EOSINOPHILIC GASTROENTERITIS
Description
◉ CASE 1:
• A woman aged 71
• Two-year symptoms:
• diarrhea, nausea, and a 10-pound weight loss.
◉ INVESTIGATIONS
• 8.2% were eosinophilic (↑).
• 26 U/mL of serum IgE (↑; N 6–12)
• EGD: erythema, ulcers, thickened folds, distal esophagitis, and many antral polyps (0.5–1 cm).
◉ HISTOLOGY:
• The mucosa of the stomach and duodenum exhibits dense eosinophilic infiltration and degranulation.
• CT: Normal
◉ CASE 2:
• A man aged 57
• Four months of symptoms:
• upper abdominal pain, bloating, fullness, nausea, and generalized aches.
◉ INVESTIGATION:
• 33% have eosinophilia (marked).
• Amylase/Lipase: 415 U/L, somewhat high.
• Gastric outlet obstruction in a barium examination.
• ENDOSCOPY: Narrowing at the pylorus, thickened antral and duodenal folds.
• BIOPSY: Moderate infiltration of eosinophils.
• CT: Normal pancreas, thickened duodenal and pyloric folds.
◉ CASE 3 –
• 74-year-old man
• Symptoms (3 years):
• Bloating, nausea, vomiting, diarrhea, discomfort, 10-lb weight loss.
◉ INVESTIGATIONS:
• Eosinophilia: 9.6%
• Serum IgE: 54 U/mL (↑)
• Barium: Narrowing of 2nd–3rd duodenum, reflux of contrast into bile duct.
• CT: Confirmed duodenal stenosis.
• EGD: Esophagitis, erythematous antrum, duodenal narrowing.
• Biopsy: Moderate eosinophilic infiltration in antrum, bulb, and colon.
◉ CASE 4 –
• 43-year-old African-American man
• Symptoms (3 months):
• Intermittent abdominal pain, nausea, vomiting, diarrhea, fullness, weight loss (8 lb).
• Past history: Mild asthma.
◉ INVESTIGATIONS:
• Eosinophilia: 20%.
• Serum IgE: 650 U/mL (extremely high).Amylase/Lipase: 471 / 1785 U/L => acute pancreatitis.
• CT: Dilated stomach, thickened antral/duodenal folds, normal pancreas.
• EGD: Esophagitis, multiple antral erosions, duodenal ulcerated nodules.
• Biopsies:
• Esophagus – mild eosinophilic infiltration
• Antrum/Duodenum – dense eosinophilic infiltration
• Colon – mild eosinophilia
◉ CASE 5:
• An Indian woman in her 60s
• Three weeks of symptoms:
• diarrhea, vomiting, abdominal pain, and weight loss (20 lbs).
• History: mild case of asthma.
◉ INVESTIGATIONS:
• 17% have eosinophilia.
• 375 / 1115 U/L of amylase/lipase indicates pancreatitis.
• CT: Normal.
• The erythematous ampulla was prominent, and biopsies revealed a thick infiltration of eosinophils.
• EGD: Duodenitis with antral/duodenal narrowing, gastritis, and distal esophagitis.
◉ EPIDEMIOLOGY AND ASSOCIATION
• Rare disease; common onset age range: 40–70 years.
• None of these individuals had a food allergy, yet 40% of them had asthma.
• According to the literature, 50% of cases are food allergies and about 50% are allergies.
◉ CLINICAL PRESENATION
• Diarrhea and abdominal discomfort are universal symptoms.
• Additional symptoms:
• bloating, weight loss, postprandial fullness, nausea, and vomiting.
• Obstruction of the gastric outlet is the main characteristic (all 5).
• Additional symptoms: Two incidences of acute pancreatitis.
◉ INVOLMENT SITE
• Duodenum and stomach: 100% of cases.
• Esophagus: 80%, or 4 out of 5.
• Two out of three colon biopsies (66%).
• Ampulla/pancreas: 2 instances (40%).
◉ LAB RESULTS
• All 5 (8–33%) have peripheral eosinophilia.
• Serum IgE was elevated in two out of three tests.
• Amylase/Lipase: Increased in cases of pancreatitis.
• Stool tests: Always negative for parasites or ova.
◉ Radiologic and Endoscopic Features
1 Endoscopic manifestations:
• erosions, nodules, thickened folds, pseudopolyps, erythema, and ulceration.
2 Radiologic
• Duodenal stenosis, mucosal thickness, and obstruction of the stomach outflow are detected by barium and CT.
• A unique discovery: barium reflux into the biliary tree (Case 3) as a result of duodenal stricture.
◉ COMPLICATIONS
• 100% occlusion of the gastric outflow.
• Fibrosis and duodenal strictures.
