Eosinophilic gastroenteritis

Helicobacter pylori-negative Chronic Gastritis in Children: A Systematic Review

OBJECTIVES

To systematically review the current evidence on Helicobacter pylori-negative chronic gastritis including natural history, available therapies and outcomes.

METHODS

Articles providing data on the prevalence, treatment or outcomes of Helicobacter pylori-negative gastritis were identified through a systematic search in the MEDLINE and EMBASE databases. All original research articles from human studies until October 31, 2021, were included.

RESULTS

A total of 54 studies were included consisted of eosinophilic gastritis (n = 9), autoimmune gastritis (n = 11), collagenous gastritis (n = 16), focally enhanced gastritis (n = 6), lymphocytic gastritis (n = 5) and other causes including idiopathic gastritis and chronic renal failure related (n = 7). Most of the included studies were either cross-sectional or longitudinal cohorts except for collagenous gastritis, which mainly included case reports and case series. The prevalence of paediatric eosinophilic gastritis ranges between 5 and 7/100,000 and patients have generally favourable outcome with 50% to 70% clinical and histological response to either corticosteroids or elimination diets. Autoimmune gastritis and collagenous gastritis are extremely rare entities, commonly present with refractory iron deficiency anaemia, while lymphocytic gastritis is relatively common (10%-45%) in children with coeliac disease. Data on treatments and outcomes of autoimmune, collagenous, and focally enhanced gastritis are lacking with limited data implying poor response to therapy in the former 2 diagnoses.

CONCLUSIONS

Helicobacter pylori-negative gastritis is uncommonly reported, mainly in small cohorts, mixed adult-paediatric cohorts or as sporadic case reports. As common symptoms are not specific, thus not always result in an endoscopic evaluation, the true prevalence of these distinct disorders may be underestimated, and thus under reported.

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.

Eosinophilic gastroenteritis: diagnosis and clinical perspectives

Eosinophilic gastroenteritis (EGE) is a digestive disorder in children and adults that is characterized by eosinophilic infiltration in the stomach and intestine. The underlying molecular mechanisms predisposing to this disease are unknown, but it seems that hypersensitivity response plays a major role in its pathogenesis, as many patients have a history of seasonal allergies, food sensitivities, asthma, and eczema. Symptoms and clinical presentations vary, depending on the site and layer of the gastrointestinal wall infiltrated by eosinophils. Laboratory results, radiological findings, and endoscopy can provide important diagnostic evidence for EGE; however, the cornerstone of the diagnosis remains the histological examination of gastric and duodenal specimens for evidence of eosinophilic infiltration (>20 eosinophils per high-power field), and finally clinicians make the diagnosis in correlation with and by exclusion of other disorders associated with eosinophilic infiltration. Although spontaneous remission is reported in around 30%–40% of EGE cases, most patients require ongoing treatment. The management options for this disorder include both dietary and pharmacological approaches, with corticosteroids being the mainstay of therapy and highly effective. The subsequent course is quite variable. Some patients have no recurrences, while a few experience recurrent symptoms during or immediately after corticosteroid interruption. An alternative therapeutic armamentarium includes mast-cell stabilizers, leukotriene antagonists, antihistamines, immunomodulators, and biological agents. In this review, we provide a summary of the different diagnostic tools utilized in practice, as well as the different therapeutic approaches available for EGE management.

Eosinophilic Enteritis: A Delayed Diagnosis

Eosinophilic gastrointestinal disorders are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Patients often present with a wide range of signs and symptoms as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal. As a part of the workup, patients frequently undergo computed tomography scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59-year-old male patient presenting with 2 months of nausea, abdominal pain, and weight loss. He underwent esophagogastroduodenoscopies, colonoscopies, video capsule study, and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic and radiographic findings can be variable and are usually unpredictable. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high-power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/high-power field confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course.

