Eosinophilic gastroenteritis presenting as upper gastrointestinal hematoma and ulcers after endoscopic biopsy: A case report and literature review

Preliminary evidence in treatment of eosinophilic gastroenteritis in children: A case series

BACKGROUND

Eosinophilic gastroenteritis is a rare inflammatory disorder in children. However, there is still no standard guideline in the treatment of pediatric eosinophilic gastroenteritis.

AIM

To report our experience with the diagnosis and treatment of children with eosinophilic gastroenteritis.

METHODS

From January 2017 to December 2019, a total of 22 children were diagnosed with eosinophilic gastroenteritis.

RESULTS

Endoscopic examination showed eosinophil infiltration in the duodenum [mean number of eosinophils/high-power field (HPF) = 53.1 ± 81.5], stomach (mean number of eosinophils/HPF = 36.8 ± 50.5), and terminal ileum (mean number of eosinophils/HPF = 49.0 ± 24.0). All 18 children with low eosinophil infiltration (< 14%) responded well to the initial drug treatment without relapse, while two of four children with high eosinophil infiltration (> 14%) relapsed after initial methylprednisolone/montelukast treatment. In addition, children with high eosinophil infiltration (> 14%) showed symptomatic relief and histological remission without further relapse after receiving budesonide/methylprednisolone as initial or relapse treatment.

CONCLUSION

Methylprednisolone/montelukast is still the best treatment for children with low eosinophil infiltration (< 14%). Budesonide can be considered as the initial or relapse treatment for children with high eosinophil infiltration (> 14%).

Eosinophilic gastroenteritis: A case series of a rare disease from an apex Tertiary Care Center in South India

Eosinophilic gastroenteritis (EGE) is a rare disease with a myriad of presentations. In this case series of four patients from South India, we describe three classical manifestations of the disease (mucosal, muscular, and serosal). Two of them had obstructive jaundice as a presenting complaint due to duodenal obstruction, whereas one had massive upper gastrointestinal bleed. There are very few case series regarding this disease from India. Its presentation as hemetemesis and obstructive jaundice is also very rare,with only few such case reports reported till now.

Successful use of montelukast in eosinophilic gastroenteritis: a case report and a literature review

BACKGROUND

Eosinophilic gastrointestinal disorders, also known as eosinophilic gastroenteritis, are rare inflammatory conditions characterized by eosinophilic infiltration of different parts of the gastrointestinal tract, along with peripheral eosinophilia in most cases. Other known causes for gut eosinophilic infiltration must be excluded to confirm the diagnosis of eosinophilic gastroenteritis. Symptoms of the disorder depend on the affected gastrointestinal tract segment and depth of involvement. Treatment includes systemic glucocorticoids and/or dietary therapy with an empiric elimination diet. Second line therapies include the leukotriene receptor antagonist montelukast, and other anti-allergy drugs such as mast cell stabilizers (including cromolyn and the H1-antihistamine ketotifen), suplatast tosilate which is a selective Th-2 cytokines (IL-4 and IL-5) inhibitor, and the monoclonal anti-IgE antibody omalizumab. We report a case of eosinophilic gastroenteritis who was successfully treated and achieved remission with montelukast as an initial monotherapy. Upon extensive literature review, this represents the second reported adult case of eosinophilic gastroenteritis who responds to montelukast alone as a first line therapy.

CASE PRESENTATION

A 49-year-old female presented with recurrent abdominal pain, vomiting, diarrhea and unexplained eosinophilia. She was diagnosed with eosinophilic gastroenteritis and was successfully treated with montelukast monotherapy. After 7 days of therapy, the patient responded well and had complete resolution of her gastrointestinal symptoms and peripheral eosinophilia. Patient remained in remission on follow-up after 12 months. We reviewed the literature for leukotriene antagonist use in the treatment of eosinophilic gastroenteritis and included the cases treated with the leukotriene antagonist montelukast as an initial therapy or as a second line therapy for refractory disease.

CONCLUSION

Montelukast may be an effective treatment for eosinophilic gastroenteritis, either alone or in combination with systemic steroids or ketotifen. Our patient is the second reported adult case of eosinophilic gastroenteritis who responded to montelukast alone as a first line therapy. Further studies and clinical trials are required to confirm efficacy compared to standard therapy.

Eosinophilic Gastroenteritis-associated Duodenal Ulcer Successfully Treated with Crushed Budesonide

Eosinophilic gastroenteritis (EGE)-associated duodenal ulcer is rare and its endoscopic and pathological features remain poorly described. A 15-year-old boy was referred to our hospital for further examination and treatment of duodenal ulcer. Esophagogastroduodenoscopy (EGD) revealed two A2-stage duodenal ulcers on the duodenal bulb. A biopsy revealed marked infiltration of eosinophils, suggestive of EGE-associated duodenal ulcers. Thus, treatment with crushed budesonide (9 mg/day) was started. EGD revealed healing of the duodenal ulcers seven months after treatment. To our knowledge, this is the first report describing EGE-associated duodenal ulcer successfully treated with crushed budesonide.

Severe anaemia after gastric biopsy in an infant with eosinophilic gastritis

Background

Eosinophilic gastrointestinal disorders (EGID) are characterized by eosinophilic inflammation and are subclassified according to the affected site(s) as eosinophilic esophagitis, eosinophilic gastritis, eosinophilic enteritis and eosinophilic colitis. Clinical presentation includes dyspeptic symptoms, vomiting, abdominal pain, diarrhoea and gastrointestinal bleeding. Peripheral eosinophilia is usually found but is not required for the diagnosis. The treatment is based on dietary elimination therapy, consisting of removal of common food triggers, most frequently cow’s milk in infants. Corticosteroids are used as first line drug therapy in EG if dietary therapy fails to achieve an adequate clinical response or is impractical.

Case presentation

A four month old infant was admitted for an episode of melena and hematemesis. An esophagogastroduodenoscopy showed haemorrhagic gastritis with ulcerative lesions and fibrin. A significant gastric bleeding was noted after the procedure. The gastric mucosa biopsies showed an eosinophilic infiltration.

Conclusions

A clinically relevant anaemia is a quite rare complication in infants with eosinophilic gastritis and a biopsy may worsen bleeding, to a potentially severe level of low haemoglobin. In infants with low haemoglobin levels and suspect eosinophilic gastritis a watchful follow up after the biopsy should be considered, as well as the possibility of postponing the biopsy to reduce the bleeding risk.