Eosinophilic gastroenteritis: epidemiology, diagnosis and management

Eosinophilic enterocolitis in duodenum, ileum, and colon: A case report

Eosinophilic gastroenteritis (EGE) is a rare disease which mainly consists of an abnormal eosinophile infiltration of the gastrointestinal tract. It's classified according to its location: eosinophilic esophagitis, eosinophilic gastritis, eosinophilic enteritis (including duodenum, jejunum and/or ileum) and eosinophilic colitis and degree of infiltration (mucosal, muscular, serosal). Depending on eosinophile concentration, type of EGE and the patient's condition it may manifest with different clinical presentations such as functional dyspepsia, abdominal pain, irritability, hypoproteinemia, diarrhea, anemia, among others. Few research has been done on such an uncommon pathology to the extent that treatment evidence is mostly limited to small case series. This case study reports an infrequent presentation of EGE in the small and large intestine as an undifferentiated gastrointestinal disease and successful corticoid management given to the patient in order to further broaden knowledge on this subject and facilitate an established clinical conduct for the treating physician.

Real-World Investigation of Eosinophilic-Associated Disease Overlap (REVEAL): Analysis of a US Claims Database

PURPOSE

The epidemiology of eosinophil-associated diseases (EADs) is not yet fully understood. While some studies have been conducted on stand-alone eosinophilic diseases, there is scarce evidence on the degree of overlap among rarer conditions.

METHODS

The retrospective Real-world inVestigation of Eosinophilic-Associated disease overLap (REVEAL) study used data from the Optum® Clinformatics® insurance claims database to describe and characterize disease overlap among 11 EADs: allergic bronchopulmonary aspergillosis, atopic dermatitis, chronic rhinosinusitis with nasal polyps, eosinophilic gastritis/gastroenteritis, eosinophilic granulomatosis with polyangiitis, eosinophilic esophagitis, bullous pemphigoid, chronic obstructive pulmonary disorder, chronic spontaneous urticaria, and non-cystic fibrosis bronchiectasis. Patient records with EADs of interest were identified between January 1, 2015, and June 30, 2018.

RESULTS

Overall, 1,326,645 patients were included; 74.4% had 1 EAD, 20.5% had ≥ 2 EADs, and 5.1% had ≥ 3 EADs. Higher rates of disease overlap were associated with older age. Higher blood eosinophil counts were also observed in patients with a greater number of overlapping conditions, suggesting a common role for eosinophilic inflammation in the pathogenesis of multiple diseases. Furthermore, greater disease overlap was associated with higher disease severity in most cohorts.

CONCLUSIONS

Results from this study have implications for quantifying unmet needs and can be used to inform treatment guidelines and raise the awareness of eosinophilic inflammation and EAD overlap among healthcare professionals from a range of disease specialties.

Eosinophilic Enteritis Flare-Up Mimicking Acute Gastroenteritis: A Rare Case

Eosinophilic enteritis is a rare subset of eosinophilic gastrointestinal disorders. It typically presents with chronic symptoms of abdominal pain, nausea, vomiting, diarrhea, and ascites. However, the clinical presentation can vary due to acute flare-ups. Here, we present a case of eosinophilic enteritis in a young female patient with intractable vomiting and diarrhea, mimicking acute gastroenteritis in the absence of other gastrointestinal symptoms. This case illustrates the challenge of diagnosing acute and diverse presentations of eosinophilic enteritis. It also highlights the importance of promptly treating and confirming the diagnosis through urgent tissue histopathology in adolescents with unexplained vomiting and diarrhea.

Impact of Patient Engagement and Social Determinants of Health on Care of Eosinophilic Gastrointestinal Disorders Patients

ABSTRACT

The purpose of this study was to identify factors that influence eosinophilic gastrointestinal disorders (EGID) patients to switch gastroenterologists, assess the prevalence of social determinants of health (SDoH) in EGID patients, and the impact of SDoH on provider switching. 191 patients/caregivers participated in this cross-sectional, online study distributed through Patient Advocacy Groups. The 35-question survey took about 20 minutes to complete and was divided into three sections: demographics; 10 questions about provider switching; and nine-domain SDoH screen.Patients with EGIDs often switch providers, most commonly due to dissatisfaction with engagement in decision making. Additionally, these patients commonly have SDoH, some of which are associated with increased provider switching. Our results highlight the need to mindfully engage patients in decision-making and disease management. Providers also need to look beyond the "clinic space" and into SDoH. These low-cost/high-impact changes in provider behavior can promote continuity of care and patient engagement.

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).