Eosinophilic gastroenteritis: An unusual type of gastroenteritis

Eosinophilic gastroenteritis (EGE) is a rare disorder characterized by eosinophilic infiltration of the bowel wall with various gastrointestinal manifestations. Till date only 280 cases have been described in the literature. A high index of suspicion, by excluding other causes of peripheral eosinophilia, is a pre requisite for accurate diagnosis. EGE is an uncommon gastrointestinal disease affecting both children and adults. It was first described by Kaijser in 1937. Presentation may vary depending on location as well as depth and extent of bowel wall involvement and usually runs a chronic relapsing course. This condition can respond to low dose steroid therapy, thereby preventing grave complications like ascites and intestinal obstruction that might need surgical intervention. The natural history of EGE has not been well documented. Eosinophilic gastroenteritis is a chronic, waxing and waning condition. Mild and sporadic symptoms can be managed with reassurance and observation, whereas disabling gastrointestinal (GI) symptom flare-ups can often be controlled with oral corticosteroids. When the disease manifests in infancy and specific food sensitization can be identified, the likelihood of disease remission by late childhood is high. GI obstruction is the most common complication. Fatal outcomes are rare.

Eosinophilic gastroenteritis: an update

Eosinophilic gastroenteritis (EGE) is characterized by dense eosinophilic inflammation of one or several digestive tract sections. The symptoms include abdominal pain, weight loss, vomiting and diarrhea. Biopsy samples taken during endoscopic examination allows the diagnosis of the disease. An infiltration of >30 eosinophils per high-power field in at least five high-power fields, exhibiting signs of eosinophilic degranulation and extending to the muscularis mucosa or submucosa are all histological indications of EGE. EGE is traditionally classified into three forms depending on the depth of inflammation in the wall (mucosal, muscular or serosal). This, together with the digestive tract segments involved, determines the clinical presentation. The natural history of EGE includes three different evolutionary patterns, since patients may suffer a single outbreak, a recurrent course or even chronic disease. Corticosteroids are the most frequently used therapy for EGE; dietary treatments should be also considered. Surgery has been limited to solving obstruction and small bowel perforation.

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 gastritis: histopathological characterization and quantification of the normal gastric eosinophil content

There is limited information about normal eosinophil counts in the gastric mucosa. The purpose of this study was to evaluate the histopathology of 60 patients whose biopsies showed increased eosinophils in the gastric mucosa. We also investigated the eosinophil content in gastric biopsies from normal controls (matched for age, sex, and zip code), from patients with Helicobacter pylori gastritis, and patients with Crohn's disease. Eosinophils were counted in five random high-power fields (HPFs) and reported in eosinophils/mm(2). Involvement of the muscularis mucosae or submucosa, sheets of eosinophils, and infiltration of the gastric epithelium were also evaluated. The median eosinophil count in the study patients was 539 eosinophils/mm(2); mean±SD=653±418 eosinophils/mm(2); range 127-2108. Sheets of eosinophils were seen in 38 patients, 27 showed involvement of the muscularis mucosae or submucosa. There were 7 patients without epithelial infiltration by eosinophils, whereas 34 were tallied as rare and 19 were scored as abundant. No study patient had no evidence of H. pylori. The mean eosinophil count for the 135 normal controls was 15.5±16.8 SD eosinophils/mm(2) (range 0-110); in the 93 controls with H. pylori gastritis the mean eosinophil count was 25±32.6 SD eosinophils/mm(2) (range 0-219); and for the 53 controls with Crohn's disease it was 31.4±44.4 SD eosinophils/mm(2) (range 0-203). There were no significant differences between the counts in biopsies from the antrum and corpus, and no significant variations by age, geographic location, or season. This study confirms that, in the United States population, the normal gastric eosinophilic counts are usually <38 eosinophils/mm(2). We recommend 'histological eosinophilic gastritis' for the diagnosis of gastric biopsies that show an average density ≥127 eosinophils/mm(2) (or ≥30 eosinophils per HPF) in at least five HPFs in the absence of known associated causes of eosinophilia.

