The pathology and causes of tissue eosinophilia in the gastrointestinal tract

Host-related low-prevalence gastritides: Epidemiological and clinical characterization

INTRODUCTION

A recent consensus meeting (RE.GA.IN) addressed "host-related, low-prevalence gastritis": eosinophilic (EoG), lymphocytic (Hp-pos_LyG and Hp-neg_LyG), collagenous (CollG), and granulomatous gastritis (GrG). Our study evaluates their clinico-epidemiological characteristics.

MATERIALS AND METHODS

We extracted all patients with a diagnosis of EoG, LyG, CollG, and GrG from a clinicopathological database and compared their demographics, clinical and endoscopic characteristics, associated conditions, and clinical awareness to those of all other subjects in the database (controls).

RESULTS

There were 1,781,005 unique patients (median age 57 years; 55.7 % female). Hispanics were overrepresented amongst those with Hp-pos_LyG. Subjects with GrG had a high prevalence of erosions and ulcers. Clinical awareness of these conditions was dismal (<1:10,000 patients). Some clinical manifestations were more common in patients with certain gastritides (e.g., vomiting and diarrhea in CollG; anemia in LyG), but none were sufficiently distinctive to suggest a clinical diagnosis. EoG was associated with EoE; LyG had a strong association with celiac disease; CollG with microscopic colitis; and GrG with Crohn disease.

CONCLUSIONS

The diagnosis of these gastritides (between <1: in 1,000 and 1 in 5000 subjects) rests on histopathology. They remain poorly characterized and clinically neglected. Yet, their associations may herald other conditions: eosinophilic gastrointestinal diseases (EGID), celiac, and Crohn disease. Patients might benefit from increased detection and characterization.

A unicentric cross-sectional observational study on chronic intestinal inflammation in total colonic aganglionosis: beware of an underestimated condition

BACKGROUND

Inflammatory Bowel Diseases (IBD) are known to occur in association with Hirschsprung disease (HSCR). Most of cases are represented by Crohn Disease (CD) occurring in patients with Total Colonic Aganglionosis (TCSA) with an estimated prevalence of around 2%. Based on these considerations and on a number of provisional data belonging to our Center for Digestive Diseases, we developed a unicentric cross-sectional observational study aimed at describing phenotype, genotype, pathology and metagenomics of all patients with TCSA and Crohn-like lesions.

RESULTS

Out of a series of 62 eligible TCSA patients, 48 fulfilled inclusion criteria and were enrolled in the study. Ten patients did not complete the study due to non-compliance or withdrawal of consent and were subsequently dropped out. A total of 38 patients completed the study. All patients were tested for chronic intestinal inflammation by a combination of fecal calprotectine (FC) or occult fecal blood (OFB) and underwent fecal metagenomics. Nineteen (50%) tested positive for FC, OFB, or both and subsequently underwent retrograde ileoscopy. Fourteen patients (36.8%) presented Crohn-like lesions, occurring after a median of 11.5 years after surgery (range 8 months - 21.5 years). No statistically significant differences regarding demographic, phenotype and genotype were observed comparing patients with and without lesions, except for need for blood transfusion that was more frequent in those with lesions. Faecal microbiome of patients with lesions (not that of caregivers) was less biodiverse and characterized by a reduction of Bacteroidetes, and an overabundance of Proteobacteria. FC tested negative in 3/14 patients with lesions (21%).

CONCLUSIONS

Our study demonstrated an impressive 10-folds higher incidence of chronic inflammation in TCSA. Up to 50% of patients may develop IBD-like lesions postoperatively. Nonetheless, we failed in identifying specific risk factors to be used to implement prevention strategies. Based on the results of our study, we suggest screening all TCSA patients with retrograde ileoscopy regardless of FC/OFB values. The frequency of endoscopic assessments and the role of FC/OFB screening in prompting endoscopy is yet to be determined.

