Gastro Case Challenge: An Incarcerated 24-Year-Old With Dyspnea, Fatigue, and Chronic Nausea

Nicola E. Burch, MBChB, MRCP; Victoria M. Gordon, MBBS, MRCP


March 18, 2022

For a definitive diagnosis of eosinophilic gastroenteritis, the following four criteria must be met[2,6]:

  • Presence of GI symptoms

  • Demonstration of eosinophilic infiltration (>20 eosinophils per high-power field) in one or more areas of the GI tract

  • Absence of alternative causes of eosinophilia

  • No involvement outside of the GI tract (ie, no systemic eosinophilic pathology)

Histologic subclassification of eosinophilic gastroenteritis is determined according to the layer of the GI tract involved (mucosa, muscularis, or serosa). The clinical manifestations are also dependent on the affected area. Patients presenting with vomiting, abdominal pain, diarrhea, bloody stools, failure to thrive, and iron deficiency anemia often have mucosal infiltration. Patients with obstructive symptoms or dysphagia tend to have muscular involvement. Serosal involvement presents with eosinophilic ascites, which has been well described in the literature.[2,4]

The differential diagnosis includes all conditions with presenting features similar to those described above (ie, inflammatory bowel disease), as well as those that produce eosinophilia. Eosinophilic infections include parasitic infections (Ancylostoma caninum, giardiasis, strongyloidosis, and other zoonoses), connective tissue diseases (scleroderma, dermatomyositis, polymyositis), vasculitis (Churg-Strauss syndrome, polyarteritis nodosa), drug reactions (sulfonamides, penicillin, cephalosporin, carbamazepine, azathioprine, L-tryptophan, gold salts), celiac disease, and lymphoma.[2]

Investigations must center on confirmation of peripheral eosinophilia, evidence of increased eosinophil counts in GI tissue (defined variably as 10-50 eosinophils per high-power field), and the exclusion of alternative diagnoses. Imaging may help demonstrate the extent of bowel involvement, but it cannot distinguish this condition from alternative, more common diagnoses (eg, Crohn disease, ulcerative colitis).

Radiographic findings may be nonspecific or totally absent. Thickened intestinal walls and lymphadenopathy may be seen on ultrasonography and CT. Endoscopic findings are nonspecific and varied, but histologic demonstration of eosinophils in tissue samples is the criterion standard. If serosal involvement with ascites is noted, an ascitic tap that is rich in eosinophils is diagnostic.[2,3,4]


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