Eosinophilic Gastrointestinal Disorders Research Articles

Serum Interleukin-17 Evaluation in Patients With Eosinophilic Gastrointestinal Disease

Background: Eosinophilic gastrointestinal disorders or diseases (EGIDs) may result from an abnormal immune-mediated response to food antigens. Activated eosinophils release various mediators with inflammatory properties which may result in tissue and subsequently organ damage. The cytokine milieu of these patients has revealed increased levels of pro-inflammatory cytokines, including interleukin (IL)-17. This study aims to evaluate the potential role of this cytokine in the pathogenesis of EGID.Materials and Methods: This prospective study was conducted at the Allergy Outpatient Clinic, Mofid Children Hospital, Tehran, Iran from January 2016 to January 2017. In this study, Serum IL-17 was determined in all the patients referred to the Allergy Clinic with a pathologic diagnosis of EGID. Results: The median (minimum and maximum) serum IL-17 level in patients with EGID, gastroesophageal reflux disorder (GERD), and healthy controls were 4.32 (0.00-6.383), 2.82 (0.00-3.231), and 3.6 (0.00-7.165) pg/mL, respectively. The results of the non-parametric analysis revealed no significant difference between the three groups regarding IL-17 (P=0.16). However, by classifying EGID in two separate groups with the involvement of upper (eosinophilic esophagitis and eosinophilic gastritis) and lower (eosinophilic enteritis, eosinophilic colitis) gastrointestinal (GI) tracts, a significant difference in serum IL-17 level became evident (P=0.004). Conclusion: We found a significant relationship between IL-17 and upper GI involvement in EGID.

Eosinophilic gastritis-a rare diagnosis

Introduction: Eosinophilic Gastritis (EG), one of the less common amongst Eosinophilic Gastrointestinal Disorders (EGID),with a prevalence of 6.3 cases/100.000, is an uncommon cause of unspecific abdominal symptoms, including epigastric pain.Case: A 23-year-old female, was admitted with recurrent episodes of nausea, vomiting, abdominal pain and weight loss. She was discharged one week previously after being treated for similar symptoms. The patient had failed an outpatient treatment with a Proton Pump Inhibitor (PPI). During her re-admission, Esophagogastroduodenoscopy (EGD) was performed, and results were significant for gastritis without ulcers or esophagitis. While awaiting biopsy results, the patient experienced a minimal improvement in her symptoms with intravenous fluids and PPI. Extensive workup remained negative except of eosinophilia in peripheral blood. Gastric mucosal biopsy revealed eosinophilic infiltrates in Lamina Propria, confirming the diagnosis of Eosinophilic Gastritis. Helicobacter pylori on immunohistochemistry was negative. The patient was counseled regarding the Six Food Elimination Diet for the management of this condition. Her symptoms began to improve under dietary restrictions. Repeated EGD with biopsy at 12 weeks showed resolved eosinophilic infiltrates.Discussion: EG remains a rare diagnosis, and it should be included as a differential diagnosis in every patient with refractory symptoms of nausea, vomiting, abdominal pain, and failure to thrive. Diagnosis of EGID is established after the exclusion of other causes of eosinophilia in the gastrointestinal tract.

Clinical and Psychological Impact of COVID-19 Infection in Adult Patients with Eosinophilic Gastrointestinal Disorders during the SARS-CoV-2 Outbreak.

Eosinophilic gastrointestinal diseases (EGIDs) are chronic gastrointestinal conditions requiring corticosteroid and immunosuppressive therapy for disease control. Patients with EGIDs usually report impaired quality of life. We aimed to report the clinical and psychological impact of COVID-19 infection in EGID patients. In this prospective web-based study we invited all consecutive EGID patients attending the University Hospital of Salerno (Campania) and Padua (Veneto) to fill an ad hoc COVID-19 survey. Moreover, a telemedicine service for direct consultation was organized. Data regarding the occurrence and perception of COVID-19 infection as well as clinical information were recorded. The study population included 102 EGID patients (mean age 36.6 years, 34 females), of whom 89 had eosinophilic esophagitis, nine had gastroenteritis, and four had colitis. No patient was diagnosed with COVID-19 or had recurrence of his/her primary disease. All of them were adherent to therapy and preventive measures adoption. Most patients were worried because of COVID-19 and social preventing measures but did not consider themselves at major risk or susceptible to COVID-19 or other infections due to their chronic condition or therapy. Female gender and low education level were associated to a higher psychological perception of COVID-19 compared to lockdown status or other demographic and clinical factors (p < 0.05). Overall, COVID-19 had a limited clinical impact on patients with EGIDs. The degree of education and sex, but not the fact of living in a lockdown area, influenced the perception of SARS-CoV-2 infection.