[Eosinophilic inflammation of the digestive tract]

Eosinophilic inflammation of the digestive tract is an inflammatory disease characterized by extensive infiltration of eosinophils into the gastrointestinal tract. It can be either a primary disorder of the digestive tract or be secondary to another cause of tissue eosinophilia. Primary disorders include eosinophilic esophagitis (OE) and eosinophilic gastroenteritis (GEEo). These are 2 rare pathologies considered to be diseases related to a Th2-mediated food allergy. The role of the pathologist is twofold: (1) he must make the diagnosis of tissue esosinophilia and propose the various causes, knowing that a secondary cause is the most frequently observed; (2) identify the abnormal number of polymorphonuclear eosinophils, which implies knowing the normal distribution of eosinophils in the different digestive segments. To carry the diagnosis of EO, the threshold of polymorphonuclear eosinophils must be ≥ 15/fields × 400. There is no predefined threshold concerning the other segments of the digestive tract to carry the diagnosis of GEE_O. In addition, to make the diagnosis of primary digestive tissue eosinophilia, the patient must be symptomatic with histological evidence of eosinophilia and have ruled out all secondary causes. The main differential diagnosis of OE is gastroesophageal reflux disease. The differential diagnoses of GEEo are multiple, including primarily drugs and parasitic infections.

Number and distribution of eosinophils and lymphocytes in the Japanese pediatric gastrointestinal tract: in search of a definition for "abnormally increased eosinophils"

BACKGROUND

Primary eosinophilic gastrointestinal disorders (EGIDs) constitute chronic allergic inflammation. The number of eosinophils is one of the diagnostic criteria; more than 20 eosinophils per high-power field (HPF) in the gastrointestinal (GI) tract are considered abnormal in Japan. However, the quantity of eosinophils considered normal varies according to anatomical location and geographical region; such values have not been reported in Japanese pediatric patients, nor have the numbers of lymphocytes in the normal pediatric stomach. To establish a reference for defining diagnostic criteria for EGIDs, we evaluated the number of eosinophils in the normal Japanese pediatric GI tract.

METHODS

We examined 131 biopsy cases without significant clinical history, endoscopic abnormality, or histological abnormality. Immunohistochemical analysis of CD3 and CD20 was performed.

RESULTS

The mean eosinophil density was highest in the cecum (49.5 ± 22.4 per HPF). Counts of more than 20 eosinophils per HPF were observed in the duodenum [bulb (20.0 ± 9.6) and second portion (30.0 ± 15.8)], terminal ileum (38.3 ± 22.7), cecum (49.5 ± 22.4), ascending colon (42.3 ± 25.3), transverse colon (29.4 ± 17.0), and descending colon (32.2 ± 17.9). Counts of fewer than 10 eosinophils per HPF were observed in the stomach and rectum; a count of fewer than one eosinophil per HPF was observed in the esophagus. More than 100 CD3-positive T cells per HPF were observed in the stomach.

CONCLUSIONS

The mean numbers of eosinophils in the bowel were greater than 20 per HPF. For Japanese pediatrics, the current threshold eosinophil count should be revised.

Histopathological assessment of the microscopic activity in inflammatory bowel diseases: What are we looking for?

Advances in diagnostics of inflammatory bowel diseases (IBD) and improved treatment strategies allowed the establishment of new therapeutic endpoints. Currently, it is desirable not only to cease clinical symptoms, but mainly to achieve endoscopic remission, a macroscopic normalization of the bowel mucosa. However, up to one-third of IBD patients in remission exhibit persisting microscopic activity of the disease. The evidence suggests a better predictive value of histology for the development of clinical complications such as clinical relapse, surgical intervention, need for therapy escalation, or development of colorectal cancer. The proper assessment of microscopic inflammatory activity thus became an important part of the overall histopathological evaluation of colonic biopsies and many histopathological scoring indices have been established. Nonetheless, a majority of them have not been validated and no scoring index became a part of the routine bioptic practice. This review summarizes a predictive value of microscopic disease activity assessment for the subsequent clinical course of IBD, describes the most commonly used scoring indices for Crohn's disease and ulcerative colitis, and comments on current limitations and unresolved issues.

Non-oesophageal eosinophilic gastrointestinal diseases are undersuspected clinically and underdiagnosed pathologically

BACKGROUND

Non-oesophageal gastrointestinal eosinophilic diseases (EGID) are considered rare. However, low disease awareness among clinicians and pathologists may contribute to underdiagnosis.

AIMS

To determine how frequently requests to evaluate for EGID accompany gastrointestinal biopsies and in what proportion of suspected cases pathologists address these requests, either confirming or refuting the clinical suspicion.

METHODS

All cases in which biopsy requisitions included an explicit suspicion of EGID were extracted from a large clinicopathologic database and manually reviewed for accuracy. The diagnoses for these cases were then analysed to determine whether clinical suspicions were confirmed, refuted or ignored.

