Seeing the World through Rose Colored Glasses: The Etiology of Eosinophilic Infiltration of the Upper GI Tract in a Patient with Ulcerative Colitis

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Introduction: Eosinophilic disease of the upper GI tract is an uncommon disease. The differential diagnosis is often broad and includes parasitic infection, eosinophilic gastroenteritis, and Crohn's. We report a patient with a history of “ulcerative colitis” found to have eosinophils in the stomach and duodenum upon performance of an upper endoscopy. Methods (Case Report): A 36-year-old female with a history of ulcerative colitis and no prior travel history presented with persistent nausea. The patient had a bout of bloody diarrhea two months previously, at which time a colonoscopy revealed procto-sigmoiditis, with a normal right colon and terminal ileum. The patient underwent mesalamine therapy and saw remission. Laboratory evaluation, which included a CBC, CMP, ESR, CRP, TSH, and Β-HCG were all within normal limits. Treatment with a proton pump inhibitor and ondansetron yielded no significant improvement. Upper endoscopy was performed. Although only mild gastritis was found, biopsies of the stomach and duodenum showed greater than thirty eosinophils per high powered field. A capsule endoscopy was performed. More than five deep ulcerations were seen in the termindal ileum consistent with a diagnosis of Crohn's disease. ASCA antibodies and pANCA antibodies were negative. The patient was treated with oral budesonide with resolution of symptoms. Discussion: Eosinophili of the upper GI tract is a relatively uncommon disease. Although Crohn's disease of the upper GI tract typically presents with severe ulceration and granulomas, eosinophilic infiltration has been reported. Eosinophils in the upper GI tract have not been demonstrated with ulcerative colitis. There is one case report of a patient with simultaneous ulcerative colitis and eosinophilic gastroenteritis. Although it would seem reasonable, it is much more common to see Crohn's in patients with upper GI tract eosinophilia compared to ulcerative colitis. The capsule endoscopy can be a useful tool to confirm the diagnosis of and rule out an “overlap syndrome.”Figure: No Caption available.