Recommendations for the diagnosis and practical management of paediatric eosinophilic oesophagitis

Eosinophilic oesophagitis is an emerging and chronic disorder mediated by the immune system, and is characterised by symptoms of oesophageal dysfunction and inflammation with isolated eosinophil infiltration in the oesophagus. It is more common in males and in atopic subjects, and the symptoms vary with age. In younger children, there is vomiting, abdominal pain and dietary problems, with dysphagia and food impaction in older children and adolescents. The diagnosis is based on the presence of symptoms and oesophageal inflammation with ≥15 eosinophils/high power field, and after ruling out other causes of oesophageal eosinophilia. Without treatment, the disease usually persists and can progress to fibrostenotic forms more common in adults. The treatment options included proton pump inhibitors, empirical elimination diets, and swallowed topical corticosteroids. Maintenance therapy is advisable after the induction treatment. Diet is the only treatment that is directed at the cause of the disease, on identifying the triggering food or foods. The response to the treatments requires a histological assessment due to the poor agreement between the symptoms and the oesophageal inflammation.The practical management of Eosinophilic oesophagitis presents with challenges, due to, among other causes, the current lack of availability of specific drugs, and its approach with, occasionally complex, diet treatments. The present document, prepared by the Working Group on Eosinophilic Gastrointestinal Disorders of the Spanish Society of Paediatric Gastroenterology, Hepatology and Nutrition, has as its objective to help in the diagnostic and therapeutic approach to paediatric eosinophilic oesophagitis, based on the recent evidence-based consensus guidelines.

Targeted Therapies for Eosinophilic Gastrointestinal Disorders.

The growing recognition of eosinophilic gastrointestinal disorders has revealed the limitations of current treatment (mainly based on dietary modification and corticosteroids), and include refractoriness, high recurrence rates, and the need for long-term therapy. Research efforts, mainly in eosinophilic esophagitis (EoE), have unveiled essential pathophysiological mechanisms leading to these disorders, which bear some similarities to those of atopic manifestations and are shared by eosinophilic gastroenteritis (EGE) and eosinophilic colitis (EC). Novel targeted therapies, some imported from bronchial asthma and atopic dermatitis, are currently being assessed in EoE. The most promising are monoclonal antibodies, including those targeting interleukin (IL)-13 (cendakimab) and IL-4 (dupilumab), with phase 3 trials currently ongoing. The potential of anti-integrin therapy (vedolizumab) and Siglec-8 blockers (antolimab) in EGE are also promising. Non-biological therapies for eosinophilic gut disorders, which include preventing the activation of Janus kinase (JAK)-signal transducer and activator of transcription (STAT) and chemoattractant receptor expressed on T helper 2 cells (CRTH2) signaling pathways, and other potential targets that deserve investigation in eosinophilic gut disorders, are reviewed.

Dietary treatment of eosinophilic gastrointestinal disorders in children.

To provide an overview of recent developments on dietary treatment of eosinophilic gastrointestinal disorders (EGID) in children. Food antigens are the main triggers of eosinophilic esophagitis (EoE); however, currently available allergy tests cannot reliably identify eliciting antigens. Studies evaluating the six-food empiric elimination diet (6FED-milk, wheat/gluten, egg, soy/legumes, nuts and fish/seafood) have shown histological remission rates of 72%. Milk, egg, wheat/gluten, and, to a lesser extent, soy/legumes were the most frequent food triggers with only one or two culprit foods identified for most patients. A 4-food elimination strategy afforded a 64% remission rate. A step-up two-four-six food elimination diet generated a 43% remission rate at the two-food elimination stage, and similar reported rates for 4FED and 6FED. Endoscopic procedures were reduced by a 20% compared with 6FED. In a prospective study including 63 children, exclusive milk elimination has been effective in 44% of them. Controlled elimination and reintroduction with histological assessment is necessary. Dietary therapy of EoE has evolved from more restrictive to less restrictive diets to provide better balance between efficacy vs. nutritional deficiencies and quality of life. Data on efficacy of dietary therapy in other EGIDs are very scarce.

