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Eosinophilic ascites: A diagnostic and therapeutic challenge

View Article: PubMed Central - PubMed

ABSTRACT

Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites.

No MeSH data available.


Findings on contrast-enhanced abdominal computed tomography. A: Sagittal section demonstrates thickened loops of small bowel (arrow); B: Coronal image demonstrates free peritoneal fluid (arrow), thickened loops of small bowel and circumferential mural thickening of the distal stomach (heavy arrow).
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Figure 1: Findings on contrast-enhanced abdominal computed tomography. A: Sagittal section demonstrates thickened loops of small bowel (arrow); B: Coronal image demonstrates free peritoneal fluid (arrow), thickened loops of small bowel and circumferential mural thickening of the distal stomach (heavy arrow).

Mentions: A 35-year-old female presented to the clinic with complaints of abdominal distension and an episode of self-limiting diarrhea three weeks ago. She admitted to the recent use of green tea and increased consumption of nuts in her diet. Past medical history was remarkable for recurrent allergic bronchitis. On examination there was no evidence of pallor, icterus or peripheral edema and abdominal examination revealed moderate distention with a doughy consistency. Abdominal ultrasonography demonstrated moderate ascites with no signs of portal hypertension, liver or renal disease. Contrast-enhanced abdominal computed tomography confirmed the presence of free peritoneal fluid, diffuse circumferential thickening of small bowel loops, distal stomach and esophagus (Figure 1). Laboratory examination revealed peripheral eosinophilic leukocytosis with 52% eosinophils (total leukocyte count 22900 cells/mm3) and no immature myeloid precursors. The C-reactive protein, erythrocyte sedimentation rate and IgE levels were within normal limits. Tumor marker CA-125 was normal. Skin prick test results for food allergens and stool examination for bacteria, ova and parasites were negative. Diagnostic paracentesis was moderately cellular with 100% eosinophils, negative for malignant cells and sterile (Figure 2). Upper endoscopy and colonoscopy demonstrated mild erythema of the gastric antrum with an unremarkable esophagus, duodenum, colon and terminal ileum. Histology revealed a mild inflammatory infiltrate in the lamina propria of the gastric antrum and duodenum comprising of lymphocytes, plasma cells and scattered eosinophils (Figure 3). Echocardiographic findings were normal. Bone marrow aspiration and biopsy showed hypercellularity with a marked increase in mature eosinophils without blasts. The findings confirmed a diagnosis of subserosal EGE.


Eosinophilic ascites: A diagnostic and therapeutic challenge
Findings on contrast-enhanced abdominal computed tomography. A: Sagittal section demonstrates thickened loops of small bowel (arrow); B: Coronal image demonstrates free peritoneal fluid (arrow), thickened loops of small bowel and circumferential mural thickening of the distal stomach (heavy arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5037340&req=5

Figure 1: Findings on contrast-enhanced abdominal computed tomography. A: Sagittal section demonstrates thickened loops of small bowel (arrow); B: Coronal image demonstrates free peritoneal fluid (arrow), thickened loops of small bowel and circumferential mural thickening of the distal stomach (heavy arrow).
Mentions: A 35-year-old female presented to the clinic with complaints of abdominal distension and an episode of self-limiting diarrhea three weeks ago. She admitted to the recent use of green tea and increased consumption of nuts in her diet. Past medical history was remarkable for recurrent allergic bronchitis. On examination there was no evidence of pallor, icterus or peripheral edema and abdominal examination revealed moderate distention with a doughy consistency. Abdominal ultrasonography demonstrated moderate ascites with no signs of portal hypertension, liver or renal disease. Contrast-enhanced abdominal computed tomography confirmed the presence of free peritoneal fluid, diffuse circumferential thickening of small bowel loops, distal stomach and esophagus (Figure 1). Laboratory examination revealed peripheral eosinophilic leukocytosis with 52% eosinophils (total leukocyte count 22900 cells/mm3) and no immature myeloid precursors. The C-reactive protein, erythrocyte sedimentation rate and IgE levels were within normal limits. Tumor marker CA-125 was normal. Skin prick test results for food allergens and stool examination for bacteria, ova and parasites were negative. Diagnostic paracentesis was moderately cellular with 100% eosinophils, negative for malignant cells and sterile (Figure 2). Upper endoscopy and colonoscopy demonstrated mild erythema of the gastric antrum with an unremarkable esophagus, duodenum, colon and terminal ileum. Histology revealed a mild inflammatory infiltrate in the lamina propria of the gastric antrum and duodenum comprising of lymphocytes, plasma cells and scattered eosinophils (Figure 3). Echocardiographic findings were normal. Bone marrow aspiration and biopsy showed hypercellularity with a marked increase in mature eosinophils without blasts. The findings confirmed a diagnosis of subserosal EGE.

View Article: PubMed Central - PubMed

ABSTRACT

Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites.

No MeSH data available.