Food-Induced Acute Pancreatitis

Food allergy, a commonly increasing problem worldwide, defined as an adverse immune response to food. A variety of immune-related effector cells such as mast cells, eosinophils, neutrophils, and T cells are involved in food-related allergic responses categorized as IgE mediated, non-IgE mediated, and mixed (IgE and non-IgE) depending upon underlying immunological mechanisms. The dietary antigens mainly target the gastrointestinal tract including pancreas that gets inflamed due to food allergy and leads acute pancreatitis. Reports indicate several food proteins induce pancreatitis; however, detailed underlying mechanism of food-induced pancreatitis is unexplored. The aim of the review is to understand and update the current scenario of food-induced pancreatitis. A comprehensive literature search of relevant research articles has been performed through PubMed, and articles were chosen based on their relevance to food allergen-mediated pancreatitis. Several cases in the literature indicate that acute pancreatitis has been provoked after the consumption of mustard, milk, egg, banana, fish, and kiwi fruits. Food-induced pancreatitis is an ignored and unexplored area of research. The review highlights the significance of food in the development of pancreatitis and draws the attention of physicians and scientists to consider food allergies as a possible cause for initiation of pancreatitis pathogenesis.

Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review

Eosinophilic gastrointestinal disorders, including eosinophilic esophagitis, gastroenteritis, and colitis, refer to a spectrum of clinical diseases that present with variable degrees of infiltration of the gastrointestinal tract by eosinophils in the absence of other known causes of tissue eosinophilia. Clinical symptoms and laboratory findings are usually non-specific and may or may not be accompanied by peripheral blood eosinophilia. The extent of eosinophilic infiltration of the gastrointestinal wall varies from mucosal to transmural and serosal involvement. Diagnosis requires presence of gastrointestinal symptoms, demonstration of gastrointestinal eosinophilia by biopsy, and exclusion of other known causes of tissue eosinophilia. Many studies have pointed toward the eosinophil as the major offender; however, the exact functional role of the eosinophil in the pathogenesis of eosinophilic gastrointestinal disorders remains unclear. The roles of T-helper-2 cytokines and other mediators, such as eotaxin-1 and interleukin-5, have gained significant importance in the pathobiology of eosinophilic gastrointestinal disorders. Current understanding of treatment is based on case reports and a few case series, as there is a lack of large prospective studies. Steroids are currently the mainstay of therapy, but the roles of other drugs such as leukotriene inhibitors, mast cell stabilizers, interleukin-5 inhibitors, and anti-immunoglobulin E, along with other targets in the immune pathway, are currently being explored.

Eosinophilic disorders of the gastro-intestinal tract: an update

Eosinophilic diseases of the gastrointestinal tract, including eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE), are rare chronic pathologies of the digestive system, with an immuno-mediated pathogenesis. Recent data suggest that, together with the “classic” IgE-response to allergens, also a delayed hypersensitivity mechanism could be involved in the development of eosinophilic disorders. EoE and EGE were studied only in the latest decades and as a consequence accurate data are not yet available, concerning not only pathogenesis, but also epidemiology, treatment and outcomes. The diagnosis of EoE is centered on endoscopic findings but the certainty is obtained by histological examination from biopsy samples, that has a sensitivity of 100% when based on five samples. The currently available treatments include topical corticosteroids, specific diets and endoscopic treatment. Concerning EGE, three subtypes (mucosal, muscular, and serosal) were identified. The diagnosis is based, as for EoE, on endoscopic and histological assessment, and the treatment includes pharmacological and dietetic approaches. Further studies are warranted in order to better define the etiology and pathogenesis of eosinophilic diseases of the gastrointestinal tract, and thus to develop more appropriate and specific therapies.

Eosinophilic ascites: a diagnostic challenge

Eosinophilic ascites is a rare feature of eosinophilic gastroenteritis. We would like to highlight this increasingly recognised diagnosis in a case of unexplained ascites. We present a challenging case of a woman aged 25 years who presented with nausea, vomiting, diarrhoea, generalised abdominal pain and swelling 8-week following delivery of her first baby. Her symptoms were primarily aggravated by eating, and she had also noticed postprandial itching and self-limiting generalised rash. She had a strong history of atopy. Physical examination revealed abdominal tenderness and distension with shifting dullness. Urticarial skin rash was noted on the face, neck, chest and abdomen. Routine biochemistry was normal apart from peripheral eosinophilia. Imaging confirmed moderate ascites. Diagnostic paracentesis showed exudative ascites with numerous eosinophils. Histology of the upper and lower gastrointestinal tract showed infiltration of the oesophageogastroduodenal and rectosigmoid mucosa with eosinophils. The patient significantly improved following a course of steroids and six-food elimination diet.