• 40% of cases of pancreatitis are caused by periampullary eosinophilic infiltration.
• Possibility of intestinal blockage, rupture, and intussusception in extreme situations.
◉ Pathophysiology
• Eosinophil infiltration results in the release of hazardous mediators, including leukotrienes, histamine, eosinophil cationic protein, and major basic protein.
• causes fibrosis, edema, and mucosal damage → blockage.
• Some develop pancreatitis as a result of eosinophils infiltrating the periampullary region.
◉ Distinguishing Diagnoses
• Cancer (duodenal/gastric carcinoma)
• Peptic ulcer disease
• Crohn's disease
• Strictures following surgery
• Pancreatitis chronica
• pseudocyst in the pancreas
• Gallstones
Protocol
◉ MANAGEMENT:
◉ Health Care Administration
• Corticosteroids are the mainstay (prednisone 40 mg/day → fade).
Reaction rate: about 90%. Low-dose steroids (5–10 mg/day) are used for maintenance.
• Adjuncts:
• 200 mg TID/QID of sodium cromoglycate, a mast cell stabilizer.
• Antihistamine and mast cell stabilizer ketotifen.
• Azathioprine is an agent that spares steroids.
• Leukotriene receptor blocker: montelukast.
• Suplatast tosilate is an investigational IL-4 and IL-5 inhibitor.
• Anti-IL-5 monoclonal antibody mepolizumab is helpful in treating refractory eosinophilia.
• Unless a specific food allergy is proven, diet therapy is typically useless.
◉ Surgical Management
• recommended when blockage is caused by stricturing or fibrotic diseases.
• (Case 1: gastrojejunostomy and antrectomy).
• Issues with Eosinophilic Gastroenteritis: nausea, vomiting, diarrhea, dyspepsia, stomach discomfort, and weight loss
• Postprandial fullness, bloating, and vomiting are indications of gastric outlet and duodenal obstruction.
• Unknown cause of acute pancreatitis associated with eosinophilic infiltration
• Gastritis with polypoid lesions, ulcers, erosions, or esophagitis
• Colitis
• Ascites (abdominal fluid)
• Symptoms that persist after initial treatment
• Relapses while tapering off steroids In refractory cases, gastric outlet obstruction results in surgical intervention.
◉ Nursing Interventions and Medical Management
◉ Treatment with Corticosteroids
• oral prednisone is the main treatment method
• efficient in lowering inflammation and eosinophilic infiltration Patients need to be watched for steroid side effects and symptom improvement.
• To avoid recurrence, reduce dosages and maintenance therapy
of compliance and a steady decrease in dosage
• Nursing role: Give steroids as directed, keep an eye out for side effects (such as hyperglycemia or hypertension), and counsel patients on the value of following their doctor's orders and reducing their dosage gradually.
◉ Symptom Relief:
• Using proton pump inhibitors, H2 blockers, or antacids to treat the symptoms of gastritis or esophagitis
• If necessary, take antiemetics to treat nausea and vomiting.
• Nursing role: Assess pain levels and treatment response, monitor hydration status, and offer supportive care for nausea.
• Cromoglycate of sodium
• In certain patients who only partially respond to steroids, mast cell stabilizer is used as an adjuvant.
• aids in lowering histamine and other mediator release
• Nursing role: Help with steroid dose tapering, monitor symptom progression, and administer medication as directed.
•SURGERY
• recommended when medical therapy is ineffective for severe or recurring gastric outlet blockage.
• For instance, in obstructive cases, gastrojejunostomy and antrectomy are performed.
• Nursing duties include preoperative planning, postoperative care, including wound care, pain management, and
complication monitoring, as well as patient education regarding surgical recovery.
◉ Acute Pancreatitis Conservative Treatment:
• includes nasogastric suction for symptoms of gastric outlet blockage and rehydration.
• Keep an eye on electrolytes, hydration, and pancreatic enzymes.
• Regular vital sign monitoring, maintaining fluid balance, managing pain, and educating patients about dietary restrictions during pancreatitis are all part of the nursing job.
◉ Monitoring and Evaluation
• Regular endoscopic evaluations and biopsies to assess response to treatment
• Lab monitoring for eosinophil counts and IgE levels to guide therapy
• Nursing role: Coordinate diagnostic testing, educate patient on follow-up importance, monitor for signs of relapse or complications
◉ Patient Education
• Inform patients about the chronic relapsing course of EG
• Importance of medication adherence, recognizing symptom recurrence, and timely reporting
• Nutritional advice if needed due to malabsorption or obstruction
• Nursing role: Provide psychological support, dietary counseling, and reinforce education on disease process and treatment
Notes
FOR MORE DETAILS VISIT: https://pmc.ncbi.nlm.nih.gov/articles/PMC2678588/?utm_source=chatgpt.com