RESULTS

Eosinophilic oesophagitis (EoE) was suspected in 12.8% of 903,516 patients with biopsies and confirmed in 14.9% of them. A suspicion of eosinophilic gastritis accompanied <0.001% of 1,438,206 gastric biopsy sets and was confirmed in 11.5% of them; eosinophilic duodenitis was suspected in 0.02% of ~675,519 patients with duodenal biopsies and confirmed in 8.0% of these; eosinophilic colitis was mentioned in <0.001% of 2,504,485 patients with colonic biopsies and confirmed in 0.1% of them. Less than 3% of endoscopists mentioned non-oesophageal EGID in the requisition, while most expressed a clinical suspicion of Barrett oesophagus, Helicobacter pylori gastritis, celiac disease and microscopic colitis (in 21.2%, 49.2%, 1% and 6.4% of the cases, respectively).

CONCLUSIONS

Gastroenterologists and pathologists commonly address and diagnose EoE. In contrast, both clinical suspicion and diagnosis of non-oesophageal EGID are extremely rare. Increased clinical awareness might result in a better understanding of the epidemiology and improved diagnosis of these still elusive conditions.

Utilizing Deep Learning to Analyze Whole Slide Images of Colonic Biopsies for Associations Between Eosinophil Density and Clinicopathologic Features in Active Ulcerative Colitis

BACKGROUND

Eosinophils have been implicated in the pathogenesis of ulcerative colitis and have been associated with disease course and therapeutic response. However, associations between eosinophil density, histologic activity, and clinical features have not been rigorously studied.

METHODS

A deep learning algorithm was trained to identify eosinophils in colonic biopsies and validated against pathologists' interpretations. The algorithm was applied to sigmoid colon biopsies from a cross-sectional cohort of 88 ulcerative colitis patients with histologically active disease as measured by the Geboes score and Robarts histopathology index (RHI). Associations between eosinophil density, histologic activity, and clinical features were determined.

RESULTS

The eosinophil deep learning algorithm demonstrated almost perfect agreement with manual eosinophil counts determined by 4 pathologists (interclass correlation coefficients: 0.805-0.917). Eosinophil density varied widely across patients (median 113.5 cells per mm2, interquartile range 108.9). There was no association between eosinophil density and RHI (P = 0.5). Significant differences in eosinophil density were seen between patients with Montreal E3 vs E2 disease (146.2 cells per mm2 vs 88.2 cells per mm2, P = 0.005). Patients on corticosteroids had significantly lower eosinophil density (62.9 cells per mm2 vs 124.1 cells per mm2, P = 0.006). No association between eosinophil density and biologic use was observed (P = 0.5).

CONCLUSIONS

We developed a deep learning algorithm to quantify eosinophils in colonic biopsies. Eosinophil density did not correlate with histologic activity but did correlate with disease extent and corticosteroid use. Future studies applying this algorithm in larger cohorts with longitudinal follow-up are needed to further elucidate the role of eosinophils in ulcerative colitis.

Pattern-based Histologic Approach in Very Early Onset IBD: Main Features and Differential Diagnosis

Very early onset inflammatory bowel disease (VEO-IBD) is a clinical umbrella classification composed of IBD-like diseases encompassing both classic IBD (Crohn's disease and ulcerative colitis) and monogenic disorder, both arising before 6 years of age. VEO-IBD patients present significant clinical differences from IBD occurring in older children and in adults, including more severe disease, often unresponsive to conventional IBD therapy and a greater proportion of cases featuring an underlying genetic alteration. Histologic findings of gastrointestinal biopsies can show an IBD-like pattern (both Crohn's disease-like and ulcerative colitis-like pattern), an apoptotic-like and enterocolitis-like pattern. Findings of specific morphologic alterations, such as villous blunting, apoptosis, dense eosinophilic infiltrates, lack of plasma cells and severe glandular atrophy, can suggest a monogenic disorder. Moreover, individuals with monogenic disorders may develop significant problems such as primary immunodeficiency, impacting treatment options. Finally, IBD histology in childhood can differ from that in older patients and adults. This complexity makes a differential diagnosis between IBD and other pediatric diseases involving the gastrointestinal tract difficult, especially considering that histologic features can be similar between different diseases. Without an appropriate diagnosis, the clinical course of VEO-IBD has greater potential for escalated treatment regimens involving extensive surgery and more intensive medical therapies rather than specific therapy directed toward the underlying defect. For these reasons, a pattern-based histologic approach correlated with clinical and laboratory findings with a multidisciplinary approach is fundamental to reach a correct diagnosis in an adequate clinical context.