Strategy for Food Reintroduction Following Empiric Elimination and Elemental Dietary Therapy in the Treatment of Eosinophilic Gastrointestinal Disorders.

This review presents the available data regarding efficacy of nutritional therapy, highlighting clinical decision points and a strategy for reintroduction of foods following an elemental diet for treatment of eosinophilic gastrointestinal disorders. Elemental and empiric elimination diets are highly effective treatments for eosinophilic gastrointestinal diseases. Standardization in the reintroduction phase, after utilizing the diet for disease remission, is lacking. Clinicians are confronted with multiple challenges regarding the best practice for food reintroduction and identification of potential dietary triggers including order of foods being challenged and duration between endoscopic procedures. Individualization is required for preference and adherence to optimize quality of life and treatment success for this burdensome and life altering immune driven gastrointestinal disorder. Age specific concerns for children, teenagers, and adults should be assessed using a patient centric approach.

Colitis eosinofílica, un diagnóstico poco sospechado

La enfermedad gastrointestinal eosinofílica (EGIE) agrupa diversas patologías que pueden comprometer el tracto gastrointestinal. La más conocida de ellas es la esofagitis eosinofílica, mientras que la menos distinguida es la colitis eosinofílica (CE), que fue informada por primera vez en la literatura de 1959.&#x0D; La CE se caracteriza por la existencia de trastornos funcionales digestivos y la diarrea se constituye en el más importante de estos. Aunque no existen unos criterios diagnósticos claros, se considera que los pacientes deben presentar hemogramas con eosinofilia y hallazgos histológicos de infiltración eosinofílica, los cuales son determinados por el estudio histológico de las biopsias tomadas mediante la colonoscopia.&#x0D; Así pues, la CE afecta especialmente a neonatos y adultos jóvenes, y se ha relacionado con causas genéticas y alérgicas. El tratamiento inicial consiste en la suspensión de los alérgenos. Dentro del arsenal farmacológico, se emplea la prednisolona, así como medicamentos entre los que se incluyen la budesonida y los inmunomoduladores en los casos refractarios, con lo cual se logra una adecuada respuesta. Presentamos una actualización de este tema.

Patients with eosinophilic gastrointestinal disorders and hypereosinophilia share common characteristics regardless of single or multi-organ involvement

Patients with eosinophilic gastrointestinal disorders and hypereosinophilia share common characteristics regardless of single or multi-organ involvement

EOSINOPHILIC ESOPHAGITIS AND EOSINOPHILIC GASTROENTERITIS- NOT SO RARE?

Eosinophilic gastro-intestinal disorder is an uncommon disorder presenting with non-specic gastrointestinal symptoms. It is diagnosed by demonstrating eosinophilic inltration of gut wall after excluding other causes of eosinophilia. It is likely a hypersensitivity response to food allergen. The most common symptoms of patients are abdominal pain, nausea, vomiting, early satiety, and diarrhoea. It responds well to corticosteroids. We hereby present two cases – eosinophilic esophagitis and eosinophilic duodenitis- seen in a span of one month, presenting with vague gastro-intestinal symptoms for over a year. Their endoscopic biopsy showed eosinophilic inltration of mucosa. The aim of presenting the cases is to increase awareness of this disorder as high index of suspicion is necessary to diagnose these patients.

Eosinophilic colitis: clinical review and 2020 update.

Eosinophilic colitis (EC) is a rare inflammatory disease included in the chapter of eosinophilic gastrointestinal disorders (EGIDs), diagnosed by the presence of primary eosinophilic infiltrate in the colon wall in symptomatic patients. While the etiology of primary colonic eosinophilia is unknown, several conditions are involved in the pathogenesis of secondary eosinophilic colonic infiltrate (food allergens, parasitic infections, drugs), which have to be excluded in order to correctly diagnose the primary form of the disease. Up to now, EC is lacking of codified guidelines regarding diagnostic criteria (especially eosinophil threshold values) and treatment, thus a correct approach to EC remains very challenging. Imaging, laboratory tests and endoscopy might be helpful in ruling out other mimic conditions, but EC is still a diagnosis of exclusion. Several treatment options are feasible, but most of the evidences are drawn from case reports and small case series, thus limiting their value. We carried out a review of the current literature to evaluate the more appropriate and modern clinical strategy for diagnosis and management of EC.

