Eosinophilic-Crohn overlap colitis and review of the literature

Eosinophils, Eosinophilic Gastrointestinal Diseases, and Inflammatory Bowel Disease: A Critical Review

BACKGROUND/OBJECTIVES

Inflammatory bowel disease (IBD) and eosinophilic gastrointestinal diseases (EGIDs) are complex, multifactorial chronic inflammatory disorders affecting the gastrointestinal tract. Their epidemiology, particularly for eosinophilic esophagitis (EoE), is increasing worldwide, with a rise in the co-diagnosis of IBD and EGIDs. Both disorders share common risk factors, such as early exposure to antibiotics or specific dietary habits. Moreover, from a molecular perspective, eosinophilic infiltration is crucial in the diagnosis of eosinophilic disorders, and it also plays a pivotal role in IBD histological diagnosis. Indeed, recent evidence highlights the significant role of eosinophils in the health of the intestinal mucosal barrier and as mediators between innate and acquired immunity, even indicating a potential role in IBD pathogenesis. This narrative review aims to summarize the current evidence regarding the common clinical and molecular aspects of EGIDs and IBD and the current state of knowledge regarding overlap conditions and their pathogenesis.

METHODS

Pubmed was searched until May 2023 to assess relevant studies describing the epidemiology, pathophysiology, and therapy of EGIDs in IBD.

RESULTS

The immune pathways and mechanisms underlying both EGIDs and IBD remain partially known. An improved understanding of the role of eosinophils in overlapping conditions could lead to enhanced diagnostic precision, the development of more effective future therapeutic strategies, and a more accurate prediction of patient response. Consequently, the identification of red flags indicative of an eosinophilic disorder in IBD patients is of paramount importance and must be evaluated on a case-by-case basis.

Challenges in Diagnosis and Management of Unusual Cases of Eosinophilic Enteritis in Rural Health Settings: A Comprehensive Review

This comprehensive review delves into the challenges associated with diagnosing and managing unusual cases of eosinophilic enteritis in rural health settings. Eosinophilic enteritis, characterized by an abnormal accumulation of eosinophils in the gastrointestinal (GI) tract, poses distinct difficulties in diagnosis due to its varied presentations. In rural contexts, limited access to specialized diagnostic tools, a shortage of healthcare professionals, and geographical constraints compound these challenges. This abstract encapsulates the critical issues explored in the review, emphasizing the importance of addressing atypical cases and rural healthcare's unique hurdles. The conclusion is a rallying call for collaborative action, advocating for improved education, telemedicine solutions, and enhanced access to specialized care. The implications extend beyond eosinophilic enteritis, with the potential to instigate systemic improvements in rural healthcare globally. This review is a crucial contribution to understanding eosinophilic enteritis in rural settings and advocates for transformative measures to improve diagnosis, management, and overall healthcare outcomes.

Eosinophilic Colitis, an Uncommon Cause of Diarrhea: Case Report and Literature Review

Eosinophilic colitis and hypereosinophilic syndrome with colic involvement are rare diagnosis that are characterized by wide-ranging gastrointestinal symptoms and idiopathic infiltration of eosinophils in the colon. The diagnostic workup is challenging since there are no standardized criteria. We report a case of a man admitted to the hospital with a history of nonbloody chronic diarrhea. The detailed workup demonstrated blood eosinophilia, and the colonic biopsies revealed extensive eosinophilic infiltration. He was treated with steroids with clinical and analytical improvement. Due to relapsing colitis after therapy withdrawal, he was chronically medicated with 10 mg of prednisolone with ultimate symptom control. This case report describes the diagnostic workup and highlights the most important features of this often underdiagnosed entity.

Flexible Sigmoidoscopy Utility in the Diagnosis of Pediatric Gastrointestinal Disorders

AIM

 Although flexible sigmoidoscopy (FS) is utilized in children for the diagnosis of pediatric gastrointestinal conditions, such as inflammatory bowel disease and juvenile polyp disorders, the diagnostic yield of FS in pediatric patients is unknown.