Pathologist's approach to paediatric and neonatal eosinophilic gastrointestinal disorders

Children are not simply miniature adults. The evaluation of their gastrointestinal disorders is therefore different from that in full-grown adults and requires a particular clinical/pathologic approach.

Different studies have tried to assess the normal eosinophil distribution in the gastrointestinal tract in adults while very few studies have investigated the paediatric population, consequently complicating the pathologist’s ability in identifying an abnormal number of eosinophils in this setting of patients.

When evaluating gastrointestinal tract biopsies with eosinophilia, eosinophilic count must be considered along with other histological features like eosinophil distribution in the gastrointestinal wall, their degranulation, cryptitis and crypt abscesses, other accompanying inflammatory cells, apoptotic bodies, foreign material or microorganisms; these findings, although rarely specific, may be a useful aid for diagnosis.

Reports should not include a diagnosis of primary eosinophilic gastrointestinal disorders (EoGID) if clinical data and test results do not rule out other forms of gastrointestinal eosinophilia. A more descriptive definition like “with eosinophilic pattern” should be favoured over a specific diagnosis of “eosinophilic disorder” in order to avoid potential confusion between different entities.

Histological Scores in Patients with Inflammatory Bowel Diseases: The State of the Art

The histological assessment has been advocated as a detailed and accurate measure of disease activity in inflammatory bowel diseases (IBD). In ulcerative colitis (UC), histological activity has been demonstrated to be associated with higher rates of relapse, prolonged corticosteroid use and long-term complications, even when endoscopic remission is achieved. Therefore, histological healing may represent a potential treatment target. Several histological scores have been developed and are available today. The Robarts histopathology index (RHI) and the Nancy index (NI) are the only two recommended by the European Crohn’s and Colitis Organization (ECCO) for use in patients with UC. Conversely, in Crohn’s disease (CD), the discontinuous nature of lesions has limited standardized histological assessment. Most of the available histological scoring systems in CD are complex and not validated. The aim of this review is to comprehensively summarize the latest evidence regarding histological scoring systems in IBD. We guide the reader through understanding the importance of an accurate microscopic evaluation using validated scoring systems, highlighting the strengths and pitfalls of each score. The priorities of future research needs are also addressed.

Measuring Histologic Activity in Inflammatory Bowel Disease: Why and How

Histology is used to confirm the diagnosis of inflammatory bowel disease, exclude superimposed infections, and to evaluate for dysplasia. Histology has rarely been used to measure disease activity and guide therapy despite evidence that histologic measurements have value in predicting important clinical outcomes. More recently, there have been numerous studies supporting a role for histologic disease activity measurements in predicting a variety of outcomes including relapse, hospitalizations, steroid use, and dysplasia. The histologic assessment was superior to endoscopic measurements in many of these studies. This review will summarize the recent literature regarding histologic disease activity measurements in ulcerative colitis and Crohn disease. A detailed description of histologic scoring systems will also be provided to provide pathologists with the necessary tools to accurately measure disease activity.

Small intestinal mucosa-associated lymphoid tissue lymphoma with deep ulcer and severe stenosis: A case report

INTRODUCTION

Although eosinophils are commonly present on the mucosa of the gastrointestinal tract, various pathological conditions may cause a secondary increase in eosinophil quantity.

PRESENTATION OF CASE

A 78-year-old man was referred to our hospital due to abdominal pain. Examinations revealed an ulcerative lesion with white moss in the terminal ileum and severe stenosis on the oral and anal sides. Tissue biopsies obtained from the ulcer margins showed a predominance of chronic inflammatory cells and abundant eosinophils in addition to lymphocytes/plasma cells. Secondary causes of tissue eosinophilia were suspected; however, the diagnosis could not be confirmed because of atypical endoscopic findings. Partial resection of the ileum was performed for therapeutic and diagnostic purposes. Histopathology of the resected specimen identified a lymphoepithelial lesion with an invasive tendency. While CD20 staining was positive, MUM-1 and Bcl-6 staining were negative. Based on these findings, the lesion was diagnosed as a small intestinal mucosa-associated lymphoid tissue lymphoma (Lugano staging, stage II₁).

DISCUSSION

Hypereosinophilia in this lesion was suggested to be secondary to chronic inflammation due to tumor growth or impaired transit.