Fecal Calprotectin as a Useful Non-Invasive Screening Marker for Eosinophilic Gastrointestinal Disorder in Korean Children.

BackgroundEosinophilic gastrointestinal disorder (EoGID) is an emerging disease condition in Korean children, but its diagnosis requires invasive endoscopic biopsies. Fecal calprotectin (FCal) is a noninvasive biomarker for intestinal inflammation to differentiate organic gastrointestinal diseases from functional abdominal pain disorder. This study aimed to evaluate the diagnostic accuracy of FCal and to determine the optimal cutoff to differentiate EoGID from functional abdominal pain disorder.MethodsA total of 253 children (122 boys, 131 girls; mean age 12.2 ± 3.6, range 2.9–17.8 years) who underwent endoscopy with biopsies for chronic gastrointestinal symptoms were recruited, except for 38 children diagnosed with inflammatory bowel disease, and divided into EoGID (n = 67) and functional abdominal pain disorder (n = 186). FCal, white blood cell (WBC) counts, eosinophil counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels were measured in all subjects at initial diagnosis.ResultsFCal levels weakly correlated with WBC (r = 0.127, P = 0.044) and CRP (r = 0.126, P = 0.040) but not with ESR and eosinophil count. FCal levels were significantly higher in the EoGID group than in the functional abdominal pain disorder group (mean 179.5 ± 242.9 mg/kg vs. 44.3 ± 68.1 mg/kg; P < 0.001), while WBC, ESR, CRP, and eosinophil count did not differ between the two groups (all P > 0.05). An optimal cutoff of FCal 73.2 mg/kg distinguished EoGID from functional abdominal pain disorder with a sensitivity of 50.7% and a specificity of 84.6%.ConclusionFCal is a useful and reliable noninvasive marker for differentiating EoGID from functional abdominal pain disorder in Korean children with chronic gastrointestinal symptoms when optimal cutoffs are applied.

Risk factors of delayed tolerance in children with cow milk protein allergy attending gastroenterology clinic in Alexandria University Children’s Hospital

Background Cow’s milk protein allergy (CMPA) is the most common type of food allergy. The prevalence is increasing in both developing and developed countries. The clinical presentations are variable in intensity and may involve many different organ systems. The diagnosis depends on positive response to an elimination diet, with recurrence of the symptoms upon re-challenge. CMPA usually resolves during early childhood, but some factors may delay the acquisition of tolerance. Aim The aim was to investigate the possible risk factors that may be associated with delayed tolerance to cow’s milk in patients with CMPA. Patients and methods The study included 95 patients aged 1 month to 3 years with proved CMPA attending the Gastroenterology Clinic at Alexandria University Children Hospital. Cases were recruited for 6 months, starting from January 1, 2018, to the end of June 2018. The demographic data, age at onset, clinical presentations, nutritional history, and family history of atopy were reported. The diagnosis was confirmed through elimination-re-challenge trial. All patients were treated by a milk-free diet with the use of appropriate milk substitutes according to the age. After a 6–9-month period of elimination, gradual re-introduction of milk was attempted, and the development of tolerance to milk was evaluated. Factors associated with delayed tolerance were compared in both the tolerant and intolerant groups. Results At their initial visit, the mean age of the studied patients was 8.5±4.9 months, and 17.9% were underweight. The mean age at onset of symptoms was 2.2±2.2 months, whereas the mean duration before diagnosis was 3.3±2.8 months. Overall, 85.3% were born via cesarean section. Chronic or delayed symptoms were reported in 93.7%. All patients had gastrointestinal symptoms. Chronic diarrhea was the commonest symptoms (90.53%) followed by vomiting (42%). In addition, 28.4% had cutaneous symptoms. Moreover, 81% were formula fed. Food protein-induced proctocolitis was the most common syndrome among patients with chronic symptoms. Overall, 85.26% of them were born via cesarean section. Early introduction of dairy products was encountered in 37.9%. In addition, 10% of the patients had cross-reaction to soy and 14.5% had multiple food allergy (MFA). Additionally, 56.8% had a family history of atopy. Overall, 68.42% tolerated cow milk after gradual re-introduction. Delayed diagnosis of CMPA symptoms, delayed introduction of complementary food, rural residence, family history of atopy, cross-reactivity to soya or MFA were associated with delayed tolerance to cow’s milk. Patients with immediate symptoms [immunoglobulin (Ig)E mediated] or food protein-induced enterocolitis syndrome or those with CMPA-associated eosinophilic gastrointestinal disorders showed delayed tolerance. Tolerance was achieved more frequently in patients with delayed (non-IgE mediated) symptoms, in patients with exclusive gastrointestinal symptoms, and in patients with food protein-induced proctocolitis. Conclusion The tolerance rate after 6–9 months of elimination was 63.2%, which is comparable to the international rates. IgE-mediated CMPA, food protein-induced enterocolitis syndrome, CMPA-associated eosinophilic gastrointestinal disorders, and MFA have delayed tolerance.

