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Eosinophilic Gastroenteritis Colitis

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Eosinophilic Gastroenteritis Colitis Powered By Docstoc
					     Eosinophilic
Gastroenteritis & Colitis
        Ghassan Wahbeh MD
          Stacey Berry MD
         Troy Torgerson MD
         Kenneth Song MD

         Children’s Hospital
                UW
             Contents
Background
Case presentations
   Ghassan Wahbeh & Stacey Berry
Worms, wheezes, and weird
diseases: Immunology perspective
   Troy Torgerson
Literature review
   Kenneth Song
                                   Background
 Reported as early as 1930’s*
 Definition
   • Inflammation of the GI tract (esophagus
     to rectum) due to eosinophilic
     infiltration of various depths
 Primary & Secondary
 Clinical subtypes

* Kaijser R. Allergic disease of the gut from the point of view of
the surgeon. Arch Klin Chir 1937; 188:36–64.
  Affects all age groups
  Described in animals *
  Strong association with allergies
  Recent ↑ awareness vs. incidence




* Eosinophilic gastroenteritis in a dog. Sarah McTavish. Can Vet
J. 2002 June; 43(6): 463–465 *
Case Presentation
Case 1
             Case 1
15 year old female
Abdominal pain for 2 years
Rare rectal bleeding, no diarrhea
No weight loss, N/V
Nasal allergies
“A” student, soccer player
Normal growth, puberty
         Investigations
Normal Exam
Labs:
• Peripheral eos 600-2000
• Normal chemistry, ESR, CRP
• Normal U/S, CT, CXR, RAST
EGD / Colonoscopy
Stomach
Duodenum
Terminal ileum
Colon
          Management
Refused prednisone
No improvement
• Budesonide
• Cromolyn
• Montelukast
• Mesalamine (worse)
• Mebendazole (past history of pinworms)
pANCA, ASCA, omp-C absent
       Patient’s course
Repeat endoscopy: same
No bleeding per rectum
Tylenol, NSAID
Milder persistent pain
Worse with gas-producing foods
Unwilling to try prednisone
Normal growth
Persistent eosinophilia
Case 2
             Case 2
12 year old female
Abdominal pain, intermittent
diarrhea
for 3 years
Regurgitation, heartburn, nausea
rare rectal bleeding
Recurrent fatigue
Iron deficiency anemia (Hb 6.5 in
2003)
Normal growth
Prepubertal
         Investigations
HCT 21-25 on oral iron
Low iron indices, high Zn-
protoporphyrin
Albumin 3.4, Low D-Xylose
Normal ESR
Negative PST, RAST
+ TTG, endomysial IgA
UGISBFT: gastric & duodenal wall
thickening
Normal CT abdomen, CXR
Negative Meckel’s scan
Normal bone density
EGD, flex sig 2003
Esophagus
Stomach
Duodenum Bulb
           Patient’s Course
Responded to oral prednisone
Recurrent pain, IDA after stopped
Poor response to
•   Fluticasone
•   Cromolyn
•   Montelukast
•   Betamthasone liquid
•   PPI
EGD 2005
Stomach
Stomach
        Patient’s course
Persistent pain
Recurrent fatigue, low iron indices
Recent trial with methotrexate
“Eosinophilic infiltration, localized or
diffuse, of the gastrointestinal tract cannot
be regarded as a definitive diagnosis;
neither can a classification of disease, in
which this is a feature, be founded on the
degree or site of such infiltration.
Eosinophilia is merely a manifestation of
inflammation, often with an allergic basis,
and accompanies a number of well defined
clinicopathological conditions, some of
which have a known cause—for example,
parasitic infestation—but most of which do
not.”
            Blackshaw AJ, Levison DA. Eosinophilic infiltrates of the gastrointestinal
            tract. J Clin Pathol 1986; 39:1–7.