MATERIALS AND METHODS

 We retrospectively reviewed FS cases in children under 18 years of age over a five-year period at our institution. Indications for the procedure, endoscopic visual findings, histologic findings, final diagnosis, and any management changes based on FS findings were included.

RESULTS

 A total of 354 cases were included in the analysis for which 40 cases (11.3%) had abnormal visual findings, 48 cases (13.6%) had abnormal histologic findings, and 13 cases (3.7%) had both abnormal endoscopic visual and histologic findings. Of the 88 cases with abnormal visual and/or histologic abnormalities, only the results of 34 of these FS cases led to a change in management based on endoscopic findings (9.6%). Most patients with a non-diagnostic FS had a final diagnosis of functional abdominal pain; most patients with a diagnostic FS had a final diagnosis of colitis, not otherwise specified.

CONCLUSION

 Our findings suggest that FS is not a helpful diagnostic endoscopic intervention in pediatric patients, especially in children with reassuring history and physical exam findings.

Mimics of Crohn's Disease

Crohn's disease is a chronic inflammatory disease that can affect any portion of the gastrointestinal tract. Associated symptoms can vary based on the severity of disease, extent of involvement, presence of extraintestinal manifestations, and development of complications. Diagnosis is based on a constellation of findings. Many diseases can mimic Crohn's disease and lead to diagnostic conundrums. These include entities associated with the gastrointestinal luminal tract, vascular disease, autoimmune processes, various infections, malignancies and complications, drug- or treatment-induced conditions, and genetic diseases. Careful consideration of possible causes is necessary to establish the correct diagnosis.

The Clinical Characteristics and Treatment Outcomes of Concomitant Eosinophilic Esophagitis and Inflammatory Bowel Disease

Background

The clinical characteristics and treatment outcomes in patients with eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) have not been extensively investigated.

Methods

We determined treatment outcomes and frequencies of disease-related complications in patients with EoE and IBD.

Results

Among 69 patients who met inclusion criteria, 39 (56.5%) had a diagnosis of Crohn disease. Clinical and histologic response rates to proton pump inhibitors and topical steroids were 25.9% and 24.4%, respectively.

Conclusions

Lower than expected clinical and histologic response rates for EoE suggest the combination of EoE and IBD is a medically refractory phenotype with more difficult to treat EoE.

Cost of chronic inflammatory disease: The impact of eosinophilic esophagitis in Nevada

OBJECTIVES

The cost of treating the rare eosinophilic esophagitis (EoE) disease and its impact on patients' quality of life have not been well documented in the literature. This study seeks to fill this gap by comparing the cost of EoE with other well-known inflammatory diseases, including Crohn's disease (CD) and celiac disease (CeD).

METHODS

A Mann-Whitney U test and multiple logistic regression were used to examine the cost of EoE in the state of Nevada across all hospital settings and its impact on quality of life compared with CD and CeD.

RESULTS

Several factors were associated with the overall cost of EoE in Nevada, including patients' age, sex and region (P < 0.001). EoE was significantly more expensive to treat in the pediatric group ($4001 EoE; $985 CD; $856 CeD), among men ($2532 EoE; $1500 CD; $1724 CeD), among those residing in the southern region of Nevada ($4501 EoE; $2538 CD; $1888 CeD), and among patients seeking medical care from outpatient clinics ($3298 EoE; $741 CD; $1686 CeD) (P < 0.001). Age, sex, region and hospital setting were all associated with having a positive EoE record compared with CeD or CD (P < 0.001).

CONCLUSIONS

Data from this study indicate that the EoE burden is significantly higher in cost for certain demographics and regions compared with CD and CeD in the state of Nevada, specifically among pediatric and male patients. These differences suggest that clinicians may encounter similar issues when treating EoE.