Eosinophilic Gastroenteritis: An Underdiagnosed Condition

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Obstructive eosinophilic gastroenteritis in a patient with rheumatoid arthritis

Eosinophilic gastroenteritis (EG) is a rare disease characterised by abnormal eosinophilic infiltration of the gastrointestinal tract. We describe a case of EG presenting as an intestinal obstruction in a patient with rheumatoid arthritis (RA). A 54-year-old man with RA presented to the emergency department with abdominal pain and vomiting. On examination, his abdomen was distended and tender. Laboratory data showed leucocytosis with raised inflammatory markers and without eosinophilia. CT revealed dilated small bowel loops, with a couple of loops forming a mass and abscess formation. Emergency laparotomy was performed with segmental resection of the ileum and side-to-side anastomosis. Histology confirmed the diagnosis of EG. The patient recovered well and was asymptomatic at the time of writing this report.

[Eosinophilic gastroenteritis and colitis in pediatric patients: Increasingly frequent diseases]

Eosinophilic gastrointestinal disorders are a heterogeneous group of disorders characterized by no specific digestive symptoms associated with dense eosinophilic inflammation of the gastrointestinal tract in the absence of known causes for such tissue eosinophilia. Among these diseases, eosinophilic gastroenteritis (EGE) and colitis (EC) are less common than esophagitis, but their incidence and prevalence have been increasing over the past decade due in part to increased disease recognition. The exact pathophysiology is not clear: EGE and EC are immune-mediated diseases implicating adaptive T-helper cell type 2 immunity. According to the site of eosinophilic infiltration, there is a wide spectrum of digestive symptoms ranging from food refusal, nausea, vomiting, abdominal pain, weight loss, gastrointestinal bleeding (anemia), protein loosing enteropathy, ascites, bowel obstruction or perforation for EGE and diarrhea ± bleeding for CE. Endoscopic lesions are not specific: friability, erythematous mucosa with superficial erosions, or ulceration is often observed. Histologically, markedly increased numbers of mucosal eosinophils are seen in biopsy specimens. However, no standards for the diagnosis of EGE or CE exist and few findings support the diagnosis: intraepithelial eosinophils, eosinophil crypt abscesses, and eosinophils in muscularis mucosa and/or submucosa. Other organs are not involved. The other causes of tissue eosinophilia (infections, inflammatory bowel diseases) should be excluded. Food allergy appears to play a central role in driving inflammation in EGE and CE, as evidenced by symptomatic improvement with initiation of food exclusion or elemental diets. Dietary treatment should be the first therapeutic option in children. If the elimination diet fails, corticosteroids are currently the best characterized treatment but appropriate duration is unknown and relapses are frequent. In severe forms, immunomodulators or biologic agents (anti-IL5, anti-IgE, or anti-TNFa) can potentially play a role in the treatment of EGE and CE.

Eosinophilic enteritis

BACKGROUND

Eosinophilic enteritis, also known as eosinophilic gastroenteritis, is a rare primary eosinophilic gastrointestinal disorder (EGID) of unknown etiology characterized by the presence of an intense eosinophilic infiltrate on histopathology of the intestinal mucosa.

KEY MESSAGES

The etiology of eosinophilic enteritis remains obscure. There is growing evidence to support the role of aeroallergens and food allergens in the pathogenesis of this disorder as children and adults with EGIDs often have positive skin testing for food allergens and a familial history of allergic diseases. Moreover, significant progress has been made in elucidating that EGIDs involve mechanisms that fall between pure IgE-mediated and delayed Th2 type responses. Preclinical studies have identified a contributory role for the cytokine IL-5 and eotaxin chemokines, providing a rationale for specific disease therapy. Eosinophilic enteritis causes a wide array of gastrointestinal symptoms such as abdominal pain, diarrhea, nausea, vomiting, bloating or ascites, and its diagnosis requires a high degree of clinical likelihood given the nonspecific presentation and physical examination findings. The Klein classification arbitrarily divided patients with eosinophilic enteritis into those with predominantly mucosal, muscle layer or subserosal disease relying on the concept that clinical presentation is dependent on the predominant involved layer of the gastrointestinal tract. Main therapeutic options are represented by oral corticosteroids for a short period with good efficacy. Antihistaminic drugs and sodium cromoglycate have also been used to treat patients with eosinophilic enteritis.

CONCLUSION

Eosinophilic enteritis is generally considered as a benign disease with no relapse, but half of the patients may present a more complex natural history characterized by unpredictable relapses and a chronic course.

New efficacy of LTRAs (montelukast sodium): it possibly prevents food-induced abdominal symptoms during oral immunotherapy

BACKGROUND

The aim of the study was to elucidate whether leukotriene receptor antagonists (LTRAs) can prevent severe allergic reactions, which occur during oral immunotherapy (OIT) in children with food allergies.

