What Is Eosinophilic Enteritis?

Eosinophilic gastroenteritis is an unexplained disease characterized by diffuse or limited eosinophilic infiltration of the gastrointestinal tract, often accompanied by eosinophilia in the surrounding blood.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis (EG) is a rare disease. Kaijisser first reported 3 cases of EG in 1937. The typical EG is eosinophils in the gastrointestinal tract, and the stomach Intestinal edema is characterized by thickening. The disease usually involves the gastric antrum and the proximal jejunum. If the colon is involved, the cecum and ascending colon are more common. In addition, EG can also affect the esophagus, liver, and biliary system, causing eosinophilic esophagitis, hepatitis, and cholecystitis. It has also been reported to only affect the rectum.

Causes of eosinophilic gastroenteritis

The etiology of this disease is unclear. A few patients have a family history of asthma, food allergies, or allergic diseases, but most patients do not have a history of allergies. Endoscopy showed that eosinophils infiltrated widely in the gastrointestinal tract, from the pharynx to the rectum. Among them, the stomach and the small intestine are the most common. According to the scope of infiltration, they can be divided into limited and diffuse types.

The localized type is most common in the gastric antrum. The naked eye is a solid or rubber-like, smooth, pedicled, or pedicled polyp-like mass that protrudes into the cavity and can cause pyloric obstruction. This type is more common in patients aged 40 to 60 years. Both men and women can develop the disease, which is more acute upper abdominal cramping pain, nausea, vomiting, and diarrhea. Allergy history is unclear.

Diffuse type often causes only mucosal edema, hyperemia, and thickening, with occasional superficial ulcers and erosions. Intestinal lesions are mostly diffuse, with affected intestinal wall edema, thickening, tarnishing of the serosa surface, and fibrous exudate coverage. More common in 30 to 50 years old, more men than women, manifested as upper abdominal cramps, with nausea and vomiting. The seizures are irregular and may be related to certain foods, which cannot be alleviated with antiacid spasmolytic agents. Those with severe mucosal involvement can cause vomiting blood, black stools, diarrhea, malabsorption, intestinal protein loss, iron deficiency, and weight loss. Obvious muscle involvement can cause intestinal obstruction. Serum involvement can cause ascites or pleural effusions containing large amounts of eosinophils. About half of the patients are accompanied by other allergic diseases, such as eczema, asthma, and allergic rhinitis. Gastrointestinal symptoms are present in 80% of cases and can last for decades.

The disease lacks clinically specific manifestations and is a self-limiting allergic disease. Although it can be repeated many times, the prognosis is good and no malignant changes are seen. ?

Pathological changes of eosinophilic gastroenteritis

Eosinophilic gastroenteritis has a wide infiltration in the gastrointestinal tract, from the pharynx to the rectum, of which

Eosinophilic gastroenteritis--pathology It is most common in the stomach and small intestine. According to the infiltration range can be divided into limited or diffuse. The localized type is most common in the gastric antrum. The naked eye is a solid or rubber-like, smooth, pedicled, or pedicled polyp-like mass that protrudes into the cavity and can cause pyloric obstruction. The mild temperature type often causes only mucosal edema, hyperemia, and thickening, with occasional superficial ulcers and erosions. The intestinal lesions are mostly of the mild temperature type. The affected intestinal wall is edema, thickened, the serous surface is tarnished and covered with fibrous exudate.

Histological characteristics include:

1. Submucosal edema composed of fibroblasts and collagen fibers;

2. The matrix has a large amount of infiltration of eosinophils and lymphocytes, which can be accompanied by infiltration of macrophages, giant cells or tissue cells;

3. Submucosal blood vessels, lymphatic vessels, myometrium, serosa, and mesenteric lymph nodes can all be involved, with mucosal ulcers and pedicled or pedicled granuloma. Eosinophil infiltration can be limited to the gastrointestinal wall, or it can be transmural.

