Common and disparate clinical presentations and mechanisms in different eosinophilic gastrointestinal diseases

Eosinophilic gastrointestinal diseases (EGIDs) are a group of diseases characterized by selective eosinophil infiltration of the gastrointestinal (GI) tract in the absence of other causes of eosinophilia. These diseases are generally driven by type 2 inflammation, often in response to food allergen exposure. Among all EGIDs, the clinical presentation often includes a history of atopic disease with a variety of GI symptoms. EGIDs are traditionally separated into eosinophilic esophagitis (EoE) and non-EoE EGIDs. EoE is relatively better understood and now associated with clinical guidelines and 2 US Food and Drug Administration-approved treatments, whereas non-EoE EGIDs are rarer and less well-understood diseases without US Food and Drug Administration-approved treatments. Non-EoE EGIDs are further subclassified by the area of the GI tract that is involved; they comprise eosinophilic gastritis, eosinophilic enteritis (including eosinophilic duodenitis), and eosinophilic colitis. As with other GI disorders, the disease presentations and mechanisms differ depending on the involved segment of the GI tract; however, the differences between EoE and non-EoE EGIDs extend beyond which GI tract segment is involved. The aim of this article is to summarize the commonalities and differences between the clinical presentations and disease mechanisms for EoE and non-EoE EGIDs.

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 Enteritis Causing Recurrent Small Bowel Obstruction: A Case Report

Eosinophilic enteritis is an inflammatory condition characterized by eosinophilic infiltration of the gastrointestinal tract. This case report highlights a unique presentation of eosinophilic enteritis as a cause of recurrent small bowel obstruction. The diagnosis was elusive despite extensive abdominal imaging. A histopathologic examination of a full-thickness bowel segment showing extensive eosinophilic infiltration in the muscularis propria was vital in establishing the diagnosis. This report underscores the diagnostic complexities associated with eosinophilic enteritis and the need to consider this condition as a potential cause of recurrent abdominal pain and small bowel obstruction.

Eosinophilic enteritis: the great mimic

Eosinophilic enteritis (EoN), a subtype of eosinophilic gastrointestinal disease, is a rare and complicated inflammatory condition affecting the small intestine. This case report discusses a 42-year-old patient who presented with acute gastrointestinal symptoms including diarrhea, nausea, and vomiting. Initial laboratory investigations revealed leukocytosis, peripheral eosinophilia, and distinctive imaging findings, prompting further evaluation. Endoscopic evaluation revealed extensive mucosal lesions in the small intestine, with subsequent biopsies confirming eosinophilic infiltration, ultimately leading to the diagnosis of chronic enteritis, probably of an eosinophilic nature. The case highlights the complex differential diagnostic process involved in identifying EoN, which requires a comprehensive understanding of all the clinical and histopathological features of the disease. The efficacy of budesonide therapy is also discussed in the management of EoN and it was evidenced by our patient's positive response to treatment. This case report contributes significant insights into the understanding and management of EoN, providing essential information for the medical community to facilitate accurate diagnosis and tailored therapeutic interventions for individuals experiencing this complex disorder.

The role of biologics in pediatric food allergy and eosinophilic gastrointestinal disorders

Continuing insight into the molecular mechanisms of atopic disorders has enabled the development of biologics to precisely target these diseases. Food allergy (FA) and eosinophilic gastrointestinal disorders (EGIDs) are driven by similar inflammatory molecular mechanisms and exist along the same atopic disease spectrum. Therefore, many of the same biologics are being investigated to target key drivers of mechanisms shared across the disease states. The enormous potential of biologics for the treatment of FA and EGIDs is highlighted by the significant increases in the number of ongoing clinical trials (more than 30) evaluating their use in these disease states, as well as by the recent US Food and Drug Administration approval of dupilumab for the treatment of eosinophilic esophagitis. Here we discuss past and current research into the use of biologics in FA and EGIDs and their potential role in improving treatment options in the future, with the need to have biologics widely clinically available.

Small Bowel Endoscopic Features of Eosinophilic Gastroenteritis

Eosinophilic gastroenteritis (EoGE) is a rare digestive disorder characterized by eosinophilic infiltration of the stomach and intestines. In the diagnosis of EoE, it is extremely important to recognize distinctive endoscopic findings and accurately detect increased eosinophilia in gastrointestinal tissues. However, endoscopic findings of EoGE in the small intestine remain poorly understood. Therefore, we conducted a literature review of 16 eligible papers. Redness or erythema was the most common endoscopic finding in the small bowel, followed by villous atrophy, erosion, ulceration, and edema. In some cases, stenosis due to circumferential ulceration was observed, which led to retention of the capsule during small bowel capsule endoscopy. Although many aspects of small bowel endoscopic findings in EoGE remain elusive, the findings presented in this review are expected to contribute to the further development of EoGE practice.