A shift in the clinical spectrum of eosinophilic gastroenteritis toward the mucosal disease type

BACKGROUND & AIMS

Eosinophilic gastroenteritis (EG) is a rare disorder characterized by eosinophilic infiltration of the gastrointestinal (GI) tract. Despite the increasing prevalence of eosinophilic GI disorders, the epidemiology of EG has not been well studied. We evaluated the clinical spectrum of EG.

METHODS

We reviewed data from patients diagnosed with EG, allergic gastroenteropathy, or eosinophilia and referred to gastroenterologists from 1987 to 2007 (n = 59; 52 with mucosal, 3 with muscularis, and 4 with subserosal disease). The study included subjects diagnosed with EG and those with a history that suggested EG, defined by GI symptoms; eosinophilic infiltration of the GI tract, eosinophilic ascites, or characteristic radiographic findings with eosinophilia; and no parasitic or extraintestinal disease. Findings were compared with those from patients with unexplained GI symptoms and peripheral eosinophilia (n = 11).

RESULTS

Associations between clinical variables and EG subgroups did not differ between patients with EG and peripheral eosinophilia. Fifty percent of patients with EG who underwent food allergy testing had a positive test result; only 32% of those with EG who underwent radiographic imaging had positive test results. Patients with EG received steroid therapy; 75% with mucosal, 67% with muscle, and 100% with subserosal disease received prednisone. Eighty-eight percent of patients who received only steroids (mean follow-up period, 7 mo) and 94% of patients who received steroids in combination with another therapy (mean follow-up period, 4 mo) had improved or resolved disease.

CONCLUSIONS

Unlike eosinophilic esophagitis, EG is rare. Results from this large study suggest that EG disease type has shifted toward that of the mucosal layer.

Pathology of non-Helicobacter pylori gastritis: extending the histopathologic horizons

The development of modern endoscopic techniques, easier and greater access to healthcare, and interest in Helicobacter pylori infection and its implications have all led to a significant increase in upper endoscopies. In turn, gastroenterologists and pathologists have been recognizing an ever-increasing number of patterns of mucosal injury. Consequently, there is now an interest in a wider aspect of non-neoplastic gastric pathology, namely, non-HP (H. pylori) gastritis. In this review, we present major clinico-pathological entities, based on either the salient morphological features or the underlying etiologies.

Histopathology associated with eosinophilic gastrointestinal diseases

Eosinophilic gastrointestinal diseases (EGIDs) are broadly defined as diseases that characteristically exhibit excessive numbers of eosinophils, in normal and abnormal locations, in one or more gastrointestinal tract segments. EGIDs have multiple possible etiologies. Pathologists must avoid overdiagnosis of EGIDs by applying site-specific criteria for eosinophil density to mucosal biopsy specimens. Gastroenterologists must avoid contributing to overdiagnosis by submitting biopsy samples from each segment of the gastrointestinal tract separately, especially from the colon where the maximum mucosal eosinophil density in the right side normally exceeds that of the more distal colon. More studies of normal tissue and tissue from patients who are known or suspected to have EGIDs, with clinicopathologic correlations, are required to more fully define the spectrum of histopathology in EGIDs.

Evaluation of site-specific and seasonal variation in colonic mucosal eosinophils