CONCLUSION

There is a type of gastrointestinal MALT lymphoma showing an invasive tendency. In such cases, it may demonstrate atypical findings and hypereosinophilia in gastrointestinal tissues.

Histopathology of non-IBD colitis practical recommendations from pathologists of IG-IBD Group

Pathologists are often called upon to diagnose colitides that differ from the two main forms of inflammatory bowel disease (IBD). These non-IBD colitides include infectious colitis, microscopic colitis, ischemic colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation colitis and diversion colitis. The diagnosis of these different disease entities relies on the histopathological examination of endoscopic biopsies of the gastrointestinal tract. This paper reviews the main histomorphological characteristics of the various Non-IBD colitides.

Glucocorticoids Improve Enteral Feeding Tolerance in Pediatric Short Bowel Syndrome With Chronic Intestinal Inflammation

OBJECTIVES

A group of short bowel syndrome (SBS) patients developed chronic intestinal inflammation while struggling weaning off parenteral nutrition (PN). They did not respond to standard management of SBS and food allergy. We treated them with glucocorticoids and described the outcome.

METHODS

Our study is a retrospective descriptive study. We reviewed records from the intestinal rehabilitation program from 2006 to 2017. We identified 15 patients whose lab values, pathology results, and clinic notes were reviewed.

RESULTS

We had more patients (n = 10) with diagnosis of gastroschisis, and more female patients (n = 9). Seven patients weaned off PN with median treatment duration of 5 months, 5 of which remained on budesonide for significant period of time (median: 7.5 months). One of these 7 patients relapsed, as the patient resumed glucocorticoids because of recurrence of chronic intestinal inflammation. Six of 15 children had significant eosinophils in their initial biopsy, 5 of these children weaned off PN whereas 1 child's gastrointestinal (GI) bleeding stopped. Four patients were not able to decrease PN calorie. Two of these patients' GI bleeding stopped, the other 2 had normalized histology.

CONCLUSIONS

For SBS children with histologically confirmed chronic intestinal inflammation, glucocorticoids may help promote enteral feeding tolerance. Glucocorticoids regimen should be chosen individually. Patients are more likely to respond if initial histology has significant eosinophilic infiltration. Patients may need to remain on glucocorticoids for over 6 months.

Histopathology of Non-IBD Colitis. A practical approach from the Italian Group for the study of the gastrointestinal tract (GIPAD)

Non-IBD colitides (NIBDC) are intestinal diseases clinically and endoscopically overlapping with Inflammatory Bowel Diseases (IBD), sometimes with a similar histological picture. NIBDC include entities such as infectious colitis, ischemic colitis, pseudomembranous colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation-induced colitis, diversion colitis, and microscopic colitis, this last including two entities: collagenous and lymphocytic colitis. The knowledge of the most useful histological features and the main clinical data for each entity is mandatory in daily clinical practice, for correct pathological diagnosis and clinical management.

Beyond Helicobacter: dealing with other variants of gastritis-an algorithmic approach

In daily practice, the presence of inflammation in gastric biopsies prompts a mental algorithm, an early question being whether the lesion present is Helicobacter-associated. If Helicobacter organisms are not found, then there is a further algorithm, governed by the predominant type of inflammatory cells present, and the presence of other features such as intraepithelial lymphocytosis, a subepithelial collagen band, granulomas, coexisting chronic inflammation, focality, and superimposed reactive changes including erosions and ulcers. Each of these generates its own differential diagnosis. If no inflammation is present, then the two major changes specifically looked for are the changes associated with hypergastrinaemia, by far the most common cause of which is treatment with proton pump inhibitors, and reactive changes. These may be present with and without accompanying inflammation, and, when the epithelial changes dominate, the term gastropathy is preferred. In this article, we present an approach to non-Helicobacter inflammation and gastropathies.

Daily Dilemmas in Pediatric Gastrointestinal Pathology

The evaluation of gastrointestinal pathology in children often requires a different approach from that in adults. In this concise review, the authors outline 3 diagnostic challenges that are often encountered in daily practice; these include eosinophilic diseases, duodenal intraepithelial lymphocytosis with preserved villous architecture, and terminal ileal inflammation in the setting of idiopathic inflammatory bowel disease.

Epidemiology of Nonesophageal Eosinophilic Gastrointestinal Diseases in Symptomatic Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Primary eosinophilic gastrointestinal diseases (EGIDs) are increasingly described disorders that include eosinophilic esophagitis (EoE), eosinophilic gastritis, gastroenteritis, and colitis. The exact epidemiology of nonesophageal EGIDs (non-EoE EGIDs) is still unclear.