FINDINGS

Five children with food allergies [3 allergic to hen's egg (HE), 1 to wheat, and one to cow's milk (CM); aged between 7 and 12 years; median, 8.5 years] who were started on LTRAs during OIT were retrospectively selected from among 63 children undergoing OIT. In the rush phase, after the administration of the initial dose which was set in open food challenge test, the subsequent doses were increased by approximately 1.2 times of the previous dose and were administered every 2 hours, 4 times a day. The target doses of hen's egg, wheat (udon noodle), and cow's milk in the rush phase were 50 g, 200 g, and 200 ml, respectively. The ingestion of the target dose was continued at home every day for at least a year in the maintained phase.Four participants experienced intractable abdominal pain during the rush phase; therefore, the loading dose was not increased in these children. However, the administration of LTRAs prevented their symptoms, resulting in the completion of the rush phase. One participant also experienced intractable abdominal pain during the maintenance phase. After receiving LTRAs, the target dose was able to tolerated.

CONCLUSION

The findings from this retrospective study suggest that the administration of LTRAs is useful for the prevention of adverse allergic reactions such as abdominal pain during OIT.

Anti-TNF, infliximab, and adalimumab can be effective in eosinophilic bowel disease

BACKGROUND

Eosinophilic enterocolitis (EEC) is an emerging distinct inflammatory bowel disease of unknown etiology. There are no published data on the effect of infliximab (IFX) or adalimumab (ADA) for the treatment of refractory cases.

METHODS

A report of all pediatric cases with EEC treated with anti-tumor necrosis factor, identified after an open international call.

RESULTS

We describe here the first 8 children with refractory EEC who were treated with IFX (75% boys; mean age at diagnosis 8.6 ± 4.03 [range 1.6-14 years]; mean age at IFX treatment 11.7 ± 4.4 [range 4.2-16 years]). Allergic and infectious causes of EEC were excluded in all cases. Rapid and complete clinical remission was documented in 6 (75%) children following the induction infusions: 3 (38%) with endoscopic remission, 2 (25%) with endoscopic improvement, and 1 unknown. Four of the 6 responders had secondary loss of response and were switched to ADA, 3 of whom with sustained remission using high doses. Overall, the 6 responders were followed for a median of 7 years (range 4-12; interquartile range 6.4-8.8 years) without evidence of developing Crohn disease or ulcerative colitis. The only case with macroscopic findings on endoscopy was a primary nonresponder.

CONCLUSIONS

IFX and ADA may be effective in cases of refractory idiopathic EEC; however, because this is an uncontrolled report, further prospective studies are warranted.

Eosinophilic esophagitis in children and adolescents: epidemiology, clinical presentation and seasonal variation

BACKGROUND

Eosinophilic esophagitis (EoE) is defined by infiltration of eosinophils in the esophageal mucosa (>20 eosinophils/hpf). The epidemiology and seasonal variation have not been well studied in children and adolescents.

METHODS

Review of all esophageal biopsies performed from January 2001 to December 2006 on patients younger than 21 year of age, focusing on demographics, onset and duration of presenting symptoms, history of allergies and endoscopic findings.

RESULTS

A total of 753 upper endoscopies were performed, 44 of which showed histologic evidence of EoE (5.8 %). Fifty percent of all EoE endoscopies were grossly normal. Onset of symptoms was 23 % in the spring, 29 % in the summer, 23 % in the fall and 25 % in the winter. More cases (36 %) were diagnosed in the fall. Time between onset of symptoms and diagnosis was 115 ± 145 days (mean ± SD). The most common presenting symptoms were vomiting (61 %), dysphagia (39 %), abdominal pain (34 %), feeding disorders (14 %), heartburn (14 %), food impaction (7 %), vague chest pain (5 %) and diarrhea (5 %). Children presenting with vomiting and feeding disorders were younger (p < 0.02), whereas children presenting with heartburn and dysphagia were older (p < 0.02).

CONCLUSIONS

The incidence of EoE did not increase between 2001 and 2006. Onset of symptoms did not vary by season, indicating that allergens triggering EoE are present all year around. Vomiting and feeding disorders are seen in young children, while dysphagia and heartburn are seen in older children. As endoscopic findings were normal in 50 % of cases, an esophageal biopsy should be performed in all patients with suspected EoE.

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

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

Eosinophilic gastrointestinal diseases: review and update

Eosinophilic gastrointestinal disorders (EGIDs) are a progressively more frequent diverse group of intestinal diseases. The intention of this paper is to present the newest developments in the care of patients with EGIDs and to sum up a rising literature defining the clinical features and mechanistic elements of eosinophils and their intricate associations with the gastrointestinal tract. Clinicians ought to stay sensitive to EGIDs as a diagnostic likelihood for patients with general gastrointestinal symptoms. Further research is warranted to establish various methods leading to dysfunction coupled with eosinophilic gastrointestinal inflammation.