Several systemic disorders and gastrointestinal diseases may be associated with increased colonic mucosal eosinophils, which may vary in number throughout the normal colon. Some investigators have proposed that colonic eosinophilia reflects allergen exposure, although this hypothesis has never been validated, and values quantifying the number of mucosal eosinophils that can be regarded as a normal finding are lacking. The aims of this study were to determine the number of intramucosal eosinophils normally present throughout the colon and evaluate the relationship between colonic eosinophilia and seasonal allergen exposure. Eosinophils in the crypt epithelium and lamina propria were evaluated in 198 mucosal biopsy specimens obtained from the ascending (n = 98) and descending (n = 100) colon of patients with normal colonoscopic examinations. The cases were stratified into 12 groups, reflecting the months during which the samples were obtained, and the mean number of mucosal eosinophils was determined for each group. Daily air pollen counts were recorded, and the mean determined for each month. Fifty-five percent of mucosal biopsy specimens from the ascending colon contained eosinophils in the crypt epithelium, compared with only 5% of biopsy specimens from the descending colon (P < .001). Lamina propria eosinophils were, on average, 3 times more numerous in the ascending compared with the descending colon (P < .001). Mucosal eosinophils were slightly more numerous in samples obtained in April and May, corresponding to periods of highest pollen counts, but this relationship was not significant (P > .05). We conclude that intramucosal eosinophils are commonly present in the proximal colon but show only mild fluctuations with ambient allergen exposure.

Pathology of non-infective gastritis

The discovery of Helicobacter pylori and its intimate role in the development of the most common form of chronic gastritis has elicited a much-needed interest in non-neoplastic gastric pathology. This has been paralleled by an increase in upper endoscopic examinations, which allow recognition of novel patterns and distribution of mucosal injury. Numerous attempts at classification have been made, most based on the acuteness or chronicity of gastric mucosal injury. In this review, we will not offer a new classification but present a detailed description of the major clinicopathological entities, based either on the salient morphological features or the underlying aetiologies, i.e. iatrogenic, autoimmune, vascular or idiopathic.

Rare case of inflammatory fibrous polyp of the esophagus

Esophageal inflammatory fibrous polyps are extremely rare benign neoplasms. The manuscript illustrates a case of a man complaining of pyrosis and gastroesophageal reflux symptoms. Diagnostic work-up showed an expansive lesion of the distal esophagus simulating malignancy but with negative, repeated, multiple biopsies. The considerable size of the lesion, and the suspicion of a malignant tumor because of the presence of ulceration, indicated esophagectomy with extensive lymphadenectomy and intrathoracic esophagogastroplasty. The diagnosis of inflammatory polyp of the esophagus was achieved postoperatively. The Discussion deals with a review of the literature and considers the performed operation a good choice considering the hypothesis of a malign neoplastic evolution of this lesion.

[Allergy-associated colitis. Characterization of an entity and its differential diagnoses]

There is substantial evidence that allergic reactions exist in the gastrointestinal tract (GI). However, patients with food allergy-related enteropathy pose a diagnostic challenge to physicians because the clinical features are variable, unspecific, occur in other gastrointestinal disorders, and specific diagnostic tools are missing. Several recent studies and reviews have focused on the function of eosinophilic granulocytes in GI disease. The role of eosinophils in the pathophysiology of GI hypersensitivity reactions is poorly defined. However, some findings have been reported that imply an involvement of eosinophils in allergic reactions of the gut. The presumptive histology of allergy-associated colitis in colonic and ileal biopsies is based on prominent pure eosinophilic infiltration of a normal lamina propria, submucosa and epithelium with variable degrees of degranulation. An immunoperoxidase stain for eosinophilic peroxidase is supportive in establishing the diagnosis if suspected. Neutrophils or mononuclear infiltrates are not significantly increased and damage to the intestinal tissue is not prominent. Despite characteristic histologic changes in colonic biopsy specimens, a final diagnosis depends on careful clinical examination and exclusion of several differential diagnoses.

The differential diagnosis of eosinophilic esophagitis

Eosinophilic esophagitis is a morphologic finding that may result from a wide spectrum of clinical conditions. The distinctive histological features accompanying eosinophilic esophagitis may facilitate the diagnosis of the underlying disease entity. Unfortunately, there are no pathognomonic histologic characteristics associated with eosinophilic esophagitis. Clinical signs and symptoms, immunological markers, endoscopic findings, and response to therapy may help establish or confirm the diagnosis of a clinical condition that results in eosinophilic esophagitis. The following discussion outlines the causes of eosinophilia in an esophageal biopsy sample.

