EOSINOPHILIC ENTERITIS PRESENTING AS INTESTINAL OBSTRUCTION: A CASE REPORT
Beatriz de Rienzo-Madero*1, Daniel Kajomovitz-Bialostozky1, Mario Pelaez-Luna2, Fernando Quijano-Orvananos1
1Surgery, Centro Medico ABC, Cd de Mexico, CDMX, Mexico; 2Gastroenterology and Endoscopy, Centro Medico ABC, CDMX, Mexico
Introduction: Eosinophilic enteritis (EE) is a rare gastrointestinal (GI) disorder with a prevalence of 5.1/100,000, characterized by an intense eosinophilic infiltrate of the GI tract of unknown etiology. It may present with a wide array of symptoms: abdominal pain, diarrhea, nausea, vomiting, bloating, intestinal obstruction or ascites depending on the affected intestinal wall layer. There are no clear recommendations for treatment and up to 40% of patients have spontaneous remission.
Case: An 84 year-old male patient with history of appendectomy, intestinal resection and right hemicolectomy for unknown cause, and two episodes of intestinal obstruction, presented to the emergency room with a two day history of diffuse abdominal pain and distension accompanied by nausea and vomiting. A CBC showed leukocytosis and no eosinophilia. An IV and oral contrast-enhanced CT scan revealed dilation of the small intestine, areas of stenosis in the distal small intestine with thickening of the intestinal wall, and passage of oral contrast to the colon, compatible with a partial intestinal obstruction. Conservative management was initiated with parenteral rehydration, and nasogastric tube. A colonoscopy found aphthous ulcers in the stenosis area in the distal intestine. A filmarray and parasite studies were negative. The patient was started on budesonide and metronidazole, and 24 hours after admission his partial intestinal obstruction resolved. The final histopathology of the biopsies reported EE. He is currently treated with budesonide 9mg/d with adequate response.
Discussion: EE is characterized by an eosinophilic infiltration of different segments of the GI tract. The clinical manifestations depend on the affected segment of the GI tract, as well as the intestinal layer involved: 1) mucosal form in 44% (diarrhea, abdominal pain, malabsorption), 2) muscular form in 12% (intestinal strictures, abdominal pain, nausea, vomiting, intestinal obstruction, 3) sub-serosal in 49% (eosinophilic-rich ascites, bloating, abdominal pain). An association between EE and eosinophilia and atopic disorders has been described. The diagnosis is established by GI symptoms associated with eosinophilic infiltration of at least one intestinal segment, and exclusion of secondary causes (parasitosis, intestinal infections, associated drugs, IBD, celiac disease, autoimmune disease and vasculitis, neoplasia). 40-80% are present in the stomach and proximal intestine. There are no clear recommendations for treatment. The first line of treatment is systemic corticosteroids or budesonide. Alternatives depending on response and severity are leukotriene inhibitors, mast cell stabilizers, antihistamines H1, azathioprine and biological agents. Surgery is reserved for complications and consists of a segmental resection with or without primary anastomosis.
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