Successful management of colonic pythiosis in two dogs in Thailand using antifungal therapy

Gastrointestinal pythiosis is a severe, progressive and often a fatal disease, which is caused by the aquatic pathogen Pythium insidiosum. Treatment is challenging due to the disease's resistance to antifungal drugs. Surgical resection is frequently attempted in cases of pythiosis; however, it can be technically challenging. This report presents two dogs with decreased appetite, abdominal pain, progressive haematochezia, tenesmus and significant weight loss. With the medical histories of both being young canines, living in areas with access to natural water resources and with the main chronic gastrointestinal symptoms having not responded to symptomatic treatment, pythiosis was taken into consideration. Abdominal ultrasound revealed severe, diffuse thickening and loss of normal layering of the colonic wall. These findings led to a differential diagnosis between intestinal neoplasia and fungal disease. Full-thickness biopsies were later performed, and immunohistochemistry staining was suggested for colonic pythiosis. Medical treatment for pythiosis was successful with a combination of oral terbinafine and prednisolone. However, therapy with itraconazole in case 1 did not improve the clinical signs, and in case 2, itraconazole was used after all clinical signs have improved for clinical control. Since then, there has been no recurrence of clinical signs until the time of preparing this report (19 months for case 1, 11 months for case 2 since the cessation of treatment). The treatment was successful based on clinical signs and ultrasonographic data, and the disease remission was not confirmed by advance imaging, monitoring of pythiosis enzyme-linked immunosorbent essay concentration or repeat sampling.

Eosinophilic Gastrointestinal Diseases Beyond the Esophagus: An Evolving Field and Nomenclature

The eosinophilic gastrointestinal diseases (EGIDs) are a group of chronic, immune-mediated gastrointestinal (GI) diseases characterized by GI symptoms and pathologic eosinophilic infiltration of specific areas within the GI tract in the absence of secondary causes of eosinophilia. The non-eosinophilic esophagitis EGIDs remain understudied and likely underdiagnosed, owing in part to the lack of clarity in the terminology previously used to describe these diseases. The newly established EGID nomenclature framework includes a first-tier description of the specific location of GI tract involvement and a second-tier description with more granular characterizations of disease involvement. EGIDs can involve any segment or layer of the GI tract, so patients can present with a wide array of common, nonspecific GI symptoms. Diagnosing EGIDs requires endoscopic evaluation and biopsies showing increased eosinophilic tissue infiltration in the correct clinical context after ruling out other causes of eosinophilia. Although the pathogenesis is not yet fully understood, EGIDs are likely allergic conditions triggered by food antigen exposure. Most patients are currently treated with corticosteroids, but investigations of other pharmacologic and dietary therapies are ongoing. This article highlights the recently updated EGID nomenclature and summarizes the current understanding of the diagnosis, pathogenesis, and treatment of EGIDs.

Impressions and aspirations from the FDA GREAT VI Workshop on Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis and Perspectives for Progress in the Field

The US Food and Drug Administration hosted a workshop on July 21, 2021, to discuss the disease characteristics, natural history, and end points to assess treatment benefit in patients with eosinophilic gastrointestinal disorders (EGIDs) beyond eosinophilic esophagitis (EoE). Notably, EGIDs beyond EoE, such as eosinophilic gastritis, eosinophilic enteritis, and eosinophilic colitis, herein referred to as non-EoE EGIDs, are understudied relative to EoE. This workshop provided a forum for open discussion among stakeholders-medical professionals (including their societies and research groups), Food and Drug Administration representatives, an industry representative, and a patient representative-to facilitate drug development. Experts in many disciplines related to EGIDs, including allergy, immunology, epidemiology, gastroenterology, and pathology, and both adult and pediatric clinicians contributed. Herein, we discuss some of the insights of the material presented at the meeting and present perspectives on moving the field forward toward drug approval.

A case report about eosinophilic enteritis presenting as abdominal pain

RATIONALE

Eosinophilic enteritis (EE) is an immune-mediated antigen-driven disease that may lead to clinical symptoms and organ dysfunction and characterized by the presence of extensive eosinophilic infiltrates on histopathological examination of the intestinal mucosa.

PATIENT CONCERNS

A 29-year-old man presented with a half-month duration of paroxysmal upper abdominal pain that gradually evolved into continuous pain accompanied by the urge to defecate.

DIAGNOSES

Pathological findings of enteroscopy showed acute and chronic inflammation accompanied by eosinophilic infiltration (>20/ high-power field).