Eosinophilic gastroenteritis

The goal to create a standardized diagnostic classification scheme of food-related gastrointestinal hypersensitivity disease syndromes included the diagnosis of eosinophilic gastroenteritis. This article reviews the history of this diagnosis and the current concepts of this complex disorder. The common symptoms from the literature are discussed. Because no standards for this diagnosis exist, the wide variety of diagnostic criteria from the literature are presented. No consistent immunologic abnormalities have been associated with the diagnosis of eosinophilic gastroenteritis in the literature. A review of the current immunologic concepts associated with the diagnosis of eosinophilic gastroenteritis is presented. The history of this disorder, which spans more than 6 decades is also discussed. The contributions made by the original authors during this period are presented. Attention was directed to the variety of clinical features associated with this disorder, but particular attention was paid to the evolution of the pathophysiologic mechanisms proposed. Some of the difficulties associated with the prospective study of patients with eosinophilic gastroenteritis are also discussed. The establishment of appropriate control populations, as well as the fundamental difficulties encountered with the establishment of the certainty of the link between abnormal immunohistochemical findings, and initial clinical symptoms are presented and discussed. A new classification system is proposed for food-related gastrointestinal hypersensitivity disease syndromes. Age, symptoms, and the region of the gastrointestinal tract involved were the variables that were considered most important by consensus opinion. Finally, recommendations to refocus our collective investigative efforts are presented.

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

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

Esophageal inflammatory fibroid polyp. Endoscopic and radiologic features

We present the case of a 60-year-old male patient, who had several episodes of melena during the last years. One month ago he had a new episode of digestive bleeding, and an endoscopic study was performed that showed at 35 cm from the dental arcade a polypoid, pedunculated lesion, with a diameter of 5 cm and a submucosal aspect, a few erosions on its surface and a fibrin deposit. Its head reached the cardia, and it bled when touched by the endoscope. The biopsies taken were negative. X-ray and CT studies confirmed the existence of a mass compatible with a submucosal lesion. The patient was operated and the tumor was excised. The histologic study showed an inflammatory fibroid polyp, an entity very rarely described at the level of the stomach, duodenum, small intestine, and colon and exceptionally described at the esophageal level.

Localized eosinophilic gastroenteritis with necrotizing granulomas presenting as acute abdomen

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

Occult enteric infection by Ancylostoma caninum: a previously unrecognized zoonosis

BACKGROUND/AIMS

Human disease caused by the canine hookworm Ancylostoma caninum and a high incidence of eosinophilic enteritis have been reported from northern Queensland, Australia. The aim of this study was to evaluate patients with unexplained abdominal pain and a possible association with cryptic infections by A. caninum.

METHODS

The clinical and demographic features of patients from this region with eosinophilic enteritis (group A1, n = 42), obscure abdominal pain associated with (group A2, n = 105) and without (group A3, n = 84) blood eosinophilia were reviewed and sera were tested against A. caninum excretory-secretory antigens by enzyme-linked immunosorbent assay (ELISA) and Western blot. Four additional patients, two with confirmed A. caninum, had hookworm infection.

RESULTS

The level of dog ownership in these four groups was 79%-100%, higher than in the local population (P < 0.001). The ELISA tested positive in 71% of A1, 67% of A2, and 30% of A3, versus 8% in controls (P < 0.002). All cases tested were positive on Western blot versus 10% of controls (P < 0.0001). The ELISA values increased with chronicity and decreased during convalescence.

CONCLUSIONS

We conclude occult human A. caninum infections are common and are characterized by eosinophilic enteritis and obscure abdominal pain with or without blood eosinophilia. The diagnosis can be confirmed by serology.

