Eosinophilic granuloma of the gastro-intestinal tract

Langerhans cell (eosinophilic) granulomatosis. A clinicopathologic study encompassing 50 years

We summarize our experience with 238 cases of Langerhans cell granulomatosis (LCG), 198 of whom were followed for a median period of 10.5 years. Our patients did well unless overtreated, and no deaths were attributed to the disorder itself. The disease may appear in unifocal or multifocal form, and treatment is based on this fact. Virtually all patients recovered completely except for occasional residual orthopedic problems or residual diabetes insipidus. Several of the patients underwent subsequent pregnancies without difficulty. The granulomas primarily occur in bone, but lung, skin, and lymph nodal involvement is not uncommon. Involvement of thyroid, thymus, and other sites is rare. The hallmark of the disease is the accumulation of Langerhans cells (LCs). We review the pathology of LCG by histology, electron microscopy, and immunolabeling. LCs originally were identified in squamous epithelium, but these cells are part of the widespread system of dendritic cells. The latter cells, which arise from CD34+ progenitors, are specialized and efficient antigen-presenting cells for T-cell-mediated immunity. In LCG, however, the major associated cells are not T cells, but mature eosinophils: hence the original name eosinophilic granuloma. Confusion about terminology has been based upon the scanty and rather crude pathology reports in the original literature. The term histiocytosis X was meant to cover a spectrum of three diseases--eosinophilic granuloma, Hand-Schüller-Christian disease (HSC), and Letterer-Siwe disease (LS)--but HSC and LS have no basis in pathology and hence the terms are meaningless. The term HSC has become a synonym for multifocal eosinophilic granuloma (LCG). The term LS has been used in reporting a number of benign, malignant, or unknown conditions. We prefer the term LCG to avoid confusion with the term histiocytosis X because there is evidence that the LC is not a member of the mononuclear phagocyte system and hence not a tissue macrophage, and because the use of the term "histiocyte" has become a convenience in much of the literature when reporting incompletely understood diseases.

Eosinophilic gastroenteritis

A review was undertaken of 220 case reports of eosinophilic gastroenteritis involving the gastrointestinal tract, with particular regard to its clinical presentation and management. The stomach was the single commonest site of involvement (43%), while 36% were found to have two or more sites of disease at the time of presentation. The most common presenting symptoms were episodic abdominal pain (77%) and diarrhoea (42%). A history of allergy was present in 52% of patients, while 8% reported aggravation of symptoms following the ingestion of certain foods. Two thirds of patients had reported symptoms of more than six months duration prior to diagnosis, while in 26%, five years or more had elapsed. Although surgical intervention was undertaken in 44% of patients at some stage in their management, the most successful mode of management was the institution of steroid therapy, where 90% reported rapid clinical improvement. There is no evidence that patients with eosinophilic gastroenteritis have a higher incidence of subsequent gastrointestinal malignancies.

Psychogenic vomiting: the relation between patterns of vomiting and psychiatric diagnoses

Fifty nine patients admitted with a diagnosis of psychogenic vomiting were classified into five patterns of vomiting: continuous, habitual postprandial, irregular vomiting, nausea, and self induced. The psychiatric disorders related to the onset of vomiting were either a major depression or a conversion disorder. Continuous vomiting was usually due to a conversion disorder, while in many cases of habitual postprandial and irregular vomiting, major depression was observed. The patients' psychiatric disorders and vomiting patterns often changed during the clinical course. Assessing the psychiatric problems and vomiting patterns is important in the diagnosis and treatment of psychogenic vomiting.

Eosinophilic granuloma of the stomach

Two patients with eosinophilic granuloma of the stomach are discussed. The first patient had extensive and time-consuming investigations before the diagnosis was confirmed after surgery, while the second patient's presentation corresponded so closely to the first that a correct preoperative diagnosis was entertained with a minimum of investigations and delay. The barium-meal examinations in both patients were very typical of the condition, but the endoscopy findings and biopsy histology reports were noncontributory. Neither of the patients had a history of allergy or eosinophilia. The lesions were localized to the distal part of the stomach and the resected specimens were microscopically typical of eosinophilic granuloma of the stomach.

Inflammatory fibroid polyp of the rectum

A case of inflammatory fibroid polyp of the rectum in an 8 years old boy is reported. This lesion is not infrequently found in the gastro-intestinal tract, is very rare in childhood and has never been reported in the rectum. The pathogenetical hypothesis that fibroid represents a dynamic response to recurrent small injuries with possible different histological patterns is prospected.

Benign histiocytosis X of stomach. Previously undescribed lesion

Histiocytosis X of the stomach of a 47-year-old Japanese woman, who underwent subtotal gastrectomy following a clinical diagnosis of scirrhous carcinoma, was studied by light and electron microscopy as well as by immunohistochemistry. The histiocytoid cells proliferated monotonously in the lamina propria mucosae of the atrophied mucosa covering the body and fornix. They were arranged in a sheet- or pavement stone-pattern and included some giant cells. The histiocytoid cells had a reniform to irregularly indented nucleus and conspicuous cytoplasm. Ultrastructurally, they were characterized by interdigitating cytoplasmic extensions and abundant tubulovesicular structures including Langerhans granules. S-100 protein, alpha 1-antitrypsin, and alpha 1-antichymotrypsin were immunohistochemically identified in the cytoplasm. Endoscopic biopsies of the extragastric digestive tract, a biopsy of the lymph node, and bone marrow aspiration excluded a systemic disorder. The case is regarded as benign localized histiocytosis X of the stomach, a previously undescribed gastric lesion.