OBJECTIVE

To evaluate the epidemiology of non-EoE EGIDs in adults and children referred to outpatient clinics for gastrointestinal symptoms.

METHODS

We conducted a systematic review and meta-analysis using a protocol registered and published with the international prospective register of systematic reviews (PROSPERO CRD42018111437). We searched PubMed, EMBASE, Web of Science, Scopus, and CINAHL for cohort or cross-sectional studies published since 1990, evaluating the incidence and prevalence of non-EoE EGIDs. We assessed study quality and risk of bias using items derived from the Strengthening the Reporting of Observational Studies in Epidemiology statement.

RESULTS

A total of 576 articles were identified. Ten studies with 13,377 participants were included in the analysis, with the results showing high heterogeneity. No significant publication bias was found. The overall prevalence of non-EoE EGIDs in patients with gastrointestinal symptoms was 1.9% (95% confidence interval: 0.575-3.894; I2 = 92.72%; P < .001). Because none of the examined studies were prospectively designed, incidence rates could not be determined.

CONCLUSIONS

More prospective, large-scale, multicenter studies are needed to evaluate reported data and to further investigate the epidemiology of non-EoE EGIDs and their possible risk factors and comorbidities.

Eosinophilic Gastrointestinal Diseases in Children: A Practical Review

Primary eosinophilic gastrointestinal diseases (EGIDs) represent a heterogeneous group of disorders characterized by eosinophilic inflammation in the absence of known causes for eosinophilia, selectively affecting different segments of the gastrointestinal tract. While pediatric eosinophilic esophagitis (EoE) is a well-defined disease with established guidelines, Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC) remain a clinical enigma with evidence based on limited anecdotal case reports. Large cross-sectional studies in the US defined a prevalence of EoG and EoGE ranging from 1,5 to 6,4/100.000 and from 2,7 to 8,3/100.000 subjects respectively, while the prevalence of EoC ranges from 1,7 to 3,5/100.000 subjects. Regarding the pathogenesis, it is hypothesized that EGIDs result from the interplay between genetic predisposition, intestinal dysbiosis and environmental triggers. Clinically, EGIDs might present with different and nonspecific gastrointestinal symptoms depending on the involved intestinal tract and the extension of eosinophilic inflammatory infiltrate. The diagnosis of EGIDs requires: 1. recurrent gastrointestinal symptoms, 2. increased eosinophils for high power field in biopsy specimens, 3. absence of secondary causes of gastrointestinal eosinophilia. No validated guidelines are available on the clinical management of patients with EGIDs. Evidence from case reports and small uncontrolled case series suggests the use of dietary and corticosteroids as the first-line treatments. Considering the clinical follow-up of EGIDs, three different patterns of disease course are identified: single flare, recurring course-disease and chronic course-disease. This review will focus on pediatric EGIDs distal to esophagus, including Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC).

Diagnosis of Eosinophilic Enteritis With Video Capsule Endoscopy and Double Balloon Enteroscopy With Favorable Response to Corticosteroids

Eosinophilic enteritis is a rare disease with nonspecific symptoms, often representing a diagnostic challenge. Video capsule endoscopy (VCE) has enabled examination of the full small bowel. However, capsule retention is an unfortunate complication. We present the case of a female patient admitted for abdominal pain. Appendectomy without resolution of symptoms was performed. A normal computed tomography and magnetic resonance imaging were obtained. The diagnosis was made by VCE and double balloon enteroscopy with biopsy. Asymptomatic capsule retention was resolved after corticosteroid therapy. The patient showed a favorable clinical and endoscopic response, confirmed through a second VCE after 3 months of treatment.

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.

Eosinophil counts in colonic tissue eosinophilia: Investigating specificity and sensitivity of cutoff points and comparing two counting methods

BACKGROUND/AIMS

The aim of this study was to investigate the specificity and sensitivity of eosinophil cutoff points defining the colonic tissue eosinophilia (TE) and compare the yield of reporting the highest count versus the mean of five high-power fields (HPFs).

MATERIALS AND METHODS

One hundred and seventy-one cases of colonic TE, including 22 primary eosinophilic colitis (PEC) cases, were compared to one hundred and twenty-one normal controls in the University of Jordan. The highest eosinophil count (EC) and the mean of five HPFs were recorded. The receiver operating characteristic curve (ROC) analysis was used to find the cutoff point with the best sensitivity and specificity.

