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.