Eosinophilic Gastroenteritis: Using Presenting Findings to Predict Disease Course

Eosinophilic gastroenteritis: Imaging spectrum on intestinal ultrasonography and CT enterography

RATIONALE AND OBJECTIVES

Diagnostic delays are common in eosinophilic gastroenteritis (EGE). This study aimed to evaluate the value of imaging modalities in facilitating the diagnosis of EGE.

MATERIALS AND METHODS

Patients diagnosed with EGE who underwent either intestinal ultrasound (IUS) or computer tomography enterography (CTE) were retrospectively recruited. Medical records were reviewed for clinical information, while IUS and CTE images were reviewed to summarize characteristic findings. Imaging characteristics of EGE subtypes were also evaluated.

RESULTS

A total of 51 patients were included, with 30 undergoing IUS examinations and 42 undergoing CTE examinations. Positive findings were observed in 22 (73.3 %) patients on IUS and 32 (76.2 %) on CTE. In both modalities, the small intestine was the most commonly involved site (88.9 % on IUS and 90.6 % on CTE), with lesions predominantly diffuse (72.2 % on IUS and 75.0 % on CTE). IUS also revealed clear bowel wall stratification in 94.4 % of patients and identified a specific "piano key sign" in 22.2 % of patients. Thirty-six (70.6 %) patients were categorized into the mucosal subtype, 4 (7.8 %) muscular subtype, and 11 (21.6 %) serosal subtype. Most patients with the muscular and serosal subtypes exhibited typical manifestations (100 % and 81.8 %, respectively), while 63.9 % of patients with the mucosal subtype showed unremarkable or nonspecific imaging findings. No significant differences of baseline imaging characteristics were found between relieved and relapsed groups (P = 0.13).

CONCLUSION

Characteristic imaging findings of EGE include small intestine involvement, diffuse lesions, clear bowel wall stratification, and the "piano key sign". Imaging modalities can be useful tools to facilitate the diagnosis of EGE, especially for the muscular and serosal subtypes.

The Natural History of Eosinophilic Gastrointestinal Diseases Is Influenced by Age of Onset and Location of Involvement

INTRODUCTION

It is unknown whether concomitant esophageal involvement or anatomic location of eosinophilic infiltration affects the natural history of eosinophilic gastrointestinal disease (EGID).

METHODS

A retrospective cohort study was performed using the University of North Carolina EGID Clinicopathologic Database. Patients were adults and children with a prior EGID diagnosis based on clinicopathologic features. Demographics, clinical characteristics, treatment information, and procedural data were extracted from medical records. Clinical course and flare history were characterized.

RESULTS

Among 97 patients, 43% had EGID + esophageal involvement and 57% had EGID only. Patients with esophageal involvement had a longer diagnostic delay preceding diagnosis (36.6 vs 11.6 months, P = 0.001), more dysphagia (50% vs 18%; P = 0.001), required more chronic therapy (77% vs 52%, P = 0.016), and exhibited more progressive disease (25% vs 6%, P = 0.027). A continuous disease course was most common in eosinophilic gastritis (78%) while patients with eosinophilic gastritis + eosinophilic enteritis (29%) and eosinophilic enteritis + eosinophilic colitis (50%) had the highest proportion of progressive and relapsing disease, respectively ( P = 0.045). A continuous disease course occurred more frequently in children (71%, P = 0.03) and those with single organ involvement (65%), whereas adults had more relapsing (39%) or progressive disease (18%).

DISCUSSION

EGIDs with and without esophageal involvement display many similarities, although patients with esophageal involvement more frequently had dysphagia, had progressive disease courses, and required more chronic therapy. Location of involvement and age of onset affected the natural history with higher proportions of relapsing or progressive disease seen in adults and patients with small bowel or multiorgan involvement while a continuous disease course was more common in children and patients with gastric-only involvement.

Long-term prognosis and its associated predictive factors in patients with eosinophilic gastroenteritis

BACKGROUND

Eosinophilic gastroenteritis (EGE) is a chronic recurrent disease with abnormal eosinophilic infiltration in the gastrointestinal tract. Glucocorticoids remain the most common treatment method. However, disease relapse and glucocorticoid dependence remain notable problems. To date, few studies have illuminated the prognosis of EGE and risk factors for disease relapse.

AIM

To describe the clinical characteristics of EGE and possible predictive factors for disease relapse based on long-term follow-up.

METHODS

This was a retrospective cohort study of 55 patients diagnosed with EGE admitted to one medical center between 2013 and 2022. Clinical records were collected and analyzed. Kaplan-Meier curves and log-rank tests were conducted to reveal the risk factors for long-term relapse-free survival (RFS).

