Diagnosis of eosinophilic gastroenteritis is easily missed

AIM To analyze the clinical characteristics of eosinophilic gastroenteritis(EGE)and to investigate the situations of missed diagnosis of EGE.METHODS First,the clinical characteristics of 20 EGE patients who were treated at our hospital were retrospectively summarized.Second,159 patients who underwent gastroscopy and 211 patients who underwent colonoscopy were enrolled.The pathological diagnosis showed only chronic inflammation in their medical records.The biopsy slides of these patients were reevaluated to determine the number of infiltrating eosinophils in order to assess the probability of a missed diagnosis of EGE.Finally,122 patients who experienced refractory upper gastrointestinal symptoms for at least one month were recruited.At least 6biopsy specimens were obtained by gastroscopy,and the number of eosinophils that had infiltrated was evaluated.Those who met the pathological diagnostic criteria of EGE underwent further examination to confirm the diagnosis of EGE.The probability of a missed diagnosis of EGE was prospectively investigated.RESULTS Among the 20 patients with EGE,mucosal EGE was found in 15 patients,muscular EGE was found in 3patients and serosal EGE was found in 2 patients.Abdominal pain was the most common symptom.The number of peripheral blood eosinophils was elevated in all 20 patients,all of whom were sensitive to corticosteroids.Second,among the 159 patients who underwent gastroscopy,7(4.40%)patients met the criteria for pathological EGE(eosinophil count≥25/HPF).Among the 211 patients who underwent colonoscopy,9(4.27%)patients met the criteria for pathological EGE(eosinophil count≥30/HPF).No patients with eosinophil infiltration were diagnosed with EGE in clinical practice before or after endoscopy.Although these patients did not undergo further examination to exclude other diseases that can also lead to gastrointestinal eosinophil infiltration,these might be the cases where the diagnosis of EGE was missed.Finally,among the 122 patients with refractory upper gastrointestinal symptoms,eosinophil infiltration was seen in 7 patients(5.74%).The diagnosis of EGE was confirmed in all 7 patients after the exclusion of other diseases that can also lead to gastrointestinal eosinophil infiltration.A positive correlation was observed between the duration of the symptoms and the risk of EGE(r=0.18,P<0.01).The patients whose symptoms persisted longer than 6 mo more readily developed EGE.None of the patients were considered to have EGE by their physicians before endoscopy.CONCLUSION Although EGE is a rare inflammatory disorder,it is easily misdiagnosed.When a long history of abdominal symptoms fails to improve after conventional therapy,EGE should be considered.

Successful treatment of ileal ulcers caused by immunosuppressants in two organ transplant recipients

Although gastroduodenal ulcers are common in solid organ transplant patients, there are few reports on multiple giant ulcers in the distal ileum and ileocecal valve caused by immunosuppressants Herein, we report on a liver transplant recipient and a renal transplant recipient with multiple large ulcers in the distal ileum and ileocecal valve who rapidly achieved ulcer healing upon withdrawal of sirolimus or tacrolimus and administration of thalidomide. In case 1, a 56-yearold man with primary hepatocellular carcinoma had received a liver transplantation. Tacrolimus combined with sirolimus and prednisolone was used as the anti-rejection regimen. Colonoscopy was performed because of severe abdominal pain and diarrhea at postoperative month 10. Multiple giant ulcers were found at the ileocecal valve and distal ileum. The ulcers healed rapidly with withdrawal of sirolimus and treatment with thalidomide. There was no recurrence during 2 years of follow-up