Collagenous colitis, eosinophilic colitis, and neutropenic colitis

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

Pathological mimics of chronic inflammatory bowel disease

When all of the macroscopic and microscopic features of Crohn's disease and ulcerative colitis are present, the correct diagnosis is usually made without difficulty. When some of the changes are absent, the accuracy of diagnosis is reduced. This review has outlined those diseases which feature some of these pathological changes and may masquerade as idiopathic chronic inflammatory bowel disease. Some of the pathological mimics are iatrogenic while other common diseases, such as bacterial infection, ischaemia, and diverticulosis may produce confusing histological appearances. The picture is complicated by the fact that many of these pathological imitators may themselves cause or predispose to chronic inflammatory bowel disease, or may complicate chronic inflammatory bowel disease. For example, drugs and infectious agents are recognisable causes of relapse in ulcerative colitis; Crohn's disease may cause diverticulitis in patients with diverticulosis; and lymphoma may complicate ulcerative colitis. It behooves all practising histopathologists to recognise these mimics of ulcerative colitis and Crohn's disease to ensure appropriate management for patients with inflammatory pathology of the intestines.

The spectrum of eosinophilic gastroenteritis. Report of six pediatric cases and review of the literature

Eosinophilic gastroenteritis is an inflammatory disease of unknown etiology characterized by infiltration of the gastrointestinal tract with eosinophilic leukocytes, accompanied by varying abdominal symptoms and usually by peripheral blood eosinophilia. We report our experience with six pediatric cases presenting to the Cleveland Clinic Foundation over the past eight years. Unusual findings in our patients included ascitic fluid without eosinophilia and eosinophilic pericarditis (one patient), and eosinophilic cholecystitis (one patient). Endoscopic examination and biopsy helped to establish the diagnosis in all patients. Bone marrow aspiration supported the diagnosis by demonstrating eosinophilia and identifying reactivation of the disease, even in cases without peripheral eosinophilia. All six patients responded promptly to prednisone. Diagnosis is challenging and eosinophilic gastroenteritis may be more common than is recognized. This series of cases significantly expands the spectrum of the disease in children, and documents the usefulness of diagnostic endoscopy in this condition.

Benefit of ketotifen in patients with eosinophilic gastroenteritis

PURPOSE

Eosinophilic gastroenteritis (EG) is a rare condition of unknown etiology characterized by vomiting, diarrhea, protein-losing enteropathy, and eosinophilic infiltration of the gastrointestinal mucosa. The potential association of EG with allergy and related mast-cell release of mediators led us to evaluate the ability of an antihistamine drug to modify the course of the disease.

PATIENTS AND METHODS

Six patients with protracted gastrointestinal symptoms were diagnosed with EG because of histologic evidence of predominantly eosinophilic infiltrates in the gastrointestinal mucosa. Each patient was treated in an open trial for 12 months with ketotifen (Zaditen), an antihistamine of the H1 class that is known to stabilize mast cells.

RESULTS

All six patients improved clinically; four also gained weight. Total serum IgE levels decreased after 4 to 6 months of therapy. Clearing of eosinophilic infiltrates was documented in the four patients who underwent follow-up mucosal biopsies.

CONCLUSION

We conclude that ketotifen treatment represents a safe and effective alternative to traditional systemic corticosteroid therapy for treatment of EG.

Human eosinophilic enteritis caused by dog hookworm Ancylostoma caninum

An epidemic of eosinophilic enteritis (93 cases) has occurred in Townsville, northern Queensland, Australia. A hookworm was found attached to a resected, inflamed ileal segment from 1 patient but the species could not be identified. An adult hookworm of species Ancylostoma caninum was recovered at colonoscopy from the terminal ileum of a later patient. All of 38 patients interviewed in an epidemiological survey described behaviour which could have exposed them to infective larvae of this widespread dog parasite.