Management of pediatric eosinophilic esophagitis: an update

Eosinophilic esophagitis is an important chronic esophageal disorder with gastroesophageal reflux disease (GERD)-like symptoms, prominent esophageal mucosal eosinophilia, strongly associated with allergic disorders and unresponsive to anti-GERD therapy. Treatment of eosinophilic esophagitis has been successful with the use of dietary restrictions and topical corticosteroids. A subset of patients benefits from concurrent anti-GERD therapy; those with demonstrable esophageal strictures report variable duration symptom relief after esophageal dilation. At the current time, anti-interleukin-5 monoclonal antibody agents are being investigated in multicenter trials, and it is hoped that future therapy may be targeted against mediators of esophageal remodeling and fibrosis in eosinophilic esophagitis.

Eosinophilic colitis: epidemiology, clinical features, and current management

Primary eosinophilic gastrointestinal disorders (EGIDs) represent a spectrum of inflammatory gastrointestinal disorders in which eosinophils infiltrate the gut in the absence of known causes for such tissue eosinophilia. EGIDs can be subgrouped as eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis (EC). The least frequent manifestation of EGIDs is EC. EC is a heterogeneous entity with a bimodal age distribution, presenting with either an acute self-limited bloody diarrhea in otherwise healthy infants or as a more chronic relapsing colitis in young adults. The pathophysiology of primary EC appears related to altered hypersensitivity, principally as a food allergy in infants and T lymphocyte-mediated (i.e. non-IgE associated) in young adults. In adults, symptoms include diarrhea, abdominal pain, and weight loss. Endoscopic changes are generally modest, featuring edema and patchy granularity. Although standardized criteria are not yet established, the diagnosis of EC depends on histopathology that identifies an excess of eosinophils. Therapeutic approaches are based on case reports and small case series, as prospective randomized controlled trials are lacking. Eosinophilic colitis in infants is a rather benign, frequently food-related entity and dietary elimination of the aggressor often resolves the disorder within days. Adolescent or older patients require more aggressive medical management including: glucocorticoids, anti-histamines, leukotriene receptors antagonists as well as novel approaches employing biologics that target interleukin-5 (IL-5) and IgE. This review article summarizes the current knowledge of EC, its epidemiology, clinical manifestations, diagnosis, and treatment.

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 digestive disease (EDD) and allergic bronchial asthma; two diseases or expression of one disease in two systems?

Eosinophilic digestive disease (EDD) includes a broad spectrum of clinical presentations due to eosinophilic inflammation involving anywhere from the esophagus to the rectum. The heterogeneity in the clinical presentations of EDD is determined by the site and depth of eosinophilic infiltration. The sites of inflammation determine the nomenclature for EDD. The most well characterized of these, eosinophilic esophagitis (EE), eosinophilic gastroenteritis (EG), and eosinophilic colitis or enterocolitis. While the depth of esosinophilic infiltration through the three main layers (mucosa, musculosa and serosa) determines the prominent clinical manifestation. The recent advances in gastrointestinal endoscopy and the increasing awareness and diagnosis of EDD, in my viewpoint, can be of help to add to our understanding of the heterogeneous clinical syndrome under the broad title bronchial asthma. Here I present my viewpoint that EDD and the allergic bronchial asthma can be regarded as two clinical expressions of one disease in two different but related anatomical systems.

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.

Eosinophilic colitis: an update on pathophysiology and treatment

BACKGROUND

Primary eosinophilic gastrointestinal disorders, a spectrum of inflammatory conditions, occurs when eosinophils selectively infiltrate the gut in the absence of known causes for such tissue eosinophilia. These may be classified into eosinophilic esophagitis, eosinophilic gastroenteritis and eosinophilic colitis (EC). This review focuses on EC: its pathogenesis, epidemiology, clinical presentation, diagnosis and current approach to treatment.

SOURCES OF DATA

A literature review published in English was performed using Pubmed, Ovid, Google scholar search engines with the following keywords: eosinophilic gastrointestinal disorder, EC, eosinophils, colitis and gastrointestinal.

AREAS OF AGREEMENT

The basis for primary EC appears related to increased sensitivity to allergens, principally as a food allergy in infants and a T lymphocyte-mediated event in adults. Endoscopic changes are generally modest, featuring edema and patchy granularity.

AREAS OF CONTROVERSY

Clear clinical and pathological diagnostic criteria of EC and its management strategy.

