Eosinophilic Gastroenteritis

WHAT:    

Eosinophilic gastroenteritis is a disease of the immune system that affects the gastrointestinal (GI) system. Gastroenteritis refers to inflammation of the lining of the stomach and intestinal tract. The “eosinophilic” description of this disease refers to the fact that the inflammation is related to an abundance of a type of white blood cells called eosinophils in the walls of the stomach and intestinal tract. This special type of white blood cell is involved in the body’s response to parasites and in allergies.

DIAGNOSIS:    

The diagnosis of eosinophilic gastroenteritis will be based mainly on seeing the large amounts of eosinophils when a sample of the wall of the gastrointestinal tract is taken. The sample will be obtained by a procedure called a biopsy. A biopsy is obtained through a small tube inserted through the mouth past the stomach to the intestines where a small sample of the intestinal wall can be removed. This procedure does not hurt your child although he/she will need to be sedated so that the biopsy can be quickly obtained and the child is more comfortable. An important step in the diagnosis will be to rule out other possible causes for the elevated amounts of eosinophils in the wall. Other possible causes include parasites, H. pylori, or inflammatory bowel disease.

SIGNS & SYMPTOMS:    

Patients with eosinophilic gastroenteritis may have some or all of the following signs and symptoms:
Nausea after eating
Abdominal pain
Vomiting
Diarrhea
Bowel obstruction (intestines are blocked by an extremely thickened wall)
Weight loss
Ascites (an accumulation of fluid in the abdominal cavity similar to bloating)
Food allergies or food intolerances
Laboratory findings may include: elevated levels of eosinophils, low levels of iron and of protein (related to malabsorption, or poor ability to absorb nutrients by the intestine)

POSSIBLE CAUSES:    

The cause for the signs and symptoms is related to the infiltration of the eosinophils within the GI wall. The infiltration leads to a thickening of the intestinal wall which contributes to any or all of the signs and symptoms listed above. Exactly which symptoms the child has depends on what layer of the intestine is infiltrated and the extent and severity of the infiltration. How and why the infiltration of eosinophils into the GI tract happens is not yet known. It has been thought that some precipitating stimuli to the GI system might cause an immune response. This immune system response then becomes hypersensitisized due to unknown mechanisms.

There are two groups of patients, one in whom it is possible to identify particular foods that provoke the syndrome, and a second group in which foods do not appear to make any difference. This is important in treating the disease.

TREATMENT:   

 The treatment for eosinophilic gastroenteritis depends to some degrees on which of the 3 layers of the wall of the GI tract are affected. Children who are in the food triggered group may find some relief in adhering to a food elimination diet. A food elimination diet requires that a detailed diary is written of all foods the child eats and any correlating symptoms the child has. The goal is to discover those foods that most often trigger symptoms and if eliminating them relieves these symptoms. Food elimination diets should be done under a doctor’s care to ensure that appropriate conclusions are drawn from the diaries and that an adequate diet is maintained for growth and nutrition. In the group that does not have food-triggered symptoms, steroids are often used to reduce the inflammation. Recently, a new steroid (budesonide) that is not absorbed has been used to treat this disorder, and has shown promise in reducing symptoms without causing the side effects steroids usually have.

MEDICAL CARE:

• Elimination of foods implicated by skin testing has variable effects, but resolution of symptoms can sometimes be achieved with amino acid–based elemental diets.
• Supportive treatment with pharmacotherapy, mainly oral glucocorticosteroids, is indicated for those with obstructive symptoms.
• Patients with mucosal layer involvement may benefit from anti-inflammatory medications (eg, oral glucocorticoids, oral cromolyn) and/or diet elimination therapy, particularly if they report a history of food intolerance or allergy.
• Drugs such as montelukast, ketotifen, suplatast tosilate, mycophenolate mofetil (inosine monophosphate dehydrogenase inhibitor), and alternative Chinese medicines have been advocated but are generally not successful.

SURGICAL CARE:

• Avoid surgery if at all possible, unless it is necessary to relieve persistent pyloric or small bowel obstruction.
• Most patients respond to conservative measures and oral glucocorticosteroids.
• Reoccurrence is possible, even after surgical excision.

CONSULTATIONS:

• Refer patients with persistent abdominal symptoms and peripheral eosinophilia to a GI specialist for workup, endoscopy, and biopsies.
• Refer patients to an allergy/immunology specialist for food skin testing and evaluation of eosinophilia and high IgE levels.

DIET:

• Initially, a trial elimination diet that excludes milk, eggs, wheat and/or gluten, soy, and beef may be helpful. RAST or skin testing can identify food hypersensitivity. If a prohibitive number of food reactions are found, an amino–acid-based diet or elemental diet may be considered.

ACTIVITY:

• Encourage normal activities.