Eosinophils Beyond the Esophagus: A Review of Non-EoE Eosinophilic Gastrointestinal Diseases

Abstract

For eosinophilic esophagitis (EoE), the most well researched of the eosinophilic gastrointestinal diseases (EGIDs), there is a plethora of knowledge for its diagnosis and management; however, much less guidance is available for the non-EoE EGIDs. Efforts have been made to characterize the clinical features, epidemiology, diagnosis, and natural history of EGIDs, as the frequency of the non-EoE EGIDs has continued to rise. The diagnosis of the different non-EoE EGIDs, eosinophilic gastritis, enteritis, and colitis, can be challenging because of their rarity and heterogeneous presentations which can lead to delayed diagnosis and poor health-related quality of life in affected patients. Guidelines for histologic evaluation and diagnostic criteria for non-EoE EGID are actively being developed. Effective management of non-EoE EGIDs is possible with currently available assessments and therapies, with more treatments on the horizon, highlighting the need for improved understanding of non-EoE EGIDs. This article will review the diagnosis and management of the non-EoE EGIDs, focusing on the consensus nomenclature, nuances in diagnosis, and management options.

Keywords: Eosinophilic gastrointestinal disease; eosinophilic colitis; eosinophilic enteritis; eosinophilic gastritis; eosinophilic gastroenteritis.

Figure 1.

International consensus recommendations for EGID nomenclature. ^aAdditional research needed for this combined naming. ^bPerferred terms. ^cShould only be used to indicate both stomach and small bowel involvement. Adapted with permission from Dellon ES et al.

Figure 2.

Suggested treatment algorithm for non-EoE EGIDs. EGIDs, eosinophilic gastrointestinal diseases; EoE, eosinophilic esophagitis; eos/hpf, eosinophils per high-power field; PPI, proton pump inhibitor. ^aAllergy referral as indicated for allergic comorbidities and environmental exposures.

Figure 3.

Endoscopic images of 2 different patients with eosinophilic gastritis. Panel A shows gastric erythema, loss of vascular pattern, and some nodularity in a 50-year-old woman with history of asthma and allergic rhinitis, chronic episodic epigastric pain, nausea, vomiting, early satiety, and diarrhea. Symptoms are mild. Biopsies of the stomach demonstrate greater than 80 eos/ hpf, and duodenal biopsies show 25 eos/hpf. She has peripheral eosinophilia, with an absolute eosinophil count of 800 cells/µL. Treatment with PPIs and crushed budesonide 9 mg daily results in resolution of her tissue eosinophilia on follow-up endoscopy. Clinically, her symptoms and peripheral eosinophilia have resolved. She is maintained on PPI therapy and is ultimately able to deescalate crushed budesonide to 3 mg daily. Panel B shows large deep gastric ulcers in a 30-year-old woman with severe epigastric abdominal pain, nausea, vomiting, and inability to adequately maintain her nutrition causing a 15-lb weight loss. She is admitted to the hospital with dehydration. Laboratory results show peripheral eosinophilia of 1600 cells/µL and low albumin of 3.2 g/dL. Biopsies show prominent eosinophilia (up to 100 eos/hpf ). Due to the severity of her symptoms, she is started on intravenous pantoprazole and systemic treatment with prednisone 40 mg daily. After several days of therapy, her symptoms abate, and she is discharged home on PPI therapy and a prednisone taper, followed by transition to crushed budesonide. Her disease has been well maintained on crushed budesonide, and follow-up endoscopy shows continued remission. eos/hpf, eosinophils per high-power field; PPI, proton pump inhibitor. Images courtesy of Dr Gonsalves.