Sodium cromoglycate in the treatment of eosinophilic gastroenteritis

Two patients suffering from eosinophilic gastroenteritis (EG) were treated with sodium cromoglycate (SCG). Before treatment they showed enteric and cutaneous symptoms, such as abdominal pain, nausea, vomiting, diarrhoea and recurrent urticaria and angioedema. The histological findings were a notable amount of eosinophilic infiltration in the lamina propria and gastric glands, a villous shortening and thickening and weak eosinophilic inflammation in the duodenum. The patients were treated with 300 mg SCG, 4 times daily, for 4/5 months. During treatment, the clinical symptoms disappeared and at the end of treatment a reduced inflammation with an almost complete decrease of eosinophilic infiltration was observed. The results provide evidence of SCG efficacy in the treatment of EG and suggest its employment as an alternative to the steroids commonly used in EG.

Milk-sensitive eosinophilic gastroenteritis in a 10-day-old boy

Eosinophilic gastroenteropathy in children is a rare, idiopathic disease characterized by eosinophilic infiltration of the gastrointestinal tract. We describe a 10-day-old boy with aspecific clinical manifestations (unconsolable crying). Treatment with a semi-elemental diet was successful, suggesting a "milk-sensitive enteropathy", although he had been exclusively breast fed. Recent literature is reviewed.

Eosinophilic enteritis--a recent north Queensland experience

Thirty-three patients have been investigated in Townsville between 1983 and 1987 with eosinophilic enteritis. All were Caucasian and had been well prior to this illness. Twenty-six had similar presentations with episodic and transient abdominal pain often with features of small bowel obstruction. Four patients presented with pain and diarrhoea, two with chronic diarrhoea and one with recurrent melena. All patients at some stage during their illness developed high peripheral blood eosinophil counts, mean value 2096/mm3. Nine patients had laparotomies. The disease typically involved a short segment of ileum or jejunum with thickening and induration. The histology of the four resected specimens demonstrated a transmural inflammation with edema and an intense eosinophilic infiltrate. A solitary adult hookworm was identified in one patient adherent to the mucosa of the resected bowel. Each of the 19 patients treated with antihelminthic drugs responded promptly. Recovery was accompanied by a return to normal peripheral blood eosinophil counts. This paper reports an unusual form of eosinophilic enteritis thought due to a parasitic infection. The diagnosis should be considered in patients from North Queensland presenting with abdominal pain and eosinophilia. Laparotomy should be delayed pending a trial of conservative therapy with mebendazole.

Two cases of eosinophilic enteritis presenting as large bowel perforation and small bowel haemorrhage

Two cases of eosinophilic enteritis are reported, presenting as large bowel perforation and upper gastrointestinal bleeding respectively. These modes of presentation appear to be unique in the literature.

Malignant lymphoma with eosinophilia of the gastrointestinal tract

Lesions of the gastrointestinal tract with massive tissue eosinophilia may present a difficult diagnostic problem. In a series of 250 gastrointestinal lymphomas drawn from the files of St Bartholomew's and St Mark's Hospitals there were 28 cases of a lymphoma with distinctive histological features, characterized by a massive tissue eosinophilia. Two of these tumours were present in the stomach and 26 in the small intestine. Eight of the latter were associated with coeliac disease. On low power examination a zoning phenomenon was regularly seen and fissuring ulceration, with perforation and fistula formation, was a common finding. The tumour cells were large and pleomorphic with irregular nuclear morphology and prominent nucleoli. Eosinophils were the predominant inflammatory cell associated with the lymphoma but plasma cells, epithelioid histiocytes and small lymphocytes were also present. Vascular changes were prominent. Involved lymph nodes showed gross expansion of the paracortex by tumour. Immunohistochemical studies showed that this lymphoma was probably of T-cell origin.

Eosinophilic leucocytes and phospholipase B of rat tissues

The correlation between the eosinophilic leucocyte population and the phospholipase B activity of rat tissues has been tested with isolated cell preparations from intestine, lung, blood, bone marrow and spleen containing eosinophils in varying proportions and with pure eosinophil fractions separated by centrifugation on discontinuous metrizoate and metrizamide gradients. A uniform value of activity per cell was found in all these tissues extending previous histochemical and biochemical evidence that the eosinophil is the carrier cell for the phospholipase B to all major sites of distribution. The enzyme marker approach has been used for estimating the normal eosinophil population of rat organs and show the distribution pattern of the eosinophils in peripheral organs in the wake of increased production and release from the marrow.

