Eosinophilic Gastroenteritis Presenting as Pyloric Stenosis with EUS Demonstrating Thickened Pyloric Channel

Abstract

The diagnosis of eosinophilic gastroenteritis is based on clinical history and biopsy findings of more than 20 eosinophils per high power field. We describe a case of eosinophilic gastroenteritis presenting as pyloric stenosis. Endoscopic ultrasound (EUS) was used to aid in assessing the extent of disease and ultimately influenced patient management. Case: 62 year old woman presented with vomiting solids and liquids immediately after eating. She reported a 40 pound weight loss. Her only medication was sertraline. Physical exam was unremarkable. Laboratory tests including a CBC with differential, electrolytes, liver panel, IgE were normal; stool studies revealed no ova or parasites. Upper endoscopy revealed pyloric stenosis (Figure 1) and dilation to 10mm was done. Biopsies revealed severe chronic antral gastritis with eosinophilia. Helicobacter pylori was not detected. No eosinophils were noted on small bowel or esophageal biopsies. EUS showed thickening of the pyloric channel wall to 7mm with loss of the five layer echopattern. (Figure 2) The muscularis propria was visible in some areas only. The wall of the body and antrum appeared normal with an intact layer pattern. Patient was treated with a slow steroid taper (6 months) with gradual but persistent improvement in symptoms. Discussion: Eosinophilic gastroenteritis is generally treated with a short course of steroids. Our patient's prior episodes of pyloric stenosis had been treated with 4–6 weeks of steroids. The extent of disease was not evaluated due to the patient declining surgical intervention. EUS findings provided us useful information regarding extent of disease, guiding further management. [figure 1][figure 2]FigureFigure