Introduction

Eosinophilic gastroenteritis, first described by Kaijser in 1937, is a rare and heterogeneous condition with poorly understood etiology. The disease is characterized by patchy or diffuse eosinophilic infiltration of gastrointestinal tissue ₁ . The clinical features depend on location, depth and extent of bowel wall involved. Its presentation as acute abdomen is seldom ₂ . We report a case of eosinophillic enteritis with a clinical scenario of intestinal obstruction.

Case Report

A 37-year-old female presented with six months history of episodic attacks of sub-acute intestinal obstruction. She was managed conservatively with success. During the last month there was gradual aggravation of her symptoms till she presented with the clinical picture of acute intestinal obstruction. Examination revealed tachycardia and dehydration. The abdomen was distended and slightly tender with no guarding or rigidity. Her blood chemistry showed raised ESR levels and slight azotemia but no eosinophilia. Multiple air fluid levels and dilated small gut loops were seen on X- ray abdomen. (Fig-1)

Figure 1

Figure 1: X-ray of the abdomen showing multiple air fluid levels

The patient was resuscitated and prepared for exploratory laparatomy. A tight stricture was found in the terminal ileum with proximal dilatation. There was prominent mesenteric lymphadenopathy and mesenteric vasculature was extending to the anti-mesenteric border of the ileum giving per-operative suspicion of Crohn s disease. Resection of involved ileum and primary end-to-end anastomosis was carried out. (Fig-2)

Figure 2

Figure 2: Resected specimen of ileum showing stricture with proximal dilatation, prominent vascularity and mesenteric lymphadenopathy

The patient had satisfactory post-operative recovery and her symptoms disappeared. Histopathology of the resected specimen revealed eosinophilic enteritis with reactive mesenteric lymph-node hyperplasia. (Fig-3)

Figure 3

Figure 3: Histopathological picture of resected ileum confirming eosinophilic enteritis

Discussion

Eosinophilic enteritis is a rare clinico-pathological entity. It usually affects the gastric antrum and proximal small bowel but involvement of distal gut is rare; 85% of cases are associated with eosinophilia ₃ . Food allergy and variable IgE response has been observed in many patients harbouring this disease ₄ .

Eosinophil recruitment into inflammatory tissue is a complex process, regulated by IL-3, IL-5 and granulocyte macrophage colony stimulating factor (GM-CSF). In addition, eotaxins have an integral role in regulating the homing of eosinophils into the lamina propria ₅ .

It runs a chronic relapsing course in approximately 80% of patients and a high degree of clinical suspicion is required to establish the diagnosis of this rare pathology ₆ . Milder versions of the disease present as dull abdominal pain, anorexia, weight loss, protein losing enteropathy, chronic diarrhoea, or recurrent melaena. Acute presentation varies from acute intestinal obstruction to intestinal perforation. Malabsorptive syndrome, intestinal strictures or ascites depend on a mucosal, muscular or serosa layer infiltration, respectively ₇ .

Talley et al. ₈ suggested three diagnostic criteria including: the presence of gastrointestinal symptoms, histological demonstration of eosinophilic infiltration in the gastrointestinal tract and no evidence of parasitic or extraintestinal disease.

Peripheral blood eosinophilia is absent in 20% of patients. Elevated serum IgE levels suggest an allergic aetiology and associated malabsorption is detected by hypoalbuminaemia ₉ .

CT scan may show nodular and irregular thickening of forgut which also mimicks other conditions like Crohn's disease or lymphoma. The endoscopic appearance is nonspecific. Despite all diagnostic aids, histopathology is the gold standard. Microscopy reveals >20 eosinophils per high-power field. Infiltration is often patchy, can be missed and laparoscopic full-thickness biopsy may be required ₉ .

The role of steroids and anthelminthics is not well established; however, in few cases steroids have produced symptomatic improvement in controlling diarrhea and protein losing enteropathy. Rarely, acute obstructive presentation is dealt with laparotomy and segmental resection with anastomosis or stricturoplasty, as in our case. We did not use steroids and the patient is well after one year.

Eosinophilic enteritis is a diagnostic dilemma and clinical presentation and investigations are only contributory. Presentation with acute abdomen is even less common and surgeons should remain vigilant with this rare cause in mind.

Correspondence to

Dr. MALIK AMJAD YASIN MBBS, MCPS, FCPS. General Surgeon, Combined Military Hospital, Rawalpindi 4600, Pakistan. Tel. 92 -51- 9237283, 92-300-5365047 dramjadyasin@gmail.com dramjadyasin@hotmail.com