GROWING POINTS

Intestinal involvement of EC is primarily mucosal, presenting as a mild self-limited proctitis in infants and self-limited colitis in young adults. Therapeutic approaches based on case reports tend to use either elimination diets to avoid a presumed allergen; agents traditionally used in inflammatory disease or targeted drugs like anti-histamines or leukotriene receptor antagonists.

AREAS TIMELY FOR DEVELOPING RESEARCH

Prospective randomized controlled trials addressing the disease natural history, possible preventive methods and effective medical approach and long-term prognosis are required.

MEFV gene mutations in a patient with eosinophilic gastroenteritis

Eosinophilic gastroenteritis (EG) is an uncommon gastrointestinal disease affecting both children and adults. The underlying molecular mechanism predisposing to the clinical manifestation of eosinophilic gastroenteritis is unknown. A 39-year-old man who was followed up with the diagnosis of familial Mediterranean fever (FMF) was admitted to our clinic with diarrhea, abdominal pain, and weight loss. After endoscopic and colonoscopic examinations EG was diagnosed by histopathological examination. Symptoms were resolved with the treatment of budesonide. To our knowledge, this is the first reported case of EG with the MEFV gene mutations in the literature.

[Clinical characteristics of 17 cases of eosinophilic gastroenteritis]

BACKGROUND/AIMS

Eosinophilic gastroenteritis (EG) is a rare disease characterized by prominent eosinophilic infiltration that may involve a variable depth of one or more gastrointestinal organs. We analyzed the largest number of patients with EG among the studies carried out at a single center in Korea.

METHODS

We retrospectively analyzed the clinical, laboratory, endoscopic, and radiologic features, management, and clinical outcome in 17 patients who were diagnosed as EG from January 1994 to February 2008.

RESULTS

Median age was 36 (2-67 years). Two of the 17 patients had a history of allergy. The most common symptoms were abdominal pain and diarrhea. Fifteen patients (88.2%) had hypereosinophilia. The ESR was moderately raised in 6 out of 14 patients. Eleven patients (64.7%) had predominant involvement of the mucosa, 1 (5.9%) of muscularis, and 5 (29.4%) of subserosa. EGD revealed non-specific findings such as erythema and edema. Abdominal Computed tomography revealed gastrointestinal wall thickenings of the involved organ, and all of 5 cases of the subserosal type had ascites. Thirteen patients (76.5%) were improved by corticosteroid treatment. Among five patients who had been followed for more than one year (12-84 months), two experienced relapse after discontinuing corticosteroids.

CONCLUSIONS

EG should be considered in the differential diagnosis of unexplained gastrointestinal symptoms even in the absence of peripheral eosinophilia and in non-specific endoscopic findings.

Eosinophilic enteritis in association with systemic lupus erythematosus

Eosinophilic gastroenteritis (EGE) is an uncommon disease and has rarely been reported in association with connective tissue diseases as systemic lupus erythematosus. We report a 36-year-old woman who developed recurrent episodes of abdominal pain, nausea, vomiting and melena. Complete blood counts showed elevated eosinophil counts. Ultrasound and CT-scan images studies were significant for bowel wall thickening and ascites. The patient underwent an exploratory laparotomy with a mesenteric biopsy and appendectomy that showed eosinophil infiltration in the muscularis propria, establishing the diagnosis of EGE. The patient developed pleural effusions, with laboratory studies showing haemolytic anaemia, thrombocytopenia, positive antinuclear antibody and anticardiolipin antibodies. The patient was treated with high-dose systemic corticosteroid therapy, with successful resolution of symptoms. Three months later, she developed a new episode of abdominal pain defined as intestinal pseudo-obstruction that was resolved without complications.

Eosinophilic gastroenteritis: a review

Eosinophilic gastroenteritis is a clinicopathological disease affecting both children and adults that is characterized by patchy or diffuse eosinophilic infiltration of the gastrointestinal tract with variable resultant clinical gastrointestinal manifestations. The eosinophil, eotaxin, and Th-2 cytokines are important in pathogenesis of this disease entity. It may be confused with parasitic and bacterial infections (including Helicobacter pylori), inflammatory bowel disease, hypereosinophilic syndrome, myeloproliferative disorders, periarteritis, allergic vasculitis, scleroderma, drug injury, and drug hypersensivity. Obtaining the correct diagnosis is important, and a pathologist usually makes this distinction. Effective treatments include systemic/topical corticosteroids, specific food elimination or an elemental diet, certain drugs, and even surgery. A variety of new therapeutic approaches are now under trial.

