S2274 Eosinophilic Gastroenteritis: A Challenging Diagnosis

Abstract

INTRODUCTION: Eosinophilic gastroenteritis (EGE) is a rare disease of the digestive tract characterized by the triad of eosinophilic infiltration of the bowel wall, presence of gastrointestinal (GI) symptoms, and exclusion of other causes of peripheral eosinophilia. Clinical presentations depend on the layer—mucosal, muscularis, and subserosal—of intestinal wall and the location of GI involvement. As diagnosis and management of EGE evolves, the prevalence of EGE has increased markedly; this suggests either under- or misdiagnosis of this chronic, relapsing inflammatory disorder. CASE DESCRIPTION/METHODS: A 35-year-old male with history of childhood asthma presented with acute on subacute diffuse abdominal pain, distention, nausea, vomiting, and diarrhea. He was found to have new onset ascites, marked peripheral eosinophilia, and proteinuria. Initial laboratory studies revealed normal hepatic and renal functions. Paracentesis revealed low SAAG ascites and ascetic fluid with 89% eosinophilia on cell count. Extensive work-ups for infectious parasite and hematologic malignancy were unremarkable. Upper endoscopy showed moderate erosive gastritis with edematous mucosa and non-erosive duodenitis. He was empirically treated with oral prednisone with remarkable symptom improvement with near normalization of eosinophilia. Mucosal biopsies from endoscopy, however, were non-diagnostic showing minimal chronic, inflammation of esophagus and stomach without significant eosinophilic infiltration, and normal duodenal mucosa. Prednisone was suspended after 5 days in light of the biopsy results, however, his symptoms soon recurred at which time the decision was made to resume steroids with budesonide, again resulting in symptom relief. DISCUSSION: Given our high level of clinical suspicion for EGE, treatments were resumed despite negative biopsies with plans for colonoscopy and food elimination trials. Currently, EGE lacks widely accepted diagnostic criteria highlighting the need for a high level of clinical suspicion. This case emphasizes that subtypes of EGE may not be always consistent with the classically defining triad, and further consideration for a full thickness biopsy may be warranted in case of high clinical suspicion. EGE should be on the differential for any patient with history of hypersensitivities, GI symptoms, eosinophilia, and eosinophilic ascites. A missed diagnosis can result in high disease burden impacting patient’s quality or disability adjusted life years.