Case Report: Importance of dietary modification in successful management of eosinophilic gastroenteritis

Introduction

Eosinophilic gastroenteritis (EGE) is an extremely rare inflammatory disorder with an estimated prevalence of 22–28/100 000. We herein, present a case of EGE in an elderly patient which was successfully managed with dietary restriction. We would like to stress that food allergy is the main culprit in certain cases of EGE and dietary modification should always be the first step in the management of these cases¹.

Case presentation

A 70-year-old male with a history of gastroesophageal reflux disorder (GERD), atopic dermatitis and asthma presented in August 2018 with 2 weeks history of foul-smelling non-bloody diarrhea associated with nausea, vomiting and weight loss. He did not have a family history of colonic disorders. He denied alcohol use, smoking or use of any other illicit drugs. Physical examination was significant for dry oral mucosa and loss of skin turgor.

Discussion

EGE most commonly affects males in the third decade of life and those with a history of eczema, asthma, allergic rhinitis. The prevalence of EGE is underestimated as it is under diagnosed given the rarity of the condition especially when it presents outside of the age spectrum like in our patient. The pathogenesis of EGE remains unclear and it is hypothesized to be a hypersensitive response to certain allergens. One proposed theory is that infectious and geographical factors interact with certain genetic variants causing esophagic dysbiosis which leads to Th2 cell immune response. Dysregulation of several genes termed EOE transcriptome is also shown to play a role^2,3.

Laboratory findings seen in EGE include peripheral eosinophilia, elevated serum IgE levels, increased stool fat excretion, prolonged prothrombin time, hypoalbuminemia, anemia from intestinal malabsorption. Imaging can show thickening or nodularity of the antrum and thickened or saw tooth mucosa in the small bowel and when the muscular layer is involved irregular narrowing especially in the distal antrum and proximal small bowel can also be seen. EGE is a diagnosis of exclusion and other causes of hyperreactivity and eosinophilia should be considered such as parasitic infections, vasculitis disorders, reaction to drugs like enalapril, interferons, non-steroidal anti-inflammatory drugs (NSAIDs), Helicobacter pylori infection⁴. The diagnosis of EGE is established when the biopsy shows more than expected numbers of eosinophils and all the other causes are ruled out.

Klein et al., classified EGE based on the depth of eosinophilic infiltration. Mucosal disease presents with abdominal pain, nausea/vomiting, diarrhea and the patients develop protein losing enteropathy, malabsorption and failure to thrive. Muscular involvement causes wall thickening and impaired motility which may lead to intestinal obstruction. Serosal disease presents as either isolated ascites or ascites in addition to the symptoms of serosal and muscular disease⁵.

The recurrence rate of EGE is 50% and a dietary trial could be a long-term solution like in our patient. A six-food elimination diet (soy, wheat, egg, milk, peanut/tree nuts, and fish/shellfish) or an elemental diet is recommended. Steroids improve symptoms in 90% of cases but the recurrence rates are high. The type, dose and duration of steroid therapy is unclear. The most commonly used regimen is prednisolone at 20 to 40 mg/day, for 6 to 8 weeks including the tapering although most patients need a longer course due to relapses. Sodium cromoglicate, ketotifen, and Montelukast are other proposed treatments, the results being inconclusive. Bowel resection is performed in intestinal obstruction, but medical therapy is needed as recurrence in other segments is common⁶.

The use of biologics in the treatment of refractory EGE in being studied and could lead to new longer lasting results. Interleukin 5, an eosinophilic growth factor, is shown to play an important role in the pathogenesis of EGE. A few clinical trials assessing the use of anti- interleukin 5 in the form of humanized antibodies have shown improvement in endoscopic appearance, reduced clinical symptoms and improved quality of life while a few clinical trials showed no statistical difference in disease progression with this treatment. Trials to understand if eosinophils are key to the development and progression of eosinophilic esophagitis are underway⁸

Conclusion

The clinical guidelines for the diagnosis of EGE is sparse and the treatment offered is low-evidence based. Dietary modification, a therapy with no side-effects should be the first line of treatment and can result in resolution sparing the patient of steroid induced side effects.

Consent

Written informed consent for publication of their clinical details was obtained from the patient.