The Emerging Role of Eosinophils as Multifunctional Leukocytes in Health and Disease.

Eosinophils are terminally differentiated cytotoxic effector cells that have a role in parasitic infections and allergy by releasing their granule-derived cytotoxic proteins. However, an increasing number of recent observations indicate that eosinophils are not only associated with the pathogenesis of a wide range of diseases, but also contribute to the maintenance of homeostatic responses in previously underappreciated diverse tissues, such as the gastrointestinal (GI) tract and adipose tissue. In this review, we describe biological characteristics of eosinophils, as their developmental properties, permissive proliferation and survival, degranulation activity, and migration properties enable them to distribute to both homeostatic and inflamed tissues. We describe pathologic aspects of eosinophils with a role in asthma and in various GI diseases, including eosinophilic GI disorders, inflammatory bowel disease, and radiation-induced enteropathy. Finally, we discuss the beneficial role of eosinophils, which contribute to the resolution of pathogenic conditions and to the modulation of homeostatic biologic responses.

Distribution of eosinophils in the gastrointestinal tract of children with no organic disease.

BackgroundThis study aimed to assess the eosinophil (eos) density of the mucosa of the gastrointestinal (GI) tract in children undergoing endoscopic procedures following an extensive workup, without diagnosis of an organic disease.MethodsBiopsies from GI endoscopies performed at 3 major children’s hospitals (Athens, Madrid and Rome), between January 2012 and June 2018, were evaluated by a single pathologist in each center. Peak eos counts were expressed /high power field and /mm2. Other histological abnormalities were also reported.ResultsA total of 111 children (median age 11 years; 48 boys) underwent upper endoscopy (333 biopsies), while 44 (median age 12; 25 boys) underwent ileocolonoscopy (262 biopsies). The median (interquartile range) eos/mm2 were as follows: esophagus 0 (0-0); stomach 10.2 (3.3-15.3); duodenum 56.1 (26.1-86.7); ileum 61.2 (49.0-91.8); cecum 76.5 (40.9-99.7); ascending colon 73.9 (49.5-131.4); transverse colon 66.3 (40.8-91.5); descending colon 66.3 (30.6-81.6); sigmoid colon 39.2 (27.8-51.0); and rectum 25.5 (9.8-45.8). Geographical variations in GI tissue eos counts were found amongst the participating centers, but the causative factors need further evaluation. Functional GI disorders according to the Rome IV criteria were diagnosed in 73 children (37 boys, median age 13 years). No differences were found between children with or without functional GI disorder diagnosis, with regard to eos density in the GI tract.ConclusionThe reported peak counts of GI tissue eos in children with no organic diseases provide normative values that may be useful in the evaluation of children with GI symptoms suggestive of eosinophilic GI disorders.

Association Between Endoscopic and Histologic Findings in a Multicenter Retrospective Cohort of Patients with Non-esophageal Eosinophilic Gastrointestinal Disorders.

Little is known about the endoscopic and histologic findings of non-esophageal eosinophilic gastrointestinal diseases (EGID). To characterize the presenting endoscopic and histologic findings in patients with eosinophilic gastritis (EG), eosinophilic gastroenteritis (EGE), and eosinophilic colitis (EC) at diagnosis and 6months after initiating the treatment. We conducted a retrospective cohort study at 6 US centers associated with the Consortium of Eosinophilic Gastrointestinal Researchers. Data abstracted included demographics, endoscopic findings, tissue eosinophil counts, and associated histologic findings at diagnosis and, when available, after initial treatment. Of 373 subjects (317 children and 56 adults), 142 had EG, 123 EGE, and 108 EC. Normal endoscopic appearance was the most common finding across all EGIDs (62% of subjects). Baseline tissue eosinophil counts were quantified in 105 (74%) EG, 36 (29%) EGE, and 80 (74%) EC subjects. The mean peak gastric eosinophil count across all sites was 87 eos/hpf for EG and 78 eos/hpf for EGE. The mean peak colonic eosinophil count for EC subjects was 76 eos/hpf (range 10-500). Of the 29% of subjects with post-treatment follow-up, most had an improvement in clinical, endoscopic, and histologic findings regardless of treatment utilized. Reductions in tissue eosinophilia correlated with improvements in clinical symptoms as well as endoscopic and histologic findings. In this large cohort, normal appearance was the most common endoscopic finding, emphasizing the importance of biopsy, regardless of endoscopic appearance. Decreased tissue eosinophilia was associated with improvement in symptoms, endoscopic, and histologic findings, showing that disease activity is reversible.

