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Eosinophilic gastroenteritis

eosinophilic gastroenteritis, eosinophilic gastroenteritis symptoms
Eosinophilic gastroenteritis EG is a rare and heterogeneous condition characterized by patchy or diffuse eosinophilic infiltration of gastrointestinal GI tissue, first described by Kaijser in 193712 Presentation may vary depending on location as well as depth and extent of bowel wall involvement and usually runs a chronic relapsing course It can be classified into mucosal, muscular and serosal types based on the depth of involvement34 Any part of the GI tract can be affected, and isolated biliary tract involvement has also been reported56 The stomach is the organ most commonly affected, followed by the small intestine and the colon78

Contents

  • 1 Signs and symptoms
  • 2 Pathophysiology
  • 3 Diagnosis
  • 4 Management
  • 5 Epidemiology
  • 6 Other gastrointestinal conditions associated with allergy
  • 7 See also
  • 8 References
  • 9 External links

Signs and symptomsedit

EG typically presents with a combination of chronic nonspecific GI symptoms which include abdominal pain, diarrhea, occasional nausea and vomiting, weight loss and abdominal distension Approximately 80% have symptoms for several years;6 a high degree of clinical suspicion is often required to establish the diagnosis, as the disease is extremely rare It doesn't come all of a sudden but takes about 3–4 years to develop depending upon the age of the patient Occasionally, the disease may manifest itself as an acute abdomen or bowel obstruction910

  • Mucosal EG 25–100% is the most common variety,1112 which presents with features of malabsorption and protein losing enteropathy Failure to thrive and anaemia may also be present Lower gastrointestinal bleeding may imply colonic involvement
  • Muscular EG 13–70% present with obstruction of gastric outlet or small intestine; sometimes as an obstructing caecal mass or intussusception
  • Subserosal EG 45% to 9% in Japan and 13% in the US13 presents with ascites which is usually exudative in nature, abundant peripheral eosinophilia, and has favourable responses to corticosteroids
  • Other documented features are cholangitis, pancreatitis,14 eosinophilic splenitis, acute appendicitis and giant refractory duodenal ulcer

Pathophysiologyedit

Peripheral blood eosinophilia and elevated serum IgE are usual but not universal The damage to the gastrointestinal tract wall is caused by eosinophilic infiltration and degranulation15

As a part of host defense mechanism, eosinophils are normally present in gastrointestinal mucosa, though the finding in deeper tissue is almost always pathologic16 What triggers such dense infiltration in EG is not clear It is possible that different pathogenetic mechanisms of disease is involved in several subgroups of patients Food allergy and variable IgE response to food substances has been observed in some patients which implies role of hypersensitive response in pathogenesis Many patients indeed have history of other atopic conditions like eczema, asthma, etc

Eosinophil recruitment into inflammatory tissue is a complex process, regulated by a number of inflammatory cytokines In EG cytokines IL-3, IL-5 and granulocyte macrophage colony stimulating factor GM-CSF may be behind the recruitement and activation They have been observed immunohistochemically in diseased intestinal wall17 In addition eotaxin has been shown to have an integral role in regulating the homing of eosinophils into the lamina propria of stomach and small intestine18 In the allergic subtype of disease, it is thought that food allergens cross the intestinal mucosa and trigger an inflammatory response that includes mast cell degranulation and recruitment of eosinophils1819

Diagnosisedit

Spiral CT showing ascites and concentric thickening of colon and ileum in EG

Talley et al20 suggested 3 diagnostic criteria which is still widely used:

  1. the presence of gastrointestinal symptoms,
  2. histological demonstration of eosinophilic infiltration in one or more areas of the gastrointestinal tract or presence of high eosinophil count in ascitic fluid latter usually indicates subserosal variety,
  3. no evidence of parasitic or extraintestinal disease

Hypereosinophilia, the hallmark of allergic response, may be absent in up to 20% of patients, but hypoalbuminaemia and other abnormalities suggestive of malabsorption may be present

CT scan may show nodular and irregular thickening of the folds in the distal stomach and proximal small bowel, but these findings can also be present in other conditions like Crohn's disease and lymphoma

The endoscopic appearance in eosinophilic gastroenteritis is nonspecific; it includes erythematous, friable, nodular, and occasional ulcerative changes21 Sometimes diffuse inflammation results in complete loss of villi, involvement of multiple layers, submucosal oedema and fibrosis2223

Definitive diagnosis involves histological evidence of eosinophilic infiltration in biopsy slides Microscopy reveals >20 eosinophils per high power field1120 Infiltration is often patchy, can be missed and laparoscopic full thickness biopsy may be required

Radio isotope scan using technetium 99mTc exametazime-labeled leukocyte SPECT may be useful in assessing the extent of disease and response to treatment but has little value in diagnosis, as the scan does not help differentiating EG from other causes of inflammation2425