INTERVENTIONS

The patient was initially treated with IV infusion of dexamethasone 10 mg per day for 3 days, which was reduced to 7.5 mg per day for 2 days once pain relief was achieved. Upon discharged from our hospital, the patient was prescribed with oral prednisolone 30 mg per day, which was reduced by 5 mg per week for 6 weeks until discontinuation.

OUTCOMES

The patient was relieved from the pain after receiving dexamethasone for 5 days, and he was maintained on oral prednisolone 30 mg per day upon discharge from the hospital. On the day of discharge, the eosinophil count and derived ratios were normal.

LESSONS

In patients with EE, the dynamic changes of the eosinophil count should be monitored. Clinicians must be aware that not all patients with EE have a history of allergies. In the management and treatment of the disease, multisite biopsies should be carried out if EE is suspected, and EE is responsive to steroid therapy.

Small-bowel Capsule Endoscopic Features in Patients with Eosinophilic Gastroenteritis: Three Case Reports

Eosinophilic gastroenteritis (EGE) is an uncommon disease characterized by eosinophilic infiltration of the gastrointestinal tract in the absence of secondary causes and presents with a variety of gastrointestinal manifestations. Important diagnostic evidence for EGE can be provided by endoscopy; however, the specific small-bowel capsule endoscopic (SBCE) findings remain unknown. We herein report the SBCE findings of three cases of EGE as well as those of the previous cases. The most common findings in patients with EGE were multiple erythema and erosions with surrounding redness on SBCE; these findings should be considered for the diagnostic evaluation for EGE.

A Case of Ancylostoma ceylanicum Infection Occurring in an Australian Soldier Returned from Solomon Islands

A 26-year-old male member of the Australian Defense Force presented with a history of central abdominal pain of 4 weeks duration and peripheral eosinophilia consistent with eosinophilic enteritis. Acute hookworm disease was diagnosed as the cause. Adult worms recovered from feces after therapy with albendazole were morphologically consistent with Ancylostoma ceylanicum. As the patient had been deployed with the Regional Assistance Mission to Solomon Islands for 6 months prior to this presentation, it is very likely that the A. ceylanicum was acquired in Solomon Islands. Until now, it has been assumed that any Ancylostoma spp. recovered from humans in Solomon Islands is A. duodenale. However, this case demonstrates that human hookworm infection acquired in the Solomon Islands could be caused by A. ceylanicum.

Eosinophilic enteritis due to cow's milk allergy: Possible cause of anastomosis failure following repair of focal intestinal perforation

Reports of cow's milk allergy (CMA) after neonatal gastrointestinal surgery have recently increased. In recent years it has been suggested that the development of CMA after gastrointestinal surgery in newborn infants is due to an immune function. In addition, the development of CMA might be synergistically exacerbated by congenital abnormalities of the intestinal mucosa, general conditional changes and local damage to the intestine by invasive surgery, and poor pre- or post-surgical nutrition. CMA manifests as a variety of symptoms, such as mild vomiting and bloody stool, decreased activity, poor oral intake, and ileus. CMA may also rarely cause gastrointestinal perforation. Here, we report the case of a newborn infant who developed CMA following repair of focal small intestinal perforation, in which eosinophilic enteritis was suspected to be a possible cause of anastomosis leakage.

Unusual presentation of eosinophilic enteritis as multiple strictures of small intestine

Eosinophilic enteritis is a rare disease of unknown etiology. It is characterized by eosinophilic infiltration of the bowel wall to a variable depth and symptoms associated with gastrointestinal tract depending upon the predominant layer involved. Diagnosis of eosinophilic enteritis requires a high index of suspicion and exclusion of various disorders that are associated with peripheral eosinophilia. We report a case of unusual presentation of eosinophilic enteritis clinically presenting as intestinal obstruction due to multiple strictures of the small bowel in an adult male.

An unusual infection on an unusual gastroenteritis

A 35-year-old lady was admitted to our Department due to fever and symptoms from the respiratory and gastrointestinal system. She was recently diagnosed with eosinophilic gastroenteritis and had been on steroids until two months prior to admission. Legionella pneumophila pneumonia was diagnosed and targeted therapy was initiated. The combined approach to the two entities is discussed as well as the options for maintenance therapy.

Laparoendoscopic diagnosis of eosinophilic enteritis

As the popularity of laparoscopic cholecystectomy continues to grow, evaluation of patients with documented cholelithiasis and concomitant vague abdominal complaints becomes less rigorous. We present the case of a patient with chronic cholecystitis documented by history and ultrasonography, incidentally noted on laboratory examination to have peripheral blood eosinophilia. At the time of laparoscopy, an inflamed segment of jejunum was discovered. Limited laparotomy and wedge biopsy revealed active eosinophilic enteritis.