Eosinophilic Gastroenteritis
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Direct answer
Eosinophilic gastroenteritis is an uncommon condition in which eosinophils infiltrate the gut wall, classified by the layer involved as mucosal, muscular or serosal. It causes pain, diarrhoea, weight loss and sometimes obstruction, and it is confirmed by eosinophil-rich biopsies after parasites and drugs are excluded. Corticosteroids, usually prednisolone, are the mainstay of treatment, with dietary elimination used in selected patients.
What you must remember
- Mucosal pattern: the commonest form, with diarrhoea, protein-losing enteropathy and malabsorption, often with peripheral eosinophilia.
- Muscular pattern: eosinophilic infiltration of the muscularis propria, causing colicky pain, thickened bowel wall and obstruction.
- Serosal pattern: eosinophilic involvement of the serosa and peritoneum, producing eosinophilic ascites and abdominal discomfort.
- Patchy disease: because involvement is uneven, several biopsies from different sites are needed, and a single superficial sample can miss the diagnosis.
- Exclusions: helminths, notably Strongyloides, and drug reactions must be excluded before the diagnosis is accepted.
- Atopy: asthma, allergic rhinitis, eczema and food allergy are common, and IgE is often raised.
- Steroids: prednisolone induces remission, and the taper is slow because relapse is common.
- Surgery: strictures or perforation need surgical management alongside medical therapy.
Three patterns of eosinophilic gastroenteritis
The layer involved determines the clinical picture, the imaging and the urgency of treatment. Patients often present with postprandial pain and weight loss, and a marked eosinophilia on the blood count is the clue that prompts endoscopy. The table summarises the three patterns, which overlap in many patients.
| Pattern | Layer involved | Main features | Clue on evaluation |
|---|---|---|---|
| Mucosal | Mucosa and submucosa | Diarrhoea, protein loss, malabsorption | Commonest, eosinophils on mucosal biopsy |
| Muscular | Muscularis propria | Colicky pain, obstruction | Thickened wall on CT, deeper sampling may be needed |
| Serosal | Serosa and peritoneum | Ascites, abdominal pain | Eosinophil-rich ascitic fluid |
Recognising the layer tells the clinician whether to expect obstruction or ascites, which changes how quickly treatment is escalated. Many patients have features of more than one pattern, so the whole gut should be considered rather than one segment.
Endoscopy with multiple biopsies remains the central investigation, and the report should state the depth of tissue examined. Serosal involvement should prompt a diagnostic paracentesis, because eosinophil-rich ascitic fluid can point to the diagnosis when mucosal biopsies are unhelpful.
Where the exam tries to catch you
The diagnosis is easy to mislabel, and the steroid course is easy to stop too early.
- Trap: confirming the diagnosis from one superficial mucosal biopsy Correct: the disease is patchy, so multiple sites and deeper layers may be needed.
- Trap: labelling every eosinophilia as gastroenteritis Correct: parasitic infection, drugs and malignancy must be excluded first.
- Trap: stopping steroids as soon as symptoms settle Correct: steroids are tapered slowly, because relapse is common when treatment is withdrawn early.
- Trap: treating a stricture or perforation with steroids alone Correct: those complications need surgical management in addition to medical therapy.
Frequently asked questions
What are the three layer-based patterns of eosinophilic gastroenteritis?
The three patterns are mucosal, muscular and serosal, named by the layer of the gut wall infiltrated by eosinophils. The mucosal pattern is the commonest, and the serosal pattern is associated with eosinophilic ascites.
Which investigations exclude parasitic causes of intestinal eosinophilia?
Stool microscopy for ova and parasites and specific testing for Strongyloides stercoralis exclude parasitic causes of intestinal eosinophilia. These tests should be negative before eosinophilic gastroenteritis is diagnosed.
Why is prednisolone the mainstay of treatment in eosinophilic gastroenteritis?
Prednisolone suppresses eosinophilic inflammation and induces remission in most patients with eosinophilic gastroenteritis. It is tapered slowly, because relapse is common when the dose falls quickly.
When is dietary elimination used in eosinophilic gastroenteritis?
Dietary elimination is used in selected patients with identified food triggers, usually when steroids cause unacceptable adverse effects or relapse. It is an adjunct to steroid therapy rather than a replacement for it.
Why does eosinophilic gastroenteritis often coexist with atopy?
Eosinophilic gastroenteritis is a type of allergic inflammation, so it often occurs alongside asthma, allergic rhinitis, eczema or food allergy. Raised IgE and a personal or family history of atopy support the diagnosis.