When eosinophilic gastroenteritis is observed in association with eosinophilic infiltration of other organ systems, the diagnosis of idiopathic hypereosinophilic syndrome should be considered26

Managementedit

Corticosteroids are the mainstay of therapy with a 90% response rate in some studies Appropriate duration of steroid treatment is unknown and relapse often necessitates long term treatment Various steroid sparing agents eg sodium cromoglycate a stabilizer of mast cell membranes, ketotifen an antihistamine, and montelukast a selective, competitive leukotriene receptor antagonist have been proposed, centering on an allergic hypothesis, with mixed results1927 An elimination diet may be successful if a limited number of food allergies are identified2128

Epidemiologyedit

Epidemiology may differ between studies, as number of cases are small, with approximately 300 EG cases reported in published literature

EG can present at any age and across all races, with a slightly higher incidence in males29 Earlier studies showed higher incidence in the third to fifth decades of life13

Other gastrointestinal conditions associated with allergyedit

  • Eosinophilic esophagitis
  • Eosinophilic ascites
  • Coeliac disease
  • Protein losing enteropathy from intolerance to cow's milk protein
  • Infantile formula protein intolerance

See alsoedit

  • Aeroallergen
  • Allergy
  • Gastroenteritis
  • Malabsorption

Referencesedit

  1. ^ a b Kaijser R Zur Kenntnis der allergischen Affektionen des Verdauugskanals vom Standpunkt des Chirurgen aus Arch Klin Chir 1937; 188:36–64
  2. ^ Whitaker I, Gulati A, McDaid J, Bugajska-Carr U, Arends M 2004 "Eosinophilic gastroenteritis presenting as obstructive jaundice" European journal of gastroenterology & hepatology 16 4: 407–9 PMID 15028974 doi:101097/00042737-200404000-00007 
  3. ^ a b Klein N, Hargrove R, Sleisenger M, Jeffries G 1970 "Eosinophilic gastroenteritis" Medicine Baltimore 49 4: 299–319 PMID 5426746 doi:101097/00005792-197007000-00003 
  4. ^ Treiber, Treiber; Weidner, S 2007 "Eosinophilic Gastroenteritis" Clinical Gastroenterology and Hepatology 5 5: e16 PMID 17428742 doi:101016/jcgh200701011 
  5. ^ Polyak S, Smith T, Mertz H 2002 "Eosinophilic gastroenteritis causing pancreatitis and pancreaticobiliary ductal dilation" Dig Dis Sci 47 5: 1091–5 PMID 12018905 doi:101023/A:1015046309132 
  6. ^ a b Christopher V, Thompson M, Hughes S 2002 "Eosinophilic gastroenteritis mimicking pancreatic cancer" Postgraduate Medical Journal 78 922: 498–9 PMC 1742453  PMID 12185230 doi:101136/pmj78922498 
  7. ^ Naylor A 1990 "Eosinophilic gastroenteritis" Scottish medical journal 35 6: 163–5 PMID 2077646 
  8. ^ Jimenez-Saenz M, Villar-Rodriguez J, Torres Y, Carmona I, Salas-Herrero E, Gonzalez-Vilches J, Herrerias-Gutierrez J 2003 "Biliary tract disease: a rare manifestation of eosinophilic gastroenteritis" Dig Dis Sci 48 3: 624–7 PMID 12757181 doi:101023/A:1022521707420 
  9. ^ Shweiki E, West J, Klena J, Kelley S, Colley A, Bross R, Tyler W 1999 "Eosinophilic gastroenteritis presenting as an obstructing cecal mass--a case report and review of the literature" Am J Gastroenterol 94 12: 3644–5 PMID 10606337 doi:101111/j1572-0241199901625x 
  10. ^ Tran D, Salloum L, Tshibaka C, Moser R 2000 "Eosinophilic gastroenteritis mimicking acute appendicitis" The American surgeon 66 10: 990–2 PMID 11261632 
  11. ^ a b Baig M, Qadir A, Rasheed J 2006 "A review of eosinophilic gastroenteritis" Journal of the National Medical Association 98 10: 1616–9 PMC 2569760  PMID 17052051 
  12. ^ Lee C, Changchien C, Chen P, Lin D, Sheen I, Wang C, Tai D, Sheen-Chen S, Chen W, Wu C 1993 "Eosinophilic gastroenteritis: 10 years experience" Am J Gastroenterol 88 1: 70–4 PMID 8420276 
  13. ^ Miyamoto T, Shibata T, Matsuura S, Kagesawa M, Ishizawa Y, Tamiya K 1996 "Eosinophilic gastroenteritis with ileus and ascites" Intern Med 35 10: 779–82 PMID 8933185 doi:102169/internalmedicine35779 