3073 Eosinophilic Gastroenteritis and Eosinophilic Proctocolitis With a Large Rectal Sessile Serrated Adenoma: A Rare Association

INTRODUCTION: Eosinophilic Gastrointestinal Disorders (EGID) are a group of rare disorders characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic gastroenteritis (EGE), eosinophilic colitis (EC) and eosinophilic proctitis (EP) are different types of EGID. We report a case of rare association of EGID and a large sessile serrated adenoma in a middle-aged Hispanic female. CASE DESCRIPTION/METHODS: A 49-year-old Hispanic female presented with epigastric discomfort, nausea and hematochezia. The symptoms were insidious in onset and evolved over the span of 3 years. Upper GI Endoscopy showed mild diffuse erythematous mucosa in the antrum and body of the stomach. Colonoscopy showed a few superficial ulcers in the terminal ileum, two polyps in the transverse colon and a large laterally spreading polypoid lesion in the rectum with adjacent multiple small polypoid lesions (Figures 1 and 2). Histological assessment of the gastric biopsy specimen revealed chronic active gastritis, numerous H. pylori, in addition to very high number of eosinophils in the lamina propria. Biopsies of ileum, colon and the rectum also revealed very high number of eosinophils in the lamina propria. Stool for ova and parasite examinations were negative and no peripheral eosinophilia was noted. Patient did not have any food or environmental allergies. Other disorders that could contribute to eosinophil infiltration of the GI tract were ruled out. Hematochezia was likely due to eosinophilic proctitis and rectal polypoid lesion. Although exact eosinophilic count in the biopsy specimen of the stomach, small bowel and the colon was not reported, the clinical presentation and histology was likely consistent with EGID. Patient was treated for H. Pylori infection. Endoscopic submucosal dissection of the rectal polypoid lesion was performed (Figure 3). Pathology revealed sessile serrated adenoma. DISCUSSION: Eosinophilic gastrointestinal disorders are a group of rare gastrointestinal diseases with non-specific symptoms and clinical presentation. Diagnosis of EGE, EC and EP involves evaluating for presence of gastrointestinal symptoms, histopathology finding of eosinophilic infiltration of the GI tract and ruling out secondary causes of eosinophilia. Endoscopic examination may reveal patchy erythema, loss of vascularity and lymphonodular hyperplasia mostly localized to the rectum. The authors report this rare case of possible association of EGID and sessile serrated adenoma.