Quantitative Analysis of Distribution of the Gastrointestinal Tract Eosinophils in Childhood Functional Abdominal Pain Disorders

Background/Aims

Although functional abdominal pain disorders (FAPDs) are common in children, the accurate pathogenesis of FAPDs is not known yet. Micro-inflammation, particularly tissue eosinophilia of gastrointestinal (GI) tract, has been suggested as the pathophysiology observed in several GI disorders. We aimed to evaluate eosinophilic infiltration throughout the entire GI tract in children with FAPDs, compared to those with inflammatory bowel diseases (IBD) and to normal reference values.

Methods

We included 56 children with FAPDs, 52 children with Crohn's disease, and 23 children with ulcerative colitis. All subjects underwent esophagogastroduodenoscopic and colonoscopic examination with biopsies. Tissue eosinophil counts were assessed in 10 regions throughout the GI tract.

Results

Eosinophil counts of the gastric antrum, duodenum, terminal ileum, cecum, and ascending colon were significantly higher in children with FAPDs compared to normal reference values. Eosinophil counts of the stomach and the entire colon were observed to be significantly higher in children with IBD than in those with FAPDs. Even after selecting macroscopically uninvolved GI segments on endoscopy in children with IBD, eosinophil counts of the gastric body, cecum, descending colon, sigmoid colon, and the rectum were also significantly higher in children with IBD than those with FAPDs.

Conclusions

Significantly high eosinophil counts of the stomach and colon were observed in the order of IBD, followed by FAPDs, and normal controls, regardless of endoscopically detected macroscopic IBD lesions in children. This suggests some contribution of GI tract eosinophils in the intrinsic pathogenesis of FAPDs in children.

Clinical Implications of Pediatric Colonic Eosinophilia

OBJECTIVE

Pediatric colonic eosinophilia represents a confounding finding with a wide differential. It is often difficult to determine which children may progress to inflammatory bowel disease (IBD), which have an eosinophilic colitis (EC), and which may have no underlying pathology. There is little guidance for the practitioner on the approach to these patients. To define the clinical presentations of colonic eosinophilia and identify factors which may aid in diagnosis we reviewed patients with colonic eosinophilia and the clinicopathologic factors associated with their diagnoses.

METHODS

An 8-year retrospective chart review of children whose histopathology identified colonic eosinophilia (N = 72) compared to controls with normal biopsies (N = 35).

RESULTS

Patients with colonic eosinophilia had increased eosinophils/high-power field compared to controls (P < 0.001) and had 3 clinical phenotypes. Thirty-six percent had an inflammatory phenotype with elevated erythrocyte sedimentation rate (P < .0001), chronic inflammation on colonic biopsies (P < 0.001), and were diagnosed as having IBD. Thirty-seven percent were diagnosed as having EC, associated with male sex (P < 0.005) and peripheral eosinophilia (P = 0.041). Twenty-one percent had no significant colonic pathology. Forty-three percent of patients had >1 colonoscopy and 68% of these had change from initial diagnoses.

CONCLUSIONS

There are 3 main phenotypes of children with colonic eosinophilia. Signs of chronic systemic inflammation raise suspicion for IBD. Peripheral eosinophilia and male sex are associated with EC. A significant percent of children with colonic eosinophilia do not have colonic disease. Eosinophils/high-power field is not reliable to differentiate etiologies. Repeat colonoscopies may be required to reach final diagnoses.

Eosinophilic colitis: Case series and literature review

INTRODUCTION

Primary eosinophilic colitis (EC) in adults is a rare and poorly studied disease, with 3 case series, 2 database-based studies and 52 case reports published to date.

METHODS

Retrospective study of all adult EC cases diagnosed in a large tertiary hospital (Hospital Clínico San Carlos, Madrid) between 2006 and 2016. We included all cases with a histopathological diagnosis of EC and we selected only those cases that were clinically recognized primary EC. We report their clinical, endoscopic and histopathological features and review the literature on this topic.

