Eosinophilic Gastroenteritis and PSC

Abstract

A 25 y.o. male presents with a several-month history of episodic nausea, emesis, and fatigue. He initially denied fevers, chills, diarrhea, hematochezia, melena, weight loss, or night sweats. Laboratory analysis revealed a normal WBC count, but a mildly elevated eosinophil level of 900. An EGD showed nodular gastric mucosa with diffuse erythema and focal erosions. Gastric biopsies revealed increased eosinophils, but the sample was not diagnostic for eosinophilic gastritis. His symptoms persisted despite promethazine as needed. Repeat EGD was performed and this time gastric biopsies returned consistent with eosinophilic gastritis. He was placed on predisone at 40mg daily for 2 months with only a mild decrease in symptoms. He was referred to our center for further evaluation. A thorough evaluation for infectious etiologies was entirely negative. Skin tests to 77 allergens were normal. Serum testing revealed an ALT of 345 U/L, AST of 254 U/L, and normal bilirubin and alkaline phosphatase. An IBD panel revealed a (+) P-ANCA. Upon further questioning, the patient admitted to a history of diarrheal stools, from 5–7 per day, with intermittent hematochezia. Colonoscopy revealed pancolitis with erythematous mucosa and ulcerations. Biopsies taken from numerous colonic segments showed eosinophilc colitis. MRCP was obtained and was consistent with primary sclerosing cholangitis (PSC). Liver biopsies confirmed this diagnosis. The patient was placed on prednisone at 40 mg per day, azathioprine 50mg per day, and ursodeoxycholic acid 1800 mg per day (27mg/kg/day). His symptoms markedly improved. After 2 weeks, his azathioprine was increased to 100mg, and his steroids were tapered. Repeat upper endoscopy in 2 months revealed improvement of his gastric lesions both endoscopically and histologically. He is currently tolerating a gradual steroid taper. Eosinophilic gastroenteritis is an uncommon condition which may involve any part of the digestive system, including the biliary system. This case illustrates several rare events. First, to our knowledge it is only the third reported case in the English language of biliary involvement with eosinophilic colitis or gastritis. Second, it is the only reported case in which the biliary tract did not show marked eosinophilia. Third, it is the first reported case of improvement with antimetabolite therapy.