Saeed Graham, MD, Muhammad Farooq, MD
East Carolina University Brody School of Medicine, Greenville, NC

Introduction: Eosinophilic enteritis (EE) is a rare subtype of eosinophilic gastrointestinal disease characterized by eosinophilic infiltration of the small intestinal wall in the absence of secondary cause. The disease is further classified by depth of involvement: mucosal, muscular and subserosal, each with unique phenotype. Of these, subserosal is the rarest and eosinophilic ascites is regarded as the idiosyncratic feature of this pattern. We report a patient presenting with gastrointestinal symptoms and eosinophil rich ascitic fluid. Prior similar flare and robust steroid response supported a diagnosis of EE.

Case Description/Methods: A 23-year-old Asian male presented with 1-week history of nausea, vomiting and abdominal distension. 5 years ago, he had similar symptoms. Imaging was notable for ascites and thickening of esophagus and jejunum. Abdominal fluid analysis revealed eosinophilic ascites. After exclusion of other causes of eosinophilia, he underwent bi-directional endoscopy. Mucosa was normal in appearance and only esophageal biopsies were notable for eosinophilic infiltration. A presumptive diagnosis of EE was made and symptoms resolved rapidly with prednisone. On current admission serology was notable for 32% eosinophils; other lab parameters were within normal limits. Imaging again noted ascites and small bowel thickening (fig 1). Ascitic fluid was noted to comprise of 76% eosinophils after paracentesis. Alternate causes of eosinophilia were again excluded and symptoms resolved within 2 days after initiation of prednisone.

Discussion:

EE is classified by layer of gut wall involvement. Mucosal causes diarrhea, pain and malabsorption; muscular predisposes to obstruction and subserosal tends towards ascites. The subserosal variant is rarest and endoscopic biopsy is commonly non-diagnostic due to remoteness of the serosa from the lumen. In most cases, laparoscopic full-thickness biopsy is necessary for histological confirmation. Evaluation must also exclude alternate causes of eosinophilia such as parasitic infections, adrenal dysfunction etc. Despite negative biopsy, the presence of peripheral eosinophilia, eosinophilic ascitic fluid and quick resolution of symptoms with prednisone, strongly supported a diagnosis of EE in this patient. Support for the use of glucocorticoids, the mainstay of therapy, is gleaned from small sample case studies, underscoring the necessity of supplemental research in this area. A combination of peripheral and ascitic eosinophilia should prompt consideration of EE.

Figure: Fig 1: Coronal section abdominal computerized tomography showing abdominal and pelvic ascites in addition to small intestinal wall thickening

Disclosures:

Saeed Graham indicated no relevant financial relationships.

Muhammad Farooq indicated no relevant financial relationships.

Saeed Graham, MD, Muhammad Farooq, MD. B0647 - Eosinophilic Enteritis: An Uncommon Cause of Ascites, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.