Eosinophilic Gastroenteritis

Case: 40Y Male patient presented with abdominal pain and diarrhoea. 

Plain CT image shows thickened appearing colon (orange arrows) with surrounding fat stranding. Thickening of anterior pararenal fascia is also seen bilaterally (blue arrows). 

Contrast CT images showed edematous thickening of the terminal ileum (not shown) and large bowel upto distal descending colon. Peri-colonic inflammatory fat stranding is noted. The SMA-SMV, IMA-IMV showed normal contrast opacification. 

Contrast CT images showing mild right pleural effusion (yellow arrow) and ascites (green arrows). 

Differential Leukocyte count revealed Eosinophil count of 18% initially and rose upto 68% within 3 days. Peripheral smear showed normocytic normochromic picture with marked eosinophilia. 

Colonic biopsy showed dense chronic inflammation with predominance of eosinophils - features compatible with Eosinophilic enterocolitis.

Patient was treated with Steroids and Azathioprine, improved and was asymptomatic with normalized lab parameters in the last visit.  

Eosinophilic gastroenteritis  is a rare inflammatory disorder of the gastrointestinal tract, characterized by focal or diffuse eosinophilic infiltration of the gastrointestinal tract. Clinical features and radiological findings are non-specific, so a high index of suspicion is needed, in cases of peripheral eosinophilia (seen in >60%). This usually presents with dyspepsia and diarrhoea. It may rarely cause GOO / SBO and pancreatitis. This disease was first described by Kaijser in 1937.

Although any age group can be affected, majority of patients are in the 3rd to 5th decades, with a slight male preponderance. Most patients have history of seasonal allergies, asthma, food sensitivity, eczema, elevated IgE levels. 

EG is a self-limiting disorder in most cases and usually responds well to steroids. 

Three types of EG have been mentioned, 

1. Mucosal EG (most common) : presents with fecal blood loss, anemia, weight loss due to malabsorption or protein losing enteropathy.
2. Muscularis EG : presents with obstruction (GOO/SBO).
3. Subserosal EG : manifests as eosinophilic ascites. 

Definitive diagnosis of EG requires bowel biopsy correlation demonstrating the eosinophil infiltration. In cases of the subserosal EG, high eosinophil count in a sterile ascitic fluid by paracentesis can also be demonstrated. 

Major DD would be a intestinal parasites, which necessitates stool examination to look for ova and parasites. 

Hypereosinophilic syndrome (HES) is an idiopathic condition associated with marked peripheral eosinophilia (>1500/uL for >6months) and gastroenteritis. Heart, lungs, brain and kidneys are also affected in HES. 

Imaging features are non-specific, can show edematous wall thickening. Ascites and pleural effusion can be seen. Esophagus, stomach, small bowel and also colon can be affected. 

References:

• A Review of Eosinophilic Gastroenteritis.
• Radiopaedia. 

Thanks to Dr. GP.