Klein is divided according to the degree of infiltration of eosinophils into the gastrointestinal wall: 1. Mucosal lesion type: a large number of infiltration of eosinophils in the mucosa with obvious epithelial abnormalities, intestinal villi can completely disappear, leading to blood loss, iron deficiency, and absorption Illness and protein loss, etc. 2. Muscle lesion type: infiltration is mainly muscle layer, gastrointestinal wall thickening, nodular, leading to stenosis and obstruction; 3. serous lesion type: infiltration is mainly serous membrane , Serum thickening, and can involve mesenteric lymph nodes, the formation of ascites.

Clinical manifestations of eosinophilic gastroenteritis

The disease lacks specific clinical manifestations. Symptoms are related to the location of the lesion and the degree of infiltration. They are generally divided into two types.

Eosinophilic gastroenteritis--pathology .

(1) Miwen type is more common in 30-50 years old, slightly more men than women. The course can last for decades. 80% of patients have gastrointestinal symptoms, mainly manifested as upper abdominal cramping pain, with malignancy, vomiting, fever, no obvious regularity of seizures, and may be related to certain foods, which cannot be alleviated with anti-acid spasm, but can be spontaneous ease.

1. Eosinophilic gastroenteritis infiltration is mainly caused by mucosa in upper gastrointestinal bleeding, diarrhea, malabsorption, intestinal protein loss, hypoproteinemia, iron deficiency anemia, and weight loss. About 50% of patients have asthma or allergic rhinitis, eczema or urticaria. Fecal occult blood test was positive, with Charcoalden crystals. Eosinophils increased in 80% of patients. Serum protein decreased and D-xylose tolerance test was abnormal. X-ray gastrointestinal barium meal examination was normal or showed signs of mucosal edema. Endoscopy revealed congestion, edema, or erosion of the mucosa. The biopsy had eosinophil infiltration.

2. The infiltration of eosinophilic gastroenteritis is mainly caused by the muscular layer, which causes the stomach and small intestine wall to be significantly thickened and stiff. Patients often have symptoms and signs of pyloric obstruction or incomplete intestinal obstruction. X-ray gastrointestinal barium meal examination revealed pyloric stenosis, reduced peristalsis, or multiple polypoid filling defects in the gastric antrum. The diagnosis is based on biopsy of the stomach and small intestine, showing extensively mature eosinophils infiltrating into the submucosa and extending through the muscular layer to the serosa layer.

3, eosinophilic gastroenteritis infiltration mainly in the subserosal layer can often occur ascites or pleural effusion, which contains a large number of eosinophils. Laparotomy is common for thickening of the small intestine serosa and eosinophil infiltration. Similar changes were seen in gastric serous lesions.

(B) Localized type is more common in 40 to 60 years old, and there is no significant difference in incidence between men and women. The main symptoms are spasmodic pain, nausea, and vomiting in the upper abdomen. The onset is rapid and the course is short. The patient's allergic history was not obvious, and only a few peripheral blood images had eosinophilia. X-ray gastrointestinal barium meal imaging can show thickening of the gastric antrum, stiffness, and narrowing of the gastric antrum. It can have smooth round or oval and lobular filling defects, similar to tumors. Endoscopy revealed a polyp-like mass, congestion and edema of the mucosa, and was easily misdiagnosed as a tumor or a clonal disease. Few tissue examinations showed a large infiltration of eosinophils.

Diagnosis of eosinophilic gastroenteritis

Diagnosis is mainly based on clinical manifestations, haematology, radiology, and endoscopic and pathological findings

Diagnosis of eosinophilic gastroenteritis Off.

Talley Eosinophilic gastroenteritis Talley standard

(1) Gastrointestinal symptoms are present.

(2) Biopsy pathology shows that there is infiltration of eosinophils in one or more parts of the gastrointestinal tract from the esophagus to the colon, or radiological colon abnormalities with increased peripheral eosinophils.