RESULTS

We identified 22 primary EC cases. Patients were mostly women (77%) with a mean age of 41 years. 4 patients (18%) had coexistent allergic diseases. Most patients consulted with diarrhea (86%) and 3 patients also suffered from rectal bleeding. Blood tests showed peripheral eosinophilia in 4 cases (18%). 19 patients had no endoscopic lesions, 2 had features of unspecific colitis and one showed features suggestive of IBD. Mean and maximum number of eosinophils per high power field ranged from 16 to 199 and 20 to 253 (mean: 48 and 70). They were mainly located in the lamina propria and most cases were associated with signs of eosinophil activation. Most patients were treated by corticosteroids, diet or budesonide and the result of treatment was generally good. No complications or recurrences were reported.

CONCLUSIONS

EC etiology and pathogenesis is unknown. Its clinical, endoscopical and imaging features are not specific, and clear histopathological criteria are lacking. Identification of signs of eosinophilic activation could be helpful.

Specific MicroRNA Pattern in Colon Tissue of Young Children with Eosinophilic Colitis

Eosinophilic colitis (EC) is a common cause of haematochezia in infants and young children. The exact pathomechanism is not understood, and the diagnosis is challenging. The role of microRNAs as key class of regulators of mRNA expression and translation in patients with EC has not been explored. Therefore, the aim of the present study was to explore the miRNA profile in EC with respect to eosinophilic inflammation. Patients enrolled in the study (n = 10) had persistent rectal bleeding, and did not respond to elimination dietary treatment. High-throughput microRNA sequencing was carried out on colonic biopsy specimens of children with EC (EC: n = 4) and controls (C: n = 4) as a preliminary screening of the miRNA profile. Based on the next-generation sequencing (NGS) results and literature data, a potentially relevant panel of miRNAs were selected for further measurements by real-time reverse transcription (RT)-PCR (EC: n = 14, C: n = 10). Validation by RT-PCR resulted in significantly altered expression of miR-21, -31, -99b, -125a, -146a, -184, -221, -223, and -559 compared to controls (p ≤ 0.05). Elevation in miR-21, -99b, -146a, -221, and -223 showed statistically significant correlation to the extent of tissue eosinophilia. Based on our results, we conclude that the dysregulated miRNAs have a potential role in the regulation of apoptosis by targeting Protein kinase B/Mechanistic target of rapamycin (AKT/mTOR)-related pathways in inflammation by modulating Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB)-related signalling and eosinophil cell recruitment and activation, mainly by regulating the expression of the chemoattractant eotaxin and the adhesion molecule CD44. Our results could serve as a basis for further extended research exploring the pathomechanism of EC.

Eosinophils in Gastrointestinal Disorders: Eosinophilic Gastrointestinal Diseases, Celiac Disease, Inflammatory Bowel Diseases, and Parasitic Infections

The gastrointestinal (GI) tract provides an intriguing organ for considering the eosinophil's role in health and disease. The normal GI tract, except for the esophagus, is populated by eosinophils that are present throughout the mucosa, raising the possibility that eosinophils participate in innate mechanisms of defense. However, data from clinical studies associates increased numbers of eosinophils with inflammatory GI diseases, prompting concerns that eosinophils may have a deleterious effect on the gut. We present clinical features of 4 disease processes that have been associated with eosinophilia and suggest areas requiring investigation as to their clinical significance and scientific relevance.

ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents

BACKGROUND

The diagnosis of pediatric-onset inflammatory bowel disease (PIBD) can be challenging in choosing the most informative diagnostic tests and correctly classifying PIBD into its different subtypes. Recent advances in our understanding of the natural history and phenotype of PIBD, increasing availability of serological and fecal biomarkers, and the emergence of novel endoscopic and imaging technologies taken together have made the previous Porto criteria for the diagnosis of PIBD obsolete.

METHODS

We aimed to revise the original Porto criteria using an evidence-based approach and consensus process to yield specific practice recommendations for the diagnosis of PIBD. These revised criteria are based on the Paris classification of PIBD and the original Porto criteria while incorporating novel data, such as for serum and fecal biomarkers. A consensus of at least 80% of participants was achieved for all recommendations and the summary algorithm.

