Introductionadmin / April 6, 2019
Eosinophilic gastroenteritis (EGE) is a rare disease characterized by peripheral eosinophilia and eosinophilic infiltration of the gastrointestinal tract especially in stomach and proximal portion of small bowel (1) . It has a nonspecific clinical symptom depending on the affected GI layer including abdominal pain, nausea, vomiting, diarrhea, weight loss, ascites, and malabsorption. the diagnosis is made, based on imaging, laboratory results, clinical findings and good response following treatment with steroids (2 ).
A 51-year-old Saudi female presented to the clinic with complaints of Abdominal pain, distention and loss of appetite for 2 weeks. She denied any history of recent travel, blood transfusion, alcohol consumption. no history of shortness of breath, chest pain or skin rash. On examination the patient was alert and showed no respiratory or pain distress, was afebrile and hemodynamically stable. there was no evidence of paleness, jaundice or peripheral edema. abdominal examination showed moderate distention, diffusely tender. There was no hepatomegaly or abdominal masses. Laboratory data were as follows: Hgb 12.3 gm/dL, Htc 37.7 ,PLT 619 10^3/dL, WBC 11.1 10^3/dL , differential : neutrophils 6.57 10^3/dL , lymphocyte 2.58 10^3/dL , monocyte 0.772 10^3/dL , eosinophils 1.17 10^3/dL . Liver function tests were within normal limits. The IgE, C-reactive protein and Erythrocyte sedimentation rate levels were within normal limits. Tumor marker CA-125 was normal. Stool examination were negative for parasite and bacteria. On abdominal ultrasonography, the liver was seen normal in size and echotexture, and all vessels were patent. Moderate amount of free peritoneal fluid was seen. Abdominal and pelvis computer tomography (CT) showed moderate ascites. Esophagogastroduodenoscopy and colonoscopy were normal, duodenal biopsies revealed infiltration of eosinophils 8 cell/HPF in the lamina propria. Diagnostic paracentesis revealed hazy yellow fluid with no cytological signs of malignancy, white blood cell count of 156 cells/mm^3 , 64% of which were eosinophils, lactate dehydrogenase 622.1 U/L, albumin 2.0 gm/dL (serum albumin 2.7 gm/dL). Laboratory tests of the ascitic fluid were negative for bacterial culture and tuberculosis. The findings confirmed a diagnosis of subserosal EGE. She was treated with prednisone (40 mg/d) with rapid improvement of her symptoms, normalization of the eosinophil count and disappearance of the abdominal fluid.
Eosinophilic gastroenteritis (EGE) is a rare disease characterized by peripheral eosinophilia with eosinophilic infiltration of the GI tract presenting with nonspecific GI symptoms in association. the disease is common among the pediatric patients, with afflicted adults typically between the 3rd and 5th decade of life (3) According to Klien classification EGE classified into three pathologic types depending on eosinophilic infiltration mucosal, muscular and serosal. Most commonly affect the mucosal layer. Additionally, the muscular and serosal types are commonly associated with mucosal eosinophilic infiltration ( 4 ). reports of subsequent cases have showed a variable clinical manifestation depending on the affected GI layer, abdominal pain is the predominant presenting symptom among all 3 of the disease types. diarrhea, vomiting and malabsorption associated with the mucosal layer. muscular layer involvement results incomplete or complete intestinal obstruction. the serosal layer may cause peritoneal irritation, which can lead to ascites (5 ).
Pathogenesis of the disease is not clear but there is a strong association with atopy; 80% of the patients have a history of asthma, eczema and allergy. the exact immunological role of the eosinophils in this disease is not understood, there is evidence that the eosinophil remains a major effector cell in many types of allergic and non-allergic inflammations. (6)
Talley et al have identified three main diagnostic criteria: (1) the presence of gastrointestinal symptoms, (2) biopsies demonstrating eosinophilic infiltration of one or more areas of the gastrointestinal tract, and (3) no evidence of parasitic or extraintestinal disease. (7 )
The differential diagnosis of eosinophilic ascites includes parasitic infection (Stronglyloides and Toxocara canis), Drug reaction, abdominal tuberculosis, rupture of hydatid cyst, chronic pancreatitis, vasculitis (Churg-Strauss syndrome), hypereosinophilic syndrome, malignancy and Crohn’s disease( 8 ).
In the study by Chen et al., 13 out of 15 patients with EGE required treatment with prednisolone (10–40 mg/day) resulting in complete resolution of symptoms within 2 weeks. However, more than one-third of the treated patients relapsed in 12 months, and 13% required long-term treatment with prednisolone (5–10 mg/day) (9). In cases that fail to respond to corticosteroids, treatment with azathioprine or 6-mercaptopurine should be considered (10) .
Eosinophilic gastroenteritis is a rare disease and it should be kept in mind in patients of unexplained ascites, negative workup for parasitic infection and malignancy, presence of ascitic fluid eosinophilia and a dramatic response to treatment with steroids confirm indirectly the diagnosis of eosinophilic gastroenteritis and eosinophilic ascitis .