Eosinophilic gastroenteritis in the pediatric patient

Eosinophilic gastroenteritis is a diagnosis to be entertained whenever a patient had abdominal complaints accompanied by striking peripheral eosinophilia. A definitive diagnosis is of greater importance in this illness, since undiagnosed cases often undergo needless exploratory surgery. An infant seen at 2 years, 10 months of age with abdominal pain, nausea, and vomiting was found to have a white blood cell count of 50,000/cu mm with 54% eosinophils and eosinophilic ascites. An antral tissue biopsy yielded a diagnosis of eosinophilic gastroenteritis after many studies had been made to exclude other diagnoses. Treatment with intermittent courses of prednisone kept the patient relatively asymptomatic over the period of 20 years during which she remained under our care. Immunologic studies shed no light on the etiology of this patient's disorder. The literature dealing with diffuse, infiltrative eosinophilic gastroenteritis is reviewed.

The spectrum of eosinophilic infiltration of the gastrointestinal tract and its relationship to other disorders of angiitis and granulomatosis

Six cases of eosinophilic infiltration of the gastrointestinal tract were studied. Three cases were of the diffuse infiltrative variety (eosinophilic enteritis, two cases; eosinophilic peritonitis, one case), and three cases were of the circumscribed variety (so-called inflammatory fibroid polyp). Two of the infiltrative lesions showed necrotizing granulomas identical to those described by Churg and Strauss; one of the two also showed active vasculitis. One circumscribed lesion occurred in a patient with polyarteritis nodosa. Necrotizing eosinophilic granulomas were also noted in this lesion. Our observations suggest that the two forms of eosinophilic infiltration of the gastrointestinal tract are parts of a disease spectrum. Supporting evidence in the literature is presented. The relationship of this group of eosinophilic lesions to the hypereosinophilic syndrome, allergic granulomatosis and angiitis of Churg and Strauss, and polyarteritis nodosa is discussed.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis is an uncommon condition affecting one or more segments of the gastrointestinal tract, mainly the stomach and small bowell, the principal changes being a variable degree of both oedema and eosinophilic infiltration. Occurring at any age it is commonest in the third decade, is often associated with abdominal pain and peripheral blood eosinophilia, and responds to steroids: allergy or asthma occurs in some 25% of patients. The oedema and eosinophilia involve the submucosa generally but any layer of the gut may be affected. The aetiology is discussed: no allergic or other cause has been determined and it is probable that further knowledge of the role of the eosinophil may be necessary before the precise nature of the lesion can be understood. An association of eosinophilic gastroenteritis with malabsorptive or protein-losing enteropathies is noted.

Co-existent eosinophilic gastroenteritis and hypothalamic-pituitary dysfunction

A case of eosinophilic gastroenteritis in a 42-year-old man is described. The patient had diarrhoea, faecal blood loss, a protein-losing enteropathy, malabsorption of fat, xylose and vitamin B12. Co-existent hypopituitarism, diabetes insipidus and hypothalamic dysfunction was demonstrated. Complete clinical recovery occurred with pituitary replacement therapy alone. The association of this endocrine abnormality with the picture of eosinophilic gastroenteritis has not previously been described.

Eosinophilic gastroenteritis

Two cases of eosinophilic gastroenteritis are reported, with a discussion of eosinophilia in general and the incidence of various disorders which may be associated with it.

Inflammatory pseudotumors (inflammatory fibrous polyps) of the esophagus. A clinicopathologic study

When they involve the gastrointestinal tract, inflammatory pseudotumors, composed of inflamed fibrous and granulation tissue, produce localized, frequently polypoid, masses. These rare lesions have been described in the stomach, small intestine, and colon. Only two have been previously reported in the esophagus. In this paper, 4 cases of inflammatory pseudotumor involving the esophagus are presented. These lesions usually occur in the esophagus as raised, occasionally pedunculated, masses and may be mistaken on radiologic examination and in the operating room for a neoplasm, usually a leiomyoma. Theories concerning pathogenesis of these lesions are considered and the differential diagnostic criteria are discussed.

Inflammatory pseudotumors (inflammatory fibrous polyps) of the small intestine: A clinicopathologic study

The clinical and pathologic features of 25 inflammatory pseudotumors of the small intestine are reported. These rare lesions, which clinically may simulate neoplasms, consist of localized, frequently polypoid masses composed of inflamed fibrous and granulation tissue. Inflammatory pseudotumors may produce intussusception and small-bowel obstruction. Some are found at laparotomy performed for other reasons. The diagnosis of inflammatory pseudotumor usually can not be made until the lesion is examined histogically. Their etiology remains unknown, but their relationship to intestinal ulceration is discussed. Problems in differential histologic diagnosis are considered.

Eosinophilic granuloma of the ileum

A case of eosinophilic granuloma of the ileum is described in association with a high (50%) eosinophil count. A review of published suggested classifications, aetiology and therapy is made.

Non-osseous eosinophilic granuloma presenting as acute transverse myelitis

A patient with non-osseous eosinophilic granuloma presenting as acute transverse myelitis is documented. This is believed to be the first recorded case with such a presentation. Some aspects of the disease are discussed.