Eosinophilic infiltrates of the gastrointestinal tract

There are two lesions which are often confused despite their quite distinct clinical and pathological differences: the inflammatory fibroid polyp and eosinophilic gastroenteritis. Other eosinophilic lesions likely to be encountered in the gut also pose problems of differential diagnosis.

Eosinophilic colitis

Eosinophilic gastroenteritis, a condition of unknown etiology, has frequently been reported involving the stomach and small bowel. The colon is rarely cited as a site for the condition; however, a review of the literature reveals over 20 cases (including ours). The findings indicate that the colon is now a recognized, but rare, site of involvement and that the condition can be diagnosed via the colonoscope. No clear-cut etiology can be defined, but the presence of allergy (33 percent) and of the herring worm (two cases) is noted.

Multiple and recurrent inflammatory fibroid polyps in three generations of a Devon family: a new syndrome

The recurrence of multiple inflammatory fibroid polyps is reported in three generations of a Devon family. Only one female in each has been affected in a direct line of descent. The grandmother has had nine polyps resected over 11 years, the mother seven over 18 years, and the daughter six over six years. None of the patients or their relatives are known to have any allergies, dietary fads, or gastrointestinal infections. Chromosome studies have been normal in two patients. No cancer risk has been identified. Conventional histology, electron microscopy, and immunohistology suggest that the lesion is a self-limiting proliferation of histiocytes; the initiating event or stimulus remains unknown. A genetic factor is likely to operate in this unique family which is probably polygenic and multifactorial in nature.

Eosinophilic transient synovitis

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Inflammatory fibroid polyps of the gastrointestinal tract. An immunohistochemical and electron microscopic study

Seven cases of inflammatory fibroid polyp (IFP) are studied, two of them with electron microscopy. The morphologic findings suggest a myofibroblastic origin for the proliferating cells. Other histogenetic hypothesis which propose a neural or vascular nature for this lesion are ruled out. The ultrastructural features of the proliferating cells are different from schwann and endothelial cell tumors. Moreover, the immunohistochemical technique to detect Factor VIII related antigen was negative in the intercapillary cells of the seven cases. Our conclusion is that inflammatory fibroid polyp of the gastrointestinal tract represent a reactive lesion of myofibroblastic nature.

Pseudotumoral enterocolitis and massive eosinophilia

We report a seven year history of a 23 year old woman born in the Antilles, with pseudotumoral enterocolitis and massive eosinophilia. In 1973 she developed a haemorrhagic colitis with massive peripheral eosinophilia of up to 60000/mm3. Medical treatment, mainly corticosteroids, failed to control the disease. The patient temporarily improved after colectomy and remained in remission for two years. In 1978 the disease recurred in the rectum and small intestine with formation of tumour-like granulomata and massive infiltration by eosinophils, unresponsive to corticosteroids. Intestinal blood and protein loss continued until death seven years after onset. In spite of exhaustive investigation, no parasites, allergens, or other aetiological agents could be found. As only the gut was infiltrated, the hypereosinophilic syndrome could be excluded. The enterocolitis here described does not correspond to an eosinophilic gastroenteritis, nor to other known inflammatory bowel diseases and to our knowledge has not been reported previously.

Eosinophilic gastroenteritis presenting as acute intestinal obstruction

Eosinophilic gastroenteritis is an uncommon condition which usually affects the antrum of the stomach and may occasionally involve the small or large intestine (1). The main clinical feature is usually that of chronic colicky abdominal pain. We report a case presenting as acute small intestinal obstruction due to isolated involvement of the distal small intestine.