RESULTS

EGE showed a median onset age of 38 years and a slight female predominance (56.4%). The main clinical symptoms were abdominal pain (89.1%), diarrhea (61.8%), nausea (52.7%), distension (49.1%) and vomiting (47.3%). Forty-three (78.2%) patients received glucocorticoid treatment, and compared with patients without glucocorticoid treatments, they were more likely to have elevated serum immunoglobin E (IgE) (86.8% vs 50.0%, P = 0.022) and descending duodenal involvement (62.8% vs 27.3%, P = 0.046) at diagnosis. With a median follow-up of 67 mo, all patients survived, and 56.4% had at least one relapse. Six variables at baseline might have been associated with the overall RFS rate, including age at diagnosis < 40 years [hazard ratio (HR) 2.0408, 95% confidence interval (CI): 1.0082-4.1312, P = 0.044], body mass index (BMI) > 24 kg/m2 (HR 0.3922, 95%CI: 0.1916-0.8027, P = 0.014), disease duration from symptom onset to diagnosis > 3.5 mo (HR 2.4725, 95%CI: 1.220-5.0110, P = 0.011), vomiting (HR 3.1259, 95%CI: 1.5246-6.4093, P = 0.001), total serum IgE > 300 KU/L at diagnosis (HR 0.2773, 95%CI: 0.1204-0.6384, P = 0.022) and glucocorticoid treatment (HR 6.1434, 95%CI: 2.8446-13.2676, P = 0.003).

CONCLUSION

In patients with EGE, younger onset age, longer disease course, vomiting and glucocorticoid treatment were risk factors for disease relapse, whereas higher BMI and total IgE level at baseline were protective.

Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs.

METHODS

The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment.

RESULTS

The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed.

CONCLUSION

Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.

Discrepancy between Abdominal Symptoms and Endoscopic Findings in Patients with Gastro-duodenal Eosinophilia: A Case Series

Some patients present gastro-duodenal eosinophilia without abdominal symptoms. Nine cases with gastro-duodenal eosinophilia were seen at the Tohoku University Hospital between January 2011 and June 2022. Seven (78%) patients had a background of allergic or hyper-eosinophilic disease. Esophagogastroduodenoscopy showed erosions (n=6), discoloration (n=4), ulcers (n=3), erythema (n=3), muskmelon-like appearance (n=2), and cracks (n=1). Two cases were asymptomatic with eosinophilic gastroenteritis (EGE)-like endoscopic findings, and two were symptomatic with normal endoscopic findings. The discrepancy between the abdominal symptoms and esophagogastroduodenoscopy findings suggests that clinicians should assess patients for background allergic disease, regardless of abdominal symptoms.

A Marked Eosinophilic Infiltration in Mucosa Could Be a Better Predictive Factor for Intractable Non-Esophageal Eosinophilic Gastrointestinal Disorders

INTRODUCTION

Non-esophageal eosinophilic gastrointestinal disorders (non-EoE EGIDs) are rare, but their prevalence has recently increased. Although it has been reported that one-half of patients with non-EoE EGIDs have intractable clinical courses, their clinical features are not fully understood.

METHODS

This is a multicenter retrospective study in which 10 institutions in Japan participated. Clinical databases from January 1998 to December 2020 were reviewed to identify patients with non-EoE EGIDs. A total of 44 patients were identified; they were divided into two groups based on their clinical course: an intractable group and a non-intractable group. The clinical features were compared between the two groups by a logistic regression analysis. Remarkable eosinophilic infiltration (REI) was defined histologically when the maximal counts of mucosal eosinophils reached a threshold level in the respective area of biopsy.

RESULTS

Prevalence of drug allergy and eosinophil counts more than 500/μL (EOS), vomiting symptoms, abnormalities of the stomach, duodenum, and jejunum on computed tomography (upper gastrointestinal abnormality on computed tomography [UACT]), and REI were significantly different between the two groups. Among the factors that were potentially associated with an intractable clinical course, logistic regression revealed that REI, EOS, and UACT were significant factors. Based on an analysis of the area under the receiver operator characteristic curve, a combination of REI and EOS had the lowest Akaike's information criterion, indicating the best model to predict an intractable clinical course.

CONCLUSIONS

REI may predict an intractable course in patients with non-EoE EGIDs. In addition, the combination of REI and EOS was a better predictor than REI alone.

Eosinophilic gastroenteritis: Pathogenesis, diagnosis, and treatment

ABSTRACT

Eosinophilic gastroenteritis (EGE) is a gastrointestinal disorder of unclear etiology that is characterized by eosinophilic infiltration of the stomach and small intestine, and consists of mucosal, muscular, and serosal subtypes. Eosinophilic infiltration of the gastrointestinal tract is a fundamental histopathological characteristic of EGE and is driven by several T-helper type 2 (Th2)-dependent cytokines and induced by food allergy. Due to the lack of a diagnostic gold standard, EGE has a high rate of delayed diagnosis or misdiagnosis. However, several new diagnostic strategies have been developed, such as novel genetic biomarkers and imaging tests. Although dietary therapy and corticosteroids remain the common choices for EGE treatment, recent decades have seen the emergence of novel treatment alternatives, such as biologics that target particular molecules involved in the pathogenic process. Preliminary investigations and clinical trials have demonstrated the efficacy of biologics and provided additional insights for the era of refractory or corticosteroid-dependent EGE biologics.