Eosinophilic gastroenteritis, ascites, and pancreatitis: a case report and review of the literature.

Abstract: Eosinophilic gastroenteritis is an inflammatory disorder of the gastrointestinal tract in which eosinophilic infiltration occurs in the gut layers. A case of subserosal eosinophilic gastroenteritis was diagnosed in a patient with abdominal pain, eosinophilic ascites, and pancreatitis. To our knowledge, this is the first case report of eosinophilic gastroenteritis associated with concurrent eosinophilic ascites and pancreatitis.

Key Words: ascites, eosinophilic gastroenteritis, pancreatitis

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Eosinophilic gastroenteritis is a rarely encountered inflammatory disorder characterized by eosinophilic infiltration of the gastrointestinal tract. (1,2) Most often limited to the stomach and small intestines, eosinophilic gastroenteritis is rarely associated with other gastrointestinal manifestations, including esophagitis, duodenal ulcerations and obstruction, cholangitis, cholecystitis, colitis, ascites, and pancreatitis. (3) To our knowledge, this is the first report of a patient with eosinophilic gastroenteritis with concurrent ascites and pancreatitis. (3,4,5)

Case Report

A 30-year-old female presented with a one-month history of nausea, vomiting, diarrhea, generalized abdominal pain, and weight loss of ten pounds. Past medical history was significant only for allergic rhinitis. Physical examination was significant for a distended abdomen with ascites and no peritoneal signs.

The laboratory evaluation was significant for a white blood cell count of 11.5, with 55% eosinophils, and normal serum chemistries. Amylase and lipase levels were 94 and 1,057 respectively. Antinuclear antibody titer was 1:40 with homogeneous pattern, and anti-neutrophilic antibody was negative. Stool tests were negative for enteric pathogens, Strongyloides, and parasitic infection. Abdominal computed tomographic scan revealed marked diffuse duodenal and small bowel thickening, and moderate ascites. Paracentesis was consistent with an exudative process with white blood cell count of 2,160 (93% eosinophils). Upper endoscopy revealed normal esophagus but diffuse gastritis and duodenitis. Biopsies of the gastric fundus, antrum, and duodenum were positive for eosinophilic infiltration of the subserosa. Bowel rest was initiated, and oral prednisone 40 mg tapered over two weeks was prescribed with complete resolution of her symptoms.

Discussion

Diagnostic criteria for eosinophilic gastroenteritis include: gastrointestinal symptoms, including abdominal pain, vomiting, and diarrhea; biopsy evidence of eosinophils from the gut wall; exclusion of parasitic infection; and absence of extragastrointestinal eosinophilic infiltration. (1,2) When eosinophilic gastroenteritis is observed in association with eosinophilic infiltration of other organ systems, the diagnosis of idiopathic hypereosinophilic syndrome should be considered. (1,2,5)

The spectrum of symptomatology in eosinophilic gastroenteritis depends on the location and depth of eosinophilic infiltration in the gastrointestinal tract. (1) Klein classified eosinophilic gastroenteritis into three types based upon level of eosinophilic infiltration into the gut layers. These include predominant mucosal disease (abdominal pain, vomiting, diarrhea, and protein-losing enteropathy); muscle layer disease (bowel wall thickening, and gastric and small bowel obstruction); and subserosal disease (rarest form associated with eosinophilic ascites). (1,5)

The etiology of eosinophilic gastroenteritis is not well understood. Preexisting histories of atopic disease are often present in patients who eventually develop eosinophilic gastroenteritis. Immunologic mechanisms involving interleukin 4 and 5 remain at the forefront of the postulated pathogenesis of eosinophilic gastroenteritis. (1,2) Triggering of eosinophilic gastroenteritis may occur from antigen exposures, which stimulate eosinophilic degranulation and release of toxic eosinophilic major basic proteins into the bowel epithelium. (1,2,3)

The subserosal type of eosinophilic gastroenteritis is the predominant form associated with eosinophilic ascites. (1,2,5) These patients generally have exudative ascites, abundant peripheral eosinophilia, and favorable responses to corticosteroids. (1,2,4,5) Pancreatitis has been described in two prior cases in conjunction with eosinophilic gastroenteritis. A case of pancreatitis secondary to eosinophilic gastroenteritis was caused by mechanical obstruction of the pancreatic duct secondary to eosinophilic infiltration of the duodenum. (5) A second case of eosinophilic pancreatitis and biliary ductal dilation was reported in a patient who presented with eosinophilic gastroenteritis and suspected pancreatic tumor. Biopsy revealed dense eosinophilic infiltration of the pancreas. (4)

Corticosteroids remain the mainstay of therapy for eosinophilic gastroenteritis. (1) The duration of therapy is not well defined, but long-term prognosis for eosinophilic gastroenteritis is favorable in 90% of cases. (1) Immunologic studies have focused on drugs such as Mepolizumab (GlaxoSmith-Kline, Beverly, MA), a humanized monoclonal antibody directed against IL-5. (1,2,5)

To our knowledge, this is the first reported case of eosinophilic gastroenteritis associated with both eosinophilic ascites and pancreatitis. This case demonstrates the potential for widespread gastrointestinal presentations of eosinophilic gastroenteritis. We recommend that the entire digestive tract be thoroughly investigated when evaluating a patient with peripheral eosinophilia, especially in the presence of abdominal symptoms.

Perfection is achieved, not when there is nothing more to add, but when
there is nothing left to take away.
--Antoine de Saint Exupery

Accepted January 8, 2004.

References

1. Matushita M, Kiyoh H, Yukari M, et al. Eosinophilic gastroenteritis involving the entire digestive tract. Am J Gastroenterology 1995;90:10-15.

2. Meisel J. Regarding Matushita: eosinophilic gastroenteritis involving the entire digestive tract. Am J Gastroenterology 1996;91:2-3.

3. Lee J, Lee M. Allergic reaction to Gemfibrozil manifesting as eosinophilic gastroenteritis. Southern Medical J 2000;93:8-10.

4. Euscher E. Eosinophilic pancreatitis: a rare entity that can mimic a pancreatic neoplasm. Ann of Diagnostic Pathology 2000;4:379-385.

5. Maeshima A. Eosinophilic gastroenteritis presenting with acute pancreatitis. J of Medicine 1997;28:265-272.

RELATED ARTICLE: Key Points

* Eosinophilic gastroenteritis is most often limited to the stomach and small intestines, but rarely can be associated with widespread gastrointestinal involvement.

* Corticosteroids remain the mainstay of therapy for eosinophilic gastroenteritis.

* The entire digestive tract should be thoroughly investigated in a patient with peripheral eosinophilia.

Connie D. Le, MD, and Hien Nguyen, MD

From the Department of Internal Medicine, George Washington University Medical Center, Fairfax, VA.

Reprint requests to Connie D. Le, MD, 3808 Daniel's Run Court, Fairfax, VA 22030. Email: [e-mail]