  14. ^ Lyngbaek S, Adamsen S, Aru A, Bergenfeldt M 2006 "Recurrent acute pancreatitis due to eosinophilic gastroenteritis Case report and literature review" JOP 7 2: 211–7 PMID 16525206 
  15. ^ Tan A, Kruimel J, Naber T 2001 "Eosinophilic gastroenteritis treated with non-enteric-coated budesonide tablets" European journal of gastroenterology & hepatology 13 4: 425–7 PMID 11338074 doi:101097/00042737-200104000-00021 
  16. ^ Blackshaw A, Levison D 1986 "Eosinophilic infiltrates of the gastrointestinal tract" J Clin Pathol 39 1: 1–7 PMC 499605  PMID 2869055 doi:101136/jcp3911 
  17. ^ Desreumaux P, Bloget F, Seguy D, Capron M, Cortot A, Colombel J, Janin A 1996 "Interleukin 3, granulocyte-macrophage colony-stimulating factor, and interleukin 5 in eosinophilic gastroenteritis" Gastroenterology 110 3: 768–74 PMID 8608886 doi:101053/gast1996v110pm8608886 
  18. ^ a b Mishra A, Hogan S, Brandt E, Rothenberg M 2001 "An etiological role for aeroallergens and eosinophils in experimental esophagitis" J Clin Invest 107 1: 83–90 PMC 198543  PMID 11134183 doi:101172/JCI10224 
  19. ^ a b Pérez-Millán A, Martín-Lorente J, López-Morante A, Yuguero L, Sáez-Royuela F 1997 "Subserosal eosinophilic gastroenteritis treated efficaciously with sodium cromoglycate" Dig Dis Sci 42 2: 342–4 PMID 9052516 doi:101023/A:1018818003002 
  20. ^ a b Talley N, Shorter R, Phillips S, Zinsmeister A 1990 "Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues" Gut 31 1: 54–8 PMC 1378340  PMID 2318432 doi:101136/gut31154 
  21. ^ a b Chen M, Chu C, Lin S, Shih S, Wang T 2003 "Eosinophilic gastroenteritis: clinical experience with 15 patients" World J Gastroenterol 9 12: 2813–6 PMID 14669340 
  22. ^ Johnstone J, Morson B 1978 "Eosinophilic gastroenteritis" Histopathology 2 5: 335–48 PMID 363591 doi:101111/j1365-25591978tb01726x 
  23. ^ Katz A, Goldman H, Grand R 1977 "Gastric mucosal biopsy in eosinophilic allergic gastroenteritis" Gastroenterology 73 4 Pt 1: 705–9 PMID 892374 
  24. ^ Lee K, Hahm K, Kim Y, Kim J, Cho S, Jie H, Park C, Yim H 1997 "The usefulness of Tc-99m HMPAO labeled WBC SPECT in eosinophilic gastroenteritis" Clinical nuclear medicine 22 8: 536–41 PMID 9262899 doi:101097/00003072-199708000-00005 
  25. ^ Imai E, Kaminaga T, Kawasugi K, Yokokawa T, Furui S 2003 "The usefulness of 99mTc-hexamethylpropyleneamineoxime white blood cell scintigraphy in a patient with eosinophilic gastroenteritis" Annals of Nuclear Medicine 17 7: 601–3 PMID 14651361 doi:101007/BF03006675 
  26. ^ Matsushita M, Hajiro K, Morita Y, Takakuwa H, Suzaki T 1995 "Eosinophilic gastroenteritis involving the entire digestive tract" Am J Gastroenterol 90 10: 1868–70 PMID 7572911 
  27. ^ Barbie D, Mangi A, Lauwers G 2004 "Eosinophilic gastroenteritis associated with systemic lupus erythematosus" J Clin Gastroenterol 38 10: 883–6 PMID 15492606 doi:101097/00004836-200411000-00010 
  28. ^ Katz A, Twarog F, Zeiger R, Falchuk Z 1984 "Milk-sensitive and eosinophilic gastroenteropathy: similar clinical features with contrasting mechanisms and clinical course" The Journal of Allergy and Clinical Immunology 74 1: 72–8 PMID 6547462 doi:101016/0091-67498490090-3 
  29. ^ Guandalini, Stefano 2004 Essential Pediatric Gastroenterology and Nutrition City: McGraw-Hill Professional ISBN 0-07-141630-7  Page 210

External linksedit

  • Campaign Urging Research for Eosinophilic Disease
  • American Partnership for Eosinophilic Disorders
  • Families Affected By Eosinophilic Disorders
  • Cincinnati Center for Eosinophilic Disorders
  • Hoover boy's rare disease leaves him allergic to almost everything he eats
  • Canadian Council of Eosinophilic Disorders

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Eosinophilic gastroenteritis


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    29.10.2014


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