESULTS

Eosinophilic gastroenteritis is a rare chronic inflammatory disease of the gastrointestinal tract that mainly affects the stomach and upper small bowel. Young middle-aged adults (most men) are most frequently affected. Abdominal pain and diarrhoea are the most common symptoms. The etiology and pathogenesis is unknown. Correct diagnosis may be difficult and is based on gastrointestinal symptoms, eosinophilic infiltration of the bowel wall and exclusion of other causes of eosinophilia. Treatment is symptomatic with different doses of corticosteroids. Long-term prognosis seems good.

INTERPRETATION

The clinical presentation of eosinophilic gastroenteritis varies and underdiagnosing is therefore likely. Many patients have normal levels of eosinophils in blood and normal findings with endoscopy. Correct diagnosis therefore depends on awareness of the disease.

A patient with oeosinophilic gastroenteritis and severe malnutrition improved with home parenteral nutrition

Oeosinophilic gastroenteritis is a chronic and rare disorder characterised by massive oeosinophilic tissue infiltration involving one or more segments of the digestive tract. The management of patients with oeosinophilic gastroenteritis is complex and the therapeutic response often poor. Here we discuss the clinical case and management of a 23-year-old man with oeosinophilic gastroenteritis since the first year of life and the decision to prescribe lifelong total parenteral nutrition.

Eosinophilic diseases of the gastrointestinal tract

Eosinophilic gastrointestinal disorders (EGIDs) are a diverse group of disorders whose diagnosis is on the rise and are characterized by symptoms caused by infiltration by eosinophils of the different sections of the digestive tract. Although little is known of their etiology, it seems to be multifactorial. Alteration of the immunological capacity of the digestive mucosa is determined by the exposure of genetically predisposed individuals to potential airborne or food allergens. EGIDs are classified based on the location of the inflammatory response even though their symptoms, prognosis, and treatment vary considerably. Eosinophilic esophagitis is the most widely recognized entity in this family and is characterized by exclusive eosinophilic infiltration of the esophagus. Breakthroughs in understanding its etiopathogeny have been extrapolated to eosinophilic gastroenteritis, a rare disease identified many years ago commonly involving the stomach and small bowel which should be distinguished from hypereosinophilic syndrome. Eosinophilic colitis, which usually affects children, could be considered a specific non-IgE-mediated allergy to food protein. The physiopathological bases of these entities need to be established in order to define specific treatment aimed at preventing and altering their clinical evolution.

Esophageal Eosinophilia

The presence of esophageal eosinophilia encompasses a broad differential diagnosis, and at times a specific histologic diagnosis is not possible. This content provides a systematic approach to esophageal squamous eosinophilia with emphasis on specific, distinguishing features within this expansive differential.

Mucosal immunology, eosinophilic esophagitis, and other intestinal inflammatory diseases

The gastrointestinal mucosa constitutes the largest host-environment interface of the body. It uses both innate and adaptive immune mechanisms to provide protection from the diverse onslaught of foods, microbes, and other ingested products. The innate immune system is genetically encoded and evolutionarily ancient, possesses no memory, and lacks diversity. In contrast, the adaptive immune system is quite diverse, develops memory, and undergoes expansion after stimulation. The gastrointestinal mucosa is charged with the difficult task of mounting protective responses against invading microorganisms while simultaneously maintaining an overall state of nonresponsiveness or tolerance to innocuous substances, such as commensal bacteria and food antigens. Perturbation or malfunction of these complex protective mechanisms results in diseases, such as inflammatory bowel diseases, celiac disease, or eosinophilic gastrointestinal diseases.