(3) Excludes parasitic infections and diseases with eosinophilia outside the gastrointestinal tract, such as connective tissue disease, eosinophilia, Crohn's disease, lymphoma, and primary amyloidosis Menetrieri disease.

Leinbach Eosinophilic gastroenteritis Leinbach standard

(1) Gastrointestinal symptoms and signs appear after eating special foods.

(2) Increased eosinophils in peripheral blood.

(3) Histological evidence of eosinophilia or infiltration in the gastrointestinal tract.

Differential diagnosis of eosinophilic gastroenteritis

1, indigestion, eosinophilic gastroenteritis patients may have digestion such as abdominal pain, nausea, vomiting, bloating

Reflux esophagitis image Adverse symptoms, but often lack specificity, should be distinguished from patients with peptic ulcer, reflux esophagitis, gastric cancer, chronic pancreatitis, etc.

2, intestinal obstruction, muscle layer type can often occur intestinal obstruction, we must pay attention to exclude gastrointestinal tumors and intestinal vascular diseases.

3. Ascites is more common in serosal eosinophilic gastroenteritis. Routine and biochemical examination of ascites, CEA testing of ascites, and pathological examination of ascites can help diagnose the disease.

4. Eosinophilia is a systemic disease of unknown etiology, and it can also affect the gastrointestinal tract. 60% of the liver, 14% of the gastrointestinal tract, diffuse eosinophilic gastroenteritis, in addition to the gastrointestinal tract, 50% often involve organs outside the gastrointestinal tract.

5. Intestinal parasitic infections can cause various non-specific gastrointestinal symptoms, while peripheral blood eosinophils increase. Repeated inspection of fecal eggs can be identified.

6, allergic diseases, bronchial asthma, allergic rhinitis, urticaria, in addition to peripheral blood eosinophils may increase, each has its clinical manifestations.

7. Eosinophilic granuloma, which mainly occurs in the stomach, large and small intestines, presents a localized mass. Peripheral blood eosinophils generally do not rise. The pathological feature is that eosinophilic granuloma is mixed in the connective tissue matrix.

8. Rheumatic diseases, various vasculitis, such as allergic granulomatosis (Churg-Strauss syndrome) and nodular polyarteritis, other connective tissue diseases such as scleroderma, dermatomyositis, and polymyositis It can affect the gastrointestinal tract, appear abdominal pain, indigestion and other symptoms, and there can be varying degrees of peripheral blood eosinophilia. Small bowel mucosal biopsy can help with differential diagnosis.

Examination of eosinophilic gastroenteritis

Eosinophilic gastroenteritis laboratory test

1. Blood tests, 80% of patients have peripheral eosinophils, mucosa and submucosal lesions

Laboratory inspection Patients with predominantly muscular lesions (1 to 2) × 109 / L. When plasma cell lesions are predominant, it can reach 8 × 109 / L. There may also be iron deficiency anemia, decreased serum albumin, increased blood IgE, and increased erythrocyte sedimentation.

2. Fecal examination. The significance of acidic gastroenteritis stool examination is to exclude intestinal parasitic infections. Some can see Charcot-Leyden crystals, and then routinely check for occult blood. Some patients have mild Moderate steatorrhea. Cr-labeled albumin increased, -antitrypsin clearance increased, and D-xylose absorption test was abnormal.

Other auxiliary tests for eosinophilic gastroenteritis

1, X-ray examination, eosinophilic gastroenteritis lack specificity, X-ray barium meal can see mucosal edema, folds widened, nodular filling defects, thickening of the gastrointestinal wall, cavity narrowing and obstruction.

2. CT examination can find thickening of the gastrointestinal wall, enlargement of mesenteric lymph nodes or ascites.

3. Endoscopy and biopsy, suitable for eosinophilic gastroenteritis with mucosal and submucosal lesions as the main cause. Microscopic folds, congestion, edema, ulcers, or nodules can be seen under the microscope. Biopsy confirms a large amount of eosinophil infiltration, which is valuable for diagnosis. However, biopsy tissue is of little value in patients with muscle and serosa involvement, and sometimes needs to be confirmed by surgery and pathology.

