Eosinophilic gastroenteritis: Approach to diagnosis and management

Abstract

Eosinophilic gastroenteritis (EGE) is a rare and benign inflammatory disorder that predominantly affects the stomach and the small intestine. The disease is divided into three subtypes (mucosal, muscular and serosal) according to klein's classification, and its manifestations are protean, depending on the involved intestinal segments and layers. Hence, accurate diagnosis of EGE poses a significant challenge to clinicians, with evidence of the following three criteria required: Suspicious clinical symptoms, histologic evidence of eosinophilic infiltration in the bowel and exclusion of other pathologies with similar findings. In this review, we designed and applied an algorithm to clarify the steps to follow for diagnosis of EGE in clinical practice. The management of EGE represents another area of debate. Prednisone remains the mainstay of treatment; however the disease is recognized as a chronic disorder and one that most frequently follows a relapsing course that requires maintenance therapy. Since prolonged steroid treatment carries of risk of serious adverse effects, other options with better safety profiles have been proposed; these include budesonide, dietary restrictions and steroid-sparing agents, such as leukotriene inhibitors, azathioprine, anti-histamines and mast-cell stabilizers. Single cases or small case series have been reported in the literature for all of these options, and we provide in this review a summary of these various therapeutic modalities, placing them within the context of our novel algorithm for EGE management according to disease severity upon presentation.

Keywords: Algorithm; Diagnosis; Eosinophilic; Gastroenteritis; Management; Review.

Figure 1

Algorithm for eosinophilic gastroenteritis diagnosis. ¹Histologic ascertainment for absence of malignant cells or findings suggestive of IBD, connective tissue diseases or vasculitis. AEC: Absolute eosinophilic count; ANA: Anti-nuclear antibody; ANCA: Anti-neutrophil cytoplasmic antibodies; EC: Eosinophilic count; EUS: Endoscopic ultrasound; Hx: History; IBD: Inflammatory bowel disease; PE: Physical examination; S/A: Stool analysis; US: Ultrasound; EGE: Eosinophilic gastroenteritis.

Figure 2

Eosinophilic gastroenteritis management based on initial disease severity. Anti-TNF: Anti-tumor necrosis factor; FAT: Food allergy testing; PPI: Proton pump inhibitor; TED: Targeted elimination diet.