RESULTS

There was no significant advantage of counting five fields over counting the most densely populated HPF. Using 30 eosinophils per HPF achieved 80% sensitivity and 65% specificity. This point is close to the mean in normal controls plus one standard deviation (SD) (29 per HPF). However, there was overlap between normal counts and TE, using 30 as a cutoff point resulted in 35% false-positive rate. There was no reliable cutoff point to differentiate PEC from secondary TE.

CONCLUSION

We recommend reporting the highest EC in colonic biopsies and using 30 as a cutoff point, bearing in mind the overlap with normal and correlating with the clinical team to not treat asymptomatic patients. Clinicopathological correlation is essential to separate PEC from secondary TE.

What is the role of histopathology in the evaluation of disease activity in Crohn's disease?

Assessment of disease activity is essential for developing and determining appropriate therapy in patients with Crohn's disease. Currently, clinical and endoscopic treatment targets have been proposed, whereas histologic assessment of disease activity is not recommended in expert guidelines. Histologic assessment of disease activity has emerged as an important tool in ulcerative colitis as persistent histological inflammation is associated with clinical relapse, corticosteroid use, hospitalisation, and development of dysplasia. Similar data for Crohn's disease is limited but emerging literature suggests that histologic evaluation of disease activity may have value. This review summarizes the recent literature regarding histologic evaluation of disease activity in Crohn's disease. Correlation between histologic, endoscopic, and other markers of disease activity are discussed. Histologic scoring systems in Crohn's disease are described and practical guidance is provided to gastroenterologists and pathologists on how to report and interpret histologic data.

Clinical and pathological profile of eosinophilic gastroenteritis

BACKGROUND

Eosinophilic gastroenteritis (EoGE) can be diagnosed on the basis of histologic criteria; however, the pathology is considered to be heterogeneous. There is no consensus on the management of this enigmatic disorder with an unknown etiology.

PATIENTS AND METHODS

Data for patients diagnosed with EoGE and followed up over a 1-year period were analyzed. Their symptoms, patterns of flares, and type of treatment were documented. The shift in peripheral blood eosinophil levels was also examined.

RESULTS

A total of 10 (mean age, 44 years; range: 31-70 years; women, 5) patients were diagnosed with EoGE. The most frequent presenting symptom was abdominal pain, and eight patients were classified with mucosal type of EoGE. Chronic disease or multiple flares were observed in seven out of 10 (70.0%) patients, and all of them had a history of allergy. Four were corticosteroid dependent (three relapsed during corticosteroid tapering and one following corticosteroid withdrawal). One of them received anti-IL5 monoclonal antibody that enabled corticosteroid dose tapering. In four patients with highly elevated initial eosinophil levels at diagnosis, the peripheral eosinophil level correlated with the amelioration and deterioration of their symptoms. The remaining three patients had a single flare without relapse. Two had no history of allergy.

CONCLUSION

EoGE is a unique disorder with a variable clinical course. Although further studies are required to confirm our observations, the presence of other allergic disorders is associated with chronicity or multiple flares. Peripheral eosinophil level may be an effective biomarker for recurrence in patients with severe systemic disorders at diagnosis.

Eosinophilic gastroenteritis: Atypical cause for chronic diarrhea in human immunodeficiency virus-associated immunosuppression

Eosinophilic gastroenteritis (EGE) is an uncommon disease in both immunocompetent and immunocompromised. We describe a 57-year-old male with human immunodeficiency virus who presented to us with chronic diarrhea. He had no history of allergies and had significant weight loss, normal systemic examination, and a complete blood count showing no eosinophilia. After an esophagogastroduodenoscopy, the diagnosis of EGE was made by histopathological findings. The symptoms started improving with the initiation of treatment with oral prednisolone.

Colonic hypereosinophilia in ulcerative colitis may help to predict the failure of steroid therapy

BACKGROUND

Although glucocorticosteroids (GS) and mesalazine are effective and widely employed to treat moderate-to-severe ulcerative colitis (UC), information regarding the factors responsible for response to such therapy is still scarce. One of these factors is thought to be an increased number of mucosal eosinophils. The aim of our study was to determine whether the presence of hypereosinophilia in colonic mucosa of UC patients might influence the short-term response to l treatment with GS and mesasalazine.

METHODS

Clinical, endoscopic, and pathologic data from patients with a recent diagnosis of moderate UC, who had not undergone treatment, were obtained, and the short-term outcome after 1 month of conventional first-line treatment (mesalazine plus GS) was evaluated.