Evaluation of the patient with suspected eosinophilic gastrointestinal disease

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

Enterobiliary fistula as a complication of eosinophilic gastroenteritis: a case report

Eosinophilic gasteroenteritis is an uncommon disease with variable clinical features characterized by eosinophilic infiltration. Clinical manifestations range from non-specific gastrointestinal complaints such as nausea, vomiting, crampy abdominal pain, and diarrhea to specific findings such as malabsorption, protein loosing enteropathy, luminal obstruction, eosinophilic ascites and effusion. We report here on a case of eosinophilic gastroenteritis causing enterobiliary fistula which is an extremely unusual complication.

[Primary eosinophilic enteritis: a case report]

Primary eosinophilic enteritis is a rare entity that is characterized by eosinophil infiltration in the different layers of the small bowel. The symptoms depend on the site of infiltration and the layers affected. High blood levels of eosinophils are usually present. Computed tomography plays a fundamental role in the evaluation of this disease. We present a case of primary eosinophilic enteritis diagnosed on the basis of clinical, laboratory, and CT findings.

Idiopathic eosinophilic gastrointestinal diseases in adults

This review focuses on the latest cognitions, diagnosis and treatment strategies of the three main representatives of the eosinophilic gastrointestinal disorders (EGID): idiopathic eosinophilic oesophagitis (EE), idiopathic eosinophilic gastroenteritis (EGE) and idiopathic hypereosinophilic syndromes (HES) with gastrointestinal involvement. These disorders share important similarities: their origin is unknown and their pathogenesis is due to a histological inflammatory response characterised by eosinophilic tissue infiltration. In spite of these parallels, the courses and prognoses of the diseases differ radically: EE is restricted to the oesophagus, and though it may significantly decrease the patient's quality of life, it has a favourable long-term prognosis. In EGE, the inflammatory process involves several segments of the gastrointestinal tract but this chronic inflammation may also be considered a benign disorder. In contrast, HES is primarily a multisystem disorder that may involve several organs, including the digestive tract, and often has a fatal outcome.

Eosinophils: biological properties and role in health and disease

Eosinophils are pleiotropic multifunctional leukocytes involved in initiation and propagation of diverse inflammatory responses, as well as modulators of innate and adaptive immunity. In this review, the biology of eosinophils is summarized, focusing on transcriptional regulation of eosinophil differentiation, characterization of the growing properties of eosinophil granule proteins, surface proteins and pleiotropic mediators, and molecular mechanisms of eosinophil degranulation. New views on the role of eosinophils in homeostatic function are examined, including developmental biology and innate and adaptive immunity (as well as their interaction with mast cells and T cells) and their proposed role in disease processes including infections, asthma, and gastrointestinal disorders. Finally, strategies for targeted therapeutic intervention in eosinophil-mediated mucosal diseases are conceptualized.

[Eosinophilic esophagitis : a cause of dysphagia]

BACKGROUND

Eosinophilic esophagitis (EE) is a chronic, interleukin-5-driven inflammatory disease of the esophagus, causing dysphagia and esophageal food impactions. We analyzed the diagnostic results of patients with suspected or proven EE and in this article discuss the relevant aspects of this disease.

PATIENTS AND METHODS

Sixteen patients suffering from dysphagia or recurrent esophageal food impactions underwent rigid esophagoscopy to exclude EE. In six patients, 24-h pH monitoring was performed to exclude laryngopharyngeal reflux (LPR).

RESULTS

EE was diagnosed in only one patient, a boy with a history of peanut allergy and recurrent esophageal food impactions. In six patients, histological examination of biopsies revealed reflux esophagitis indicating gastroesophageal reflux disease (GERD). Using 24-h pH monitoring, LPR was diagnosed in four of six patients.

CONCLUSIONS

Even in patients presenting with typical symptoms of EE, this disease is rarely found. However, in male patients with asthma, allergies, or a history of recurrent esophageal food impactions, EE must be excluded. The most important differential diagnoses of EE are GERD and LPR.

Educational clinical case series in pediatric allergy and immunology

Eosinophilic inflammation may occur in any part of the intestinal tract from the esophagus to the rectum. Despite 70 yr having passed since the first reference to a case of eosinophilic gastroenteritis, the epidemiology and natural history of eosinophilic gastrointestinal disorders are still poorly known. Insights into their etiology and pathogenesis have revealed an important role for allergens; interleukins 4, 5, and 13; the eotaxin family of chemokines; and eosinophil-derived proteins. Diagnosis is confirmed by typical histologic features in a patient with a suggestive clinical phenotype. Treatment involves eliminating triggering allergens, making dietary restrictions the first choice of therapy in a compliant patient; corticosteroids [topical in eosinophilic esophagitis (EE)], despite the potential for serious side effects, are used with success in refractory and non-compliant patients. In this study we discuss EE and gastroduodenitis against the backdrop of clinical case presentations.

