Atypical Presentation of Eosinophilic Gastroenteritis (EGE)

Abstract

RATIONALE: EGE, a rare disease characterized by abnormal gastrointestinal symptoms and eosinophilic infiltration (>20 eosinophils/high-power field {HPF}) of multiple GI tract areas, usually has no identifiable cause. Commonly presenting in childhood and early adolescence, EGE predominantly affects the stomach and small bowel. We present the following atypical EGE presentation.METHODS: 48 year-old female with fibromyalgia and osteoarthritis presents with chronic abdominal pain and post-prandial diarrhea for 15 years, leading to the diagnoses of IBS, post-cholecystectomy diarrhea, and functional abdominal pain. Cholestyramine and nortriptyline were started, and she was referred to pain clinic for trigger point abdominal wall injections with minimal improvement.RESULTS: The patient was eventually hospitalized for melena and hematochezia; colonoscopy was unremarkable. Abdomen/pelvis CT revealed focal thickening in the third part of the duodenum; however, EGD and small bowel enteroscopy with biopsies were unremarkable. Repeat colonoscopy with random biopsies showed >126 eos/HPF with no evidence of acute colitis, lymphocytic colitis, collagenous colitis or dysplasia. A variant of eosinophilic gastroenteritis was diagnosed with eosinophil predominant colonic infiltration. Celiac sprue, carcinoid, and gastrinoma serologies were negative. Stool for ova/parasites was negative. Histopathology revealed no inflammatory bowel disease. ESR and VIP levels were normal. Peripheral eosinophilia was absent; food allergy history was negative. Prednisone resulted in significant improvement, but symptoms flared upon taper. Eosinophilic colitis was finally diagnosed. She will begin a trial of immunomodulators to avoid long-term steroid therapy.CONCLUSIONS: This case illustrates the wide spectrum of eosinophilic gastrointestinal disorders and highlights the importance of persistence in obtaining the diagnosis with an atypical presentation. RATIONALE: EGE, a rare disease characterized by abnormal gastrointestinal symptoms and eosinophilic infiltration (>20 eosinophils/high-power field {HPF}) of multiple GI tract areas, usually has no identifiable cause. Commonly presenting in childhood and early adolescence, EGE predominantly affects the stomach and small bowel. We present the following atypical EGE presentation. METHODS: 48 year-old female with fibromyalgia and osteoarthritis presents with chronic abdominal pain and post-prandial diarrhea for 15 years, leading to the diagnoses of IBS, post-cholecystectomy diarrhea, and functional abdominal pain. Cholestyramine and nortriptyline were started, and she was referred to pain clinic for trigger point abdominal wall injections with minimal improvement. RESULTS: The patient was eventually hospitalized for melena and hematochezia; colonoscopy was unremarkable. Abdomen/pelvis CT revealed focal thickening in the third part of the duodenum; however, EGD and small bowel enteroscopy with biopsies were unremarkable. Repeat colonoscopy with random biopsies showed >126 eos/HPF with no evidence of acute colitis, lymphocytic colitis, collagenous colitis or dysplasia. A variant of eosinophilic gastroenteritis was diagnosed with eosinophil predominant colonic infiltration. Celiac sprue, carcinoid, and gastrinoma serologies were negative. Stool for ova/parasites was negative. Histopathology revealed no inflammatory bowel disease. ESR and VIP levels were normal. Peripheral eosinophilia was absent; food allergy history was negative. Prednisone resulted in significant improvement, but symptoms flared upon taper. Eosinophilic colitis was finally diagnosed. She will begin a trial of immunomodulators to avoid long-term steroid therapy. CONCLUSIONS: This case illustrates the wide spectrum of eosinophilic gastrointestinal disorders and highlights the importance of persistence in obtaining the diagnosis with an atypical presentation.