RESULTS

There were 53 patients with a median age of 37 years (95% CI 30-47).Overall, at the end of treatment period 16 (30%) patients responded, whereas a response was not observed in the other 37 (70%) patients. Interestingly, all patients of this latter group had colonic mucosal hypereosinophilia. No significant differences were found between the two groups concerning sex and age at diagnosis, but hypereosinophilia was inversely correlated with the duration of the disease (p = 0.054), and significantly correlated to the localization of UC (p = 0.0023). In addition, The Mayo score was significantly higher in patients with hypereosinophilia (median 8; 95% CI 8-9;) when compared to patients without hypereosinophilia (median 7; 95% CI 7-7, p < 0.0001) including the Mayo endoscopic subscore (median 3; 95% CI 2-3 vs median 2; 95% CI 2-2, respectively; p = 0.007).

CONCLUSIONS

The presence of colonic mucosal hypereosinophilia may be useful to predict the short-term outcome to conventional first-line therapy in treatment-naïve UC patients. It remains to be seen whether this might be important in modifying the first-line therapy in this subgroup of patients.

In vivo Evidence for Partial Activation of Eosinophils via the Histamine H4-Receptor: Adoptive Transfer Experiments Using Eosinophils From H4R-/- and H4R+/+ Mice

Our previous in vitro studies revealed that histamine via histamine the H₄-receptors (H₄R), as compared to other stimuli, such as eotaxin or formylpeptides, rather partially activates eosinophilic granulocytes (eosinophils). In order to evaluate the H₄R-mediated activation of eosinophils in vivo, we employed dextran sodium sulfate (DSS)-induced colitis in mice, closely resembling human ulcerative colitis (UC), which is largely characterized by a local eosinophilic infiltration of the colon. IL-5-deficient BALB/c mice served as a model with reduced endogenous numbers of eosinophils, in which wild-type (H₄R^+/+) or H₄R-deficient (H₄R^−/−) eosinophils were adoptively transferred during the course of DSS-induced colitis. During the 1-week observation period, transfer of eosinophils transiently reversed the acute clinical colitis-like phenotype (body weight loss, perianal bleeding, soft stool consistency) resulting from IL-5-deficiency. This reversion was significantly more pronounced upon transfer of eosinophils from H₄R^+/+ mice as compared to those from H₄R^−/− mice. Already at the end of the observation period, the clinical effects of the transfer of H₄R^+/+ and H₄R^−/− eosinophils became similar, as were the results of the histological examination of the cola and the analyses of cytokine production in cola and in re-stimulated lymph node cells performed at this time. Thus, analyzing clinical and pathological parameters representative of colitis in this model, we demonstrate that as well as in vitro, also in vivo histamine via the H₄R only partially activates eosinophils.

Eosinophil Counts in the Small Intestine and Colon of Children Without Apparent Gastrointestinal Disease: A Meta-analysis

The aim of the current study was to review the available data regarding eosinophil density in healthy tissue specimen originating from lower gastrointestinal segments to support suggested diagnostic cutoffs widely used in clinical practice. A systematic search was performed in 3 different databases. Calculations were made with Comprehensive MetaAnalysis software using random-effects model. Cell number measurements were pooled using the random-effects model and displayed on forest plots. Summary point estimations, 95% confidence intervals (CIs), and 95% prediction intervals (PIs) were calculated. The cumulative mean cell numbers were 8.26 (95% CI 4.71-11.80) with PI of 0-25.32 for the duodenum, 11.52 (95% CI 7.21-15.83) with PI 0-60.64 for the terminal ileum, and 11.10/ high-power field (HPF) (95% CI 9.11-13.09) with PI of 0.96 to 21.23 in the large intestine and the rectum (HPF area = 0.2 mm). Previous studies included control patients with irritable bowel syndrome and functional gastrointestinal disorders. As mucosal eosinophils have a role in their pathomechanism, those patients should have been excluded. A critical point of interpreting reported data is that HPF is relative to the technical parameters of the microscopes; therefore, it is important to report findings in cell/mm. The present meta-analysis does not support the higher (>20) or lower (<10) cutoff values for healthy tissue eosinophil number. In contrast to the esophagus, there is no normal cutoff eosinophil density in the small intestine and the colon. A prospective, multicenter study to establish normal mucosal eosinophil density is clearly needed.