Eosinophilic gastroenteritis: symptoms, diagnosis and treatment

Eosinophils are a type of white blood cell involved in allergic reactions and in inflammation. In eosinophilic gastroenteritis (EGE) they collect in the wall of the stomach and bowel in numbers that are not normal, causing inflammation. NORD describes it as a rare digestive disease and notes that the eosinophilic infiltration may involve one or more layers of the gastrointestinal wall. A case report describes it as the association of non-specific gastrointestinal symptoms with a massive inflammatory infiltrate of eosinophils in one or more segments of the digestive tract.

It sits within a family of eosinophilic gastrointestinal diseases, which include eosinophilic oesophagitis, where the oesophagus alone is affected, and hypereosinophilic syndrome, where very high eosinophil counts affect many organs. A UK-specific patient leaflet on eosinophilic gastroenteritis was not available when this page was prepared, so the information draws on NORD and published case reports.

NORD lists difficulty swallowing (sometimes presenting as food getting stuck), heartburn, abdominal pain, nausea, vomiting, diarrhoea, weight loss and bloating, with the possibility of fluid in the abdomen (ascites). The particular symptoms depend on which layer and which location is involved.

NORD describes three patterns. Mucosal involvement leads to protein loss from the gut and malabsorption. Involvement of the muscle layer causes abdominal pain, vomiting, indigestion-type symptoms and bowel obstruction. Involvement of the outer layer predominantly causes ascites with marked eosinophilia, and sometimes fluid around the lungs.

NORD says the exact cause is unknown. Some cases may be caused by hypersensitivity to certain foods or other unknown allergens, a family history of allergy is often present and asthma, hay fever or eczema is present in a subset of patients. It affects both sexes, is slightly more common in men and has peak prevalence in children and adults aged 20 to 50. NORD adds that the reported prevalence has increased markedly, probably because of prior under-diagnosis.

A published case report notes that a history of allergy, although present in about half of cases, is not required for the diagnosis, and another case report describes diagnosis as based on endoscopy followed by examination of biopsies that show eosinophil infiltration in different layers of the gut.

NORD says some patients have raised IgE and eosinophils in both tissue and blood, and that a careful history may suggest to the physician that a biopsy is needed. The results of the biopsy, either endoscopic or full-thickness surgical, are usually diagnostic.

The case reports add that blood eosinophilia is present in about half of cases but is not necessary for diagnosis, and that other causes of eosinophils in the gut must be excluded, including parasitic infection, drug reactions, vasculitis and other conditions. NORD lists Crohn's disease, refractory coeliac disease, hypereosinophilic syndrome and other disorders among conditions with similar symptoms. In practice, that means endoscopy with multiple biopsies, blood tests and sometimes imaging, led by a gastroenterologist.

NORD says eliminating foods to which a person is allergic may prove helpful in some cases, and that the corticosteroid prednisone is usually an effective treatment. Sometimes budesonide can be helpful, immunosuppressive drugs such as azathioprine may be worth trying and surgery may be necessary in severe cases where there is an obstruction of the intestines. Other treatment is symptomatic and supportive.

A case report of two men describes corticosteroids being effective, with symptoms resolving and no relapse during a year of follow-up, while noting that recurrence is common after therapy and that low-dose maintenance prednisolone is used for relapsing disease, with montelukast and budesonide mentioned as alternatives in some patients. These are individual reports, and the right approach is decided by the treating gastroenterologist.

Persistent or worsening abdominal pain, repeated vomiting, unexplained weight loss, ongoing diarrhoea or abdominal swelling should be assessed by a GP. Severe pain, vomiting that does not stop, signs of bowel obstruction or being unable to keep fluids down need urgent assessment through NHS 111 or A&E. If you have already been diagnosed, your gastroenterology team will explain what to do in a flare.