2759 Eosinophilic Gastritis Responding to Proton Pump Inhibitor

INTRODUCTION: Eosinophilic gastritis is a rare condition that is part of a spectrum of gastrointestinal eosinophilic infiltration disorders which also includes eosinophilic esophagitis, enteritis, and colitis. They are characterized by excess eosinophils in the mucosal biopsy of one or more sites of the gastrointestinal tract in the absence of any specific causes of eosinophilia. Patients may present with symptoms including nausea, vomiting, abdominal pain, and weight loss. First-line of treatment is steroids. We describe a case of eosinophilic gastritis that was successfully treated with Proton pump inhibitor therapy. CASE DESCRIPTION/METHODS: A 23-year-old male presented to the outpatient clinic with a six-month history of episodic epigastric discomfort and retrosternal burning pain. Each episode lasted several hours and was precipitated by food intake. He had previously taken omeprazole 10 mg on and off for 4 weeks without any response. He had no history of any allergic disease. H.pylori stool antigen was negative. He was subsequently treated with four-week therapy of tricyclic anti-depressants with no response. Following this, he underwent upper gastrointestinal (UGI) endoscopy which showed mild erythema in the antrum. Gastric biopsy showed extensive eosinophilic infiltration with &gt;50 cells/HPF in &gt;5 HPF with normal esophageal and duodenal biopsy. Differential WBC count showed mild eosinophilia (7%). In line with a diagnosis of eosinophilic gastritis the patient was advised six food elimination which he refused. He was then started on Pantoprazole 40 mg once daily which was increased to twice daily after a week due to continued reflux symptoms. His symptoms gradually resolved over the next 12 weeks. On follow-up visit 3 months later he underwent repeat UGI endoscopy with biopsy which showed complete resolution of eosinophilic gastritis. The patient continues to remain asymptomatic. DISCUSSION: Eosinophilic gastrointestinal disorders can involve any part of the gastrointestinal tract from the esophagus to the colon. The antrum of the stomach is most commonly involved. There are no recognized guidelines for the treatment of eosinophilic gastritis, although steroid therapy is the mainstay of treatment. The role of PPI in the treatment of eosinophilic esophagitis is well known, but the utility of the same in eosinophilic gastritis has not been well defined. Our patient had symptomatic gastritis with biopsy revealing extensive eosinophilic infiltration. He responded excellently to 12-week pantoprazole therapy.

3041 Eosinophilic Colitis: A Rare Entity

INTRODUCTION: Eosinophilic colitis (EC) is a rare entity characterized by abnormal infiltration of colon mucosa by eosinophils without evidence of any secondary causes. Presentation may include asymptomatic state, chronic diarrhea, abdominal pain, rectal bleed, bowel obstruction or ascites. We present two cases of EC with very different presentations requiring minimal or no therapy. CASE DESCRIPTION/METHODS: CASE 1: 57 year old Filipino male presented with abdominal pain and new onset ascites. Paracentesis revealed elevated SAAG suggestive of portal hypertension. Imaging studies were negative for cirrhosis. Negative liver workup for chronic liver disease. Lab studies revealed microcytic anemia and peripheral eosinophilia of 10%. No eosinophilia noted in ascitic fluid. EGD showed LA Grade C esophagitis. Colonoscopy showed multiple polyps which were removed. Pathology from polyps showed markedly increased eosinophil infiltrate in mucosa and submucosa. There was no evidence of inflammatory bowel disease, Stool studies were negative for infectious etiology. No incriminating medications were found which could lead to above finding. The patient was treated with omeprazole and diuretics with complete resolution of symptoms. CASE 2: 27 year old female presented with chronic intermittent abdominal pain, nausea and diarrhea for 2 years. Her only medications were birth control pills. She had normal blood counts, electrolytes, liver, and renal function. Stool studies were negative for any infectious etiology. She had normal fecal fat and electrolytes. EGD and colonoscopy were unremarkable. Biopsies were negative for celiac disease, Helicobacter and eosinophilic esophagitis. Random colon biopsies showed benign colon mucosa with focal infiltration of colonic mucosa with eosinophils suggestive of eosinophilic colitis. There was no peripheral eosinophilia. Patient was started on probiotics with prompt resolution of symptoms. DISCUSSION: EC is a rare condition, included in the group of eosinophilic gastrointestinal disorders, characterized by eosinophil infiltration of colonic mucosa in the absence of any food allergies, parasitic/helminthic infections, drugs, IBD, celiac and autoimmune diseases. The treatment options include dietary modifications, steroids, mesalamine, immunomodulatory agents, fecal microbiota transplant and surgery. The evidence for most of treatment options is limited to case reports. One of our patients required no specific therapy while other one was treated successfully with probiotics.

Hypereosinophilia with Gastrointestinal Involvement: A Case Report

Hypereosinophilic syndrome is currently defined by an absolute blood eosinophil count of more of 1500 cell per μL for more than 1 month and by multiorgan system infiltration. Eosinophilic colitis is an exceptionally rare inflammatory condition in which eosinophils infiltrate the colonic gut. It represents the least frequent manifestation of the wide spectrum of eosinophilic gastrointestinal disorders. We describe a case of an adult male patient with persistent eosinophilia for at least twenty-five years. During this long period he had repeated abdominal colics caused by acute appendicitis with peritonitis, enterocolitis, and pancreatitis: all episodes were associated with a marked increase in blood eosinophils, but without Ig E modification. Malignant transformation of hypereosinophilia has not been detected. Oral cortisone treatment was administered only for short periods of time.