Eosinophilic Gastritis Masquerading as Recalcitrant Giant Gastric Ulcer

Abstract

Background: Eosinophilic gastroenteritis (EG) is a rare condition of unknown etiology characterized by an intense eosinophilic infiltrate throughout the GI tract, and has been reported in poorly controlled asthmatics. We present a rare case of eosinophilic gastritis in a poorly controlled asthmatic that presented as a bleeding giant gastric ulcer. Case: A 70-year-old male with HTN and poorly controlled asthma presented with bloating, coffee ground emesis and melena. He was a former heavy alcohol user, took one baby aspirin daily, no recent steroid use. The patient was stable with a Hg of 13. His WBC count was 8.8 with an elevated eosinophil count (12.9%). EGD showed a 4.2cm gastric ulcer with stigmata of recent bleeding. Biopsies showed severe eosinophilic gastritis, negative for H. pylori. In the past he also had a bleeding gastric ulcer despite use of PPIs. With each presentation there was a parallel marked peripheral eosinophilia and appeared to coincide with, or shortly precede his asthma exacerbations. Discussion: EG is a very rare disease, usually presenting as abdominal pain, vomiting and distention. A diagnosis of eosinophilic gastritis is made when >30 eosinophils are seen per high power field. About 50% of patients with EG have asthma or other atopic disorders, which may be diagnosed at the same time or years beforehand. Previously reported peripheral eosinophilia to >4000/ul have been noted. These patients may have thickened gastric mucosal folds, nodularity, or ulcerations seen on radiographs, reflecting intense eosinophilic infiltrate. Endoscopy may reveal normal or edematous mucosa with prominent gastric folds or surface erosions. Treatment with systemic corticosteroids led to bronchial and abdominal symptom resolution. Conclusion: We presented an unusual case of a patient with a history of uncontrolled asthma presenting with eosinophilic gastritis manifested as a recalcitrant giant gastric ulcer. To our knowledge this is only the second case described in the literature of eosinophilic gastritis presenting this way, and highlights the importance of considering eosinophilic disorders of the GI tract in patients with severe asthma.FigureFigure