Longstanding eosinophilic gastroenteritis of more than 20 years

Eosinophilic gastroenteritis (EGE) is an eosinophil-predominant inflammatory process that may be detected in endoscopic gastric or intestinal biopsies. The long-term natural history and effects of EGE treatment are not known. A 44-year-old man with abdominal pain was treated with oral ketotifen and followed for more than 20 years. Ketotifen provided symptomatic benefit, with prompt clinical relapse if the drug was discontinued. However, despite the use of ketotifen, the endoscopic abnormalities persisted and appeared to progress. Gastric body and antral mucosal folds appeared thickened, erythematous and friable, with minimal erosive change. Later, even during long asymptomatic periods suggesting clinical 'remission', inflammatory polypoid change, previously described in children with EGE, developed with mucosal 'pock-marking' and apparent scarring. Ketotifen treatment does not appear to prohibit or reverse the inflammatory process in the gastric mucosa in EGE, although long-term effects of steroids may be avoided. In the future, treatment of EGE may involve monoclonal antibody agents that target the specific biological effects of the eosinophil, apparently central to this unusual inflammatory process.

Evaluation of the patient with suspected eosinophilic gastrointestinal disease

This article focuses on the evaluation and management of eosinophilic gastrointestinal diseases other than eosinophilic esophagitis. Those diseases include eosinophilic gastritis, gastroenteritis, enteritis, and colitis. The diagnosis of eosinophilic gastrointestinal disease is primarily dependent on the clinical history and histopathology of multiple biopsy specimens after ruling out other causes of intestinal eosinophilia. The diagnosis of eosinophilic gastrointestinal diseases other than eosinophilic esophagitis is complicated by the lack of uniformly accepted diagnostic criteria. Treatment involves evaluation for food sensitivity, elimination diets, and the use of anti-allergy and anti-inflammatory medications with varying degrees of success. Little is known about the natural history of eosinophilic gastrointestinal diseases, underscoring the need for long-term follow-up studies of patients with these disorders.

Adult eosinophilic gastroenteritis and hypereosinophilic syndromes

Eosinophilic gastroenteritis (EGE) in the adult is a distinctive pathologically-based disorder characterized by an eosinophil-predominant mucosal inflammatory process. Most often, the disorder is detected during endoscopic investigation for abdominal pain or diarrhea. Other causes of gastric and intestinal mucosal eosinophilia require exclusion, including parasitic infections and drug-induced causes. Occasionally, the muscle wall or serosal surface may be involved. EGE appears to be more readily recognized, in large part, due to an evolution in the imaging methods used to evaluate abdominal pain and diarrhea, in particular, endoscopic imaging and mucosal biopsies. Definition of EGE, however, may be difficult, as the normal ranges of eosinophil numbers in normal and abnormal gastric and intestinal mucosa are not well standardized. Also, the eosinophilic inflammatory process may be either patchy or diffuse and the detection of the eosinophilic infiltrates may vary depending on the method of biopsy fixation. Treatment has traditionally focused on resolution of symptoms, and, in some instances, eosinophil quantification in pre-treatment and post-treatment biopsies. Future evaluation and treatment of EGE may depend on precise serological biomarkers to aid in definition of the long-term natural history of the disorder and its response to pharmacological or biological forms of therapy.

Adult eosinophilic gastroenteritis and hypereosinophilic syndromes

Eosinophilic gastroenteritis (EGE) in the adult is a distinctive pathologically-based disorder characterized by an eosinophil-predominant mucosal inflammatory process. Most often, the disorder is detected during endoscopic investigation for abdominal pain or diarrhea. Other causes of gastric and intestinal mucosal eosinophilia require exclusion, including parasitic infections and drug-induced causes. Occasionally, the muscle wall or serosal surface may be involved. EGE appears to be more readily recognized, in large part, due to an evolution in the imaging methods used to evaluate abdominal pain and diarrhea, in particular, endoscopic imaging and mucosal biopsies. Definition of EGE, however, may be difficult, as the normal ranges of eosinophil numbers in normal and abnormal gastric and intestinal mucosa are not well standardized. Also, the eosinophilic inflammatory process may be either patchy or diffuse and the detection of the eosinophilic infiltrates may vary depending on the method of biopsy fixation. Treatment has traditionally focused on resolution of symptoms, and, in some instances, eosinophil quantification in pre-treatment and post-treatment biopsies. Future evaluation and treatment of EGE may depend on precise serological biomarkers to aid in definition of the long-term natural history of the disorder and its response to pharmacological or biological forms of therapy.