2569 Eosinophilic Gastroenterocolitis: A Diagnostic Conundrum and a Rare Cause of Small Bowel Strictures

Abstract

INTRODUCTION: Eosinophilic gastroenterocolitis (EGE) is a rare disorder that can have several gastrointestinal manifestations depending on the site and depth of involvement. The diagnosis involves demonstration of eosinophilic infiltration of bowel wall and exclusion of other causes of peripheral eosinophilia. We present a rare case of eosinophilic gastroenterocolitis that presented as chronic diarrhea and partial gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 71-year-old male presented to the clinic for evaluation of a two-month history of watery diarrhea. He had recently been hospitalized for management of profuse diarrhea and dehydration. Extensive infectious work-up during the hospitalization was unrevealing. A colonoscopy with biopsies was negative for microscopic colitis and malabsorptive disorder, however, a prominent population of eosinophils suggestive of an allergic component was seen. The patient's symptoms were partially controlled on anti-motility agents. His current medication list was negative for any offending drugs. Physical examination revealed a mildly distended abdomen. Laboratory investigation showed a total leukocyte count 6.7 × 109/L. Differential count revealed polymorphs −50%, lymphocytes −34% and eosinophils −10%. Computed tomography with contrast showed segmental areas of narrowing in mid descending limb of the duodenum with partial gastric outlet obstruction. Esophagogastroduodenoscopy (EGD) showed multiple diaphragm-like strictures at the duodenal sweep which could not be passed with a regular EGD scope. Histologic examination of the specimens taken from the duodenal strictures revealed mildly increased plasma cells and eosinophils within the lamina propria with villous blunting, without increased intraepithelial lymphocytes. Numerous balloon-dilation sessions were needed to reestablish luminal patency. A diagnosis of eosinophilic gastroenterocolitis was made and the patient was started on a six-food elimination diet with complete resolution of his symptoms. Upon reintroduction, the culprit food were found to be cow's milk and wheat. DISCUSSION: EGE is classified based on the depth of eosinophilic infiltration as mucosal, submucosal and serosal. The most frequent sites of involvement include the stomach and the proximal small bowel. Diagnosis is often challenging and delay in treatment may lead to malabsorption and malnutrition. Although evidence of efficacy is lacking, treatment with dietary modification and corticosteroids has shown favorable outcomes.