Gastrointestinal eosinophilia

Gastrointestinal eosinophilia, a broad term for abnormal eosinophil accumulation in the gastrointestinal tract, involves many different disease identities. These diseases include primary eosinophil associated gastrointestinal diseases, gastrointestinal eosinophilia in hypereosinophilic syndrome, and all gastrointestinal eosinophilic states associated with known causes. Each of these diseases has its unique features but there is no absolute boundary between them. All three groups of gastrointestinal eosinophila are described in this article, although the focus is on primary gastrointestinal eosinophilia.

Evaluation and differential diagnosis of marked, persistent eosinophilia

Hypereosinophilic syndromes (HES) are a group of heterogeneous disorders many of which remain ill-defined. By definition, the HES must be distinguished from other disorders with persistently elevated eosinophilia with a defined cause. Although marked eosinophilia worldwide is most commonly caused by helminth (worm) infections, the diagnostic approach must include noninfectious (nonparasitic) causes of marked eosinophilia as well.

Los granulocitos eosinófilos: de residentes habituales de la mucosa gastrointestinal normal a protagonistas agresivos de la gastroenteritis eosinofílica

Because of their biological affinity for normal gastrointestinal (GI) mucosa, eosinophilic granulocytes are "normal residents" in the mucosa. This physiological GI eosinophilia translates into a state of "permanent normal inflammation", which means that the mucosa's local immune system is constantly confronted by dietary proteins and indigenous microorganisms. This eosinophilic infiltration of the GI mucosa is increased, reactively, in the course of local inflammatory processes, collagenosis, infections (especially helminthic infections), vasculitis, neoplasms and IgE-dependent allergic reactions to food. Lastly, GI eosinophilia that is clearly aggressive, both because of its intensity and its persistence, is what characterizes eosinophilic gastroenteritis. In the present article, we summarize the ethiopathogenic and clinico-epidemiological features of this process, as well as its position within the field of immunopathologic food intolerance.

Quantity and distribution of eosinophils in the gastrointestinal tract of children

There are a lack of data on the quantity and location of eosinophils in the gastrointestinal tract of healthy individuals. Accordingly, we examined gastrointestinal biopsies obtained during endoscopic evaluation of pediatric patients. Biopsies were previously interpreted as having no diagnostic abnormality. The presence of extracellular eosinophil constituents and the quantity of eosinophils in atopic versus nonatopic individuals was determined. In the esophagus, eosinophils were present in only 2.7% of high-power fields (hpf), with a mean value of 0.03+/-0.10 eosinophils/hpf (mean+/-standard deviation) and a maximum of 1 eosinophil/hpf. Examination of the antrum and fundus revealed similar numbers of eosinophils in the lamina propria (1.9+/-1.3 and 2.1+/-2.4 eosinophils/hpf, respectively), with no eosinophils observed in the surface epithelium. In the small intestine, there were 9.6+/-5.3 (maximum, 26 eosinophils/hpf) and 12.4+/-5.4 eosinophils/hpf (maximum, 28 eosinophils/hpf) in the intercryptal lamina propria of the duodenum and ileum, respectively. The number of eosinophils in the surface epithelium and crypt epithelium was minimal. In the large intestine, the highest concentration of eosinophils was observed in the cecum (20.3+/-8.2 eosinophils/hpf; maximum, 50 eosinophils/hpf), and there were lower concentrations in the transverse and sigmoid colon (16.3+/-5.6 and 8.3+/-5.9 eosinophils/hpf, respectively). The percentage of fields demonstrating extracellular eosinophil granules in all gastrointestinal segments was 70% to 93%, and extracellular granules were most numerous at the edge of the biopsy (P<0.05). Atopic and nonatopic patients had comparable numbers of eosinophils. These data establish baseline gastrointestinal eosinophil values in pediatric patients without apparent pathological disease.

Las esofagogastroenteritis eosinofílicas dentro del espectro de las alergias alimentarias

Under normal conditions, the digestive tube immune system is capable of establishing an effective plan of tolerance to food that is eaten daily by the human beings. However, this tolerance plan sometimes fails and in the final steps of this immunological dysreaction, other cellular elements, usual residents of the digestive mucous, such as eosinophil granulocytes, generally participate, together with the main cells of this system. This is the case, among others, of the so-called EGE-Eos. The authors summarize the spectrum of pathogenic options of these immunological food intolerances that range from those in which "all" depend on a specific IgE (GI food anaphylaxis) and those others in which "nothing" depends on this reagin (celiac sprue). An intermediate position would be occupied by the EGE-Eos in which there seems to be overlapping of immune reactions of cellular character together with a certain role of the IgE. These pathogenic pathways frequently cross a tangle of cellular and molecular events that cannot be untangled with either an image or one thousand words.