RESULTS

The revised criteria depart from existing criteria by defining 2 categories of ulcerative colitis (UC, typical and atypical); atypical phenotypes of UC should be treated as UC. A novel approach based on multiple criteria for diagnosing IBD-unclassified (IBD-U) is proposed. Specifically, these revised criteria recommend upper gastrointestinal endoscopy and ileocolonscopy for all suspected patients with PIBD, with small bowel imaging (unless typical UC after endoscopy and histology) by magnetic resonance enterography or wireless capsule endoscopy.

CONCLUSIONS

These revised Porto criteria for the diagnosis of PIBD have been developed to meet present challenges and developments in PIBD and provide up-to-date guidelines for the definition and diagnosis of the IBD spectrum.

Diagnosing eosinophilic colitis: histopathological pattern or nosological entity?

Reports of  "eosinophilic colitis"-raised colonic mucosal eosinophil density in patients with lower gastrointestinal symptoms-have increased markedly over the last fifteen years, though it remains a rarity. There is no consensus over its diagnosis and management, and uncertainty is compounded by the use of the same term to describe an idiopathic increase in colonic eosinophils and an eosinophilic inflammatory reaction to known aetiological agents such as parasites or drugs. In patients with histologically proven colonic eosinophilia, it is important to seek out underlying causes and careful clinicopathological correlation is advised. Because of the variability of eosinophil density in the normal colon, it is recommended that histological reports of colonic eosinophilia include a quantitative morphometric assessment of eosinophil density, preferably across several sites. Few reported cases of "eosinophilic colitis" meet these criteria. As no correlation has been shown between colonic eosinophil density and symptoms in older children or adults, it is suggested that treatment should be directed towards alleviation of symptoms and response to treatment assessed clinically rather than by histological estimates of intramucosal eosinophils.

Anti-TNF, infliximab, and adalimumab can be effective in eosinophilic bowel disease

BACKGROUND

Eosinophilic enterocolitis (EEC) is an emerging distinct inflammatory bowel disease of unknown etiology. There are no published data on the effect of infliximab (IFX) or adalimumab (ADA) for the treatment of refractory cases.

METHODS

A report of all pediatric cases with EEC treated with anti-tumor necrosis factor, identified after an open international call.

RESULTS

We describe here the first 8 children with refractory EEC who were treated with IFX (75% boys; mean age at diagnosis 8.6 ± 4.03 [range 1.6-14 years]; mean age at IFX treatment 11.7 ± 4.4 [range 4.2-16 years]). Allergic and infectious causes of EEC were excluded in all cases. Rapid and complete clinical remission was documented in 6 (75%) children following the induction infusions: 3 (38%) with endoscopic remission, 2 (25%) with endoscopic improvement, and 1 unknown. Four of the 6 responders had secondary loss of response and were switched to ADA, 3 of whom with sustained remission using high doses. Overall, the 6 responders were followed for a median of 7 years (range 4-12; interquartile range 6.4-8.8 years) without evidence of developing Crohn disease or ulcerative colitis. The only case with macroscopic findings on endoscopy was a primary nonresponder.

CONCLUSIONS

IFX and ADA may be effective in cases of refractory idiopathic EEC; however, because this is an uncontrolled report, further prospective studies are warranted.

Non-IBD colitides (eosinophilic, microscopic)

Microscopic colitis includes the terms lymphocytic colitis and collagenous colitis, and is a common cause of chronic diarrhoea in older adults. The incidence of microscopic colitis has increased over time and has reached levels comparable to other forms of inflammatory bowel disease. In this chapter, an updated review on the epidemiology, diagnosis and treatment of microscopic colitis has been provided. There is limited data available about eosinophilic colitis, which is the least common of the eosinophilic GI disorders. It is important to rule out the secondary causes of colonic eosinophilia in patients with suspected eosinophilic colitis.