4. Abdominal puncture. Ascites patients must undergo diagnostic abdominal puncture. Ascites is exudative and contains a large number of eosinophils. Ascites smears must be performed to distinguish eosinophils and neutrophils.

5. Laparoscopy, the lack of specific manifestations under laparoscopy, only mild peritoneal congestion, and severe cases can be similar to peritoneal metastatic cancer. The significance of laparoscopy is to perform a biopsy of the abdominal mucosa to obtain a pathological diagnosis.

6. Surgical exploration. Laparotomy is generally not performed for suspected eosinophilic gastroenteritis, but surgery is performed only when there is an intestinal obstruction or pyloric obstruction or a tumor is suspected.

Treatment of eosinophilic gastroenteritis

The principle of treatment of this disease is to remove allergens, inhibit allergic reactions and stabilize mast cells, so as to relieve symptoms and clear lesions.

Control of eosinophilic gastroenteritis diet

Discontinue use of identified or suspected allergic foods or medications. Those without a history of food and drug allergies can take a sequential approach to exclude foods that may cause sensitization, such as milk (especially in children), eggs, meat, sea shrimp, gluten products, and sensitive drugs. Many patients have rapidly improved their abdominal pain and diarrhea after excluding foods or drugs that cause disease from their diet, especially in patients with predominantly mucosal lesions. Although diet control may not cure the disease, generally, diet control should always be used as a basic measure when formulating a treatment plan, and it should be applied first.

Application of glucocorticoids in eosinophilic gastroenteritis

Hormones have a good effect on this disease. In most cases, the symptoms improve within 1 to 2 weeks after administration, manifested by the rapid elimination of abdominal cramps, diarrhea reduced and disappeared, and peripheral blood eosinophils dropped to normal levels. Serous membrane type patients with ascites as the main manifestation completely disappeared after 7-10 days after hormone application. The long-term effect is also very good. In some cases, hormone therapy can not completely eliminate the symptoms. Adding azathioprine is usually effective (50-100 mg daily). Prednisone 20-40mg / d is generally used orally, and 7-14 days is used as a course of treatment. An equivalent dose of dexamethasone can also be applied.

Application of eosinophilic gastroenteritis disodium cromoglycate

Disodium cromoglycate (sodium cromoglycate) is a mast cell stabilizer that can stabilize the mast cell membrane, inhibit its degranulation reaction, prevent the release of histamine, slow-reactive substances and bradykinin and other media to exert its antiallergic effect. In 1988, Moots reported that a patient who had failed prednisone treatment was treated with disodium cromoglycate and achieved good results. The method is 100 mg orally 4 times a day. After 10 days, the symptoms gradually improved, and after one month, the symptoms were alleviated. The eosinophils in the blood decreased from 71% to 4%. After 10 weeks, he fully recovered and gained 10kg in weight. Di-Gioacchino reported that 2 patients took 1200 mg of disodium cromoglycate daily. After 4 to 5 months of treatment, symptoms disappeared, inflammation subsided, and peripheral blood eosinophils completely returned to normal.

The usage of disodium cromoglycate is 40-60mg, 3 times a day. It is also useful up to 800-1200mg / d. The course of treatment ranges from 6 weeks to 5 months. Those who do not respond to glucocorticoid therapy or have more serious side effects can be treated with disodium cromoglycate as an alternative to the former.

Surgical treatment of eosinophilic gastroenteritis

The lesions are limited to patients with muscular infiltration, often with pyloric obstruction or small bowel obstruction. Subtotal gastrectomy or intestinal segment resection or gastrointestinal anastomosis can be considered. If there are still symptoms or elevated eosinophils after surgery, a small dose of prednisone, 5 mg or 2.5 mg / d orally can be used for maintenance for a period of time.