Eosinophilic colitis: an infrequent disease with difficult diagnose
- Javier Páramo-Zunzunegui 1 , 2,
- Ignacio Ortega-Fernandez 2,
- Silvia Benito-Barbero 2 and
- Laura Rubio-López 2
- 1 Department of Surgery, Rey Juan Carlos University, Madrid, Spain
- 2 Department of General and Digestive Surgery, Hospital Universitario de Móstoles, Móstoles, Spain
- Correspondence to Dr Javier Páramo-Zunzunegui; javier.paramo@salud.madrid.org
Abstract
Eosinophilic colitis (EC) is a rare entity. It is part of eosinophilic gastroenteritis, a rare inflammatory disorder characterised by eosinophilic infiltration of tissues that can affect any segment of the digestive tract. The diagnosis is established by the presence of an increased eosinophilic infiltrate in the colon wall in symptomatic patients. There is no characteristic clinical picture of EC. It can be associated with abdominal pain, changes in bowel movements, diarrhoea and rectal bleeding. Biopsies are mandatory if EC is suspected and despite visualising a normal mucosa. Although there are no protocol guidelines in this regard, steroid treatment is the first option in controlling the disease. Increasing the knowledge of clinicians and pathologists of this disorder and the recording its real incidence and population impact, could improve the understanding and treatment of the disease.
Background
Eosinophilic colitis (EC) is a rare entity that infrequently macroscopically affects the mucosa and, therefore, can be underdiagnosed.1 Regarding a case diagnosed and treated in our centre, we carried out a review of the most important clinical aspects of the entity. Increasing the knowledge of clinicians and pathologists of this disorder and recording its real incidence and population impact, could improve the understanding and treatment of the disease.
Case presentation
We present the case of an 87-year-old woman with a history of high blood pressure, obesity and polyarthrosis who debuted with rectal bleeding for 1 week. The patient reports recurrent self-limited episodes of abdominal pain and diarrhoea in the past 2 years. The laboratory study indicated 10 279 c/µL (reference 4–11×103 c/µL), Eosinophil count was 950 c/µL (reference 0–800 c/µL). A colonoscopic study was indicated. There was no evidence of active intestinal bleeding in the moment of the exploration. We observed slight inflammatory changes: decreased haustration, vascular pattern and submucous nodules (figure 1). We did not find another reason for haematochezia (haemorrhoids, diverticulosis or angiodysplasia) in the endoscopic examination. The pathological study shows an increased chronic lymphoplasmocyte infiltrate in the lamina propria of the colon together with the presence of eosinophilic infiltrate, of greater intensity in the ascending colon and sigmoid colon, >40 eosinophils/HMF (figure 2).
Endoscopic visualisation of the colonic wall. Note the decrease in haustration and submucosa nodularity (arrows).
Colonic wall eosinophilic infiltrate in high-magnification field.
Differential diagnosis
The patient’s differential diagnosis, due to the disease presentation and time of evolution, included a colorectal neoplasia or diverticular disease. However, despite the advanced age, the possibility that it was an inflammatory bowel disease (Crohn’s disease or ulcerative colitis) was not initially ruled out.
Treatment
The evolution of the patient was favourable with the administration of a short cycle of prednisone, 30 mg a day for 1 month, followed by a taper daily dose by 5 mg weekly until 10 mg a day for the last week. The treatment was completed with sodium cromoglycate for 10 days and lansoprazole 30 mg a day for 3 months.
Outcome and follow-up
The patient did not relapse in the last year of follow-up.
Discussion
EC is a rare disease. It is part of eosinophilic gastroenteritis (EGE), a rare entity characterised by eosinophilic infiltration of tissues that can affect any segment of the digestive tract.1 A recent meta-analysis study describes a prevalence of EGE of 1.9% (95% CI 0.57 to 3.89; p<0.001) in patients with gastrointestinal symptoms.2 A prevalence of EC of 3.3 per 100 000 habitants has been estimated in another study.3 The major advances in the aetiopathogenic knowledge of the disease are due to the study of eosinophilic oesophagitis. Two genetic susceptibility loci which encode oesophageal barrier proteins (5q22 and 2p23) have been identified in this one. It is assumed that the rest of the entities may also be related to a genetic susceptibility.4 However, the pathogenesis of EC, and EGE, is complex and there seem to be many factors that play a role in eosinophilic activation and proliferation in tissues.5 The diagnosis is established by the presence of an increased eosinophilic infiltrate in the colon wall in symptomatic patients.6 The presence of eosinophils in the distal digestive tract is a normal finding and its increase can be associated with other entities such as parasitosis, inflammatory bowel disease, hypereosinophilic syndrome or food allergies.4 An attempt has been made to establish which eosinophilic infiltrate can be considered pathological. Despite the lack of an established consensus,7–9 some studies consider a normal eosinophilic infiltrate in the colon to be <40–50 eosinophils per high-magnification field.10 The eosinophilic infiltrate can be located in any layer of the colonic wall. Muscular layer infiltration is observed in the 30%–70% of cases, which may be the cause of parietal thickening and dysmotility.5 There is no characteristic clinical picture of EC. It can be associated with abdominal pain, changes in bowel movements, diarrhoea and rectal bleeding.11 12 Analytical study may reveal associated peripheral eosinophilia (>500 eosinophils/µL), although this finding is not constant.13 Endoscopic study is frequently associated with normal macroscopic findings. Therefore, taking biopsies is mandatory if EC is suspected and, despite visualising a normal mucosa.11
Although controversial, allergy evaluations are recommended in patients with an EC diagnosis.14 These include skin and serum antigen-specific IgE tests to identify concurrent hyprsensitivity against common food allergens (wheat, peanuts, soybeans, rice, shrimp milk, egg, etc) and aeroallergens (house dust, dust mite, plants, mould, etc).14 EC requires a strict treatment, similar to inflammatory bowel disease’s. Although there are no protocol guidelines in this regard, steroid therapy represents the first choice treatment for symptomatic control in acute phase. Symptoms generally improve within 3–4 weeks of corticosteroids therapy, including progressively decreasing doses. In severe or recurrent cases, it is necessary to indicate long courses of corticosteroids or immunomodulatory treatments.15–17
Learning points
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Eosinophilic colitis (EC) is a rare disease.
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EC can be associated with abdominal pain, changes in bowel movements, diarrhoea and rectal bleeding.
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Endoscopic study is frequently associated with normal macroscopic findings.
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The diagnosis of EC is established by the presence of an increased eosinophilic infiltrate in the colon wall in symptomatic patients.
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Pathological eosinophilic infiltrate in the colon is considered >40–50 eosinophils per high-magnification field.
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Multiple biopsies are mandatory if EC is suspected and, despite visualising a normal mucosa.
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Steroid therapy represents the first choice treatment.
Footnotes
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Contributors JP-Z: idea, writing and contributor who accepts full responsibility for the finished article. IO-F: writing; RL-L: identification and treatment of the patient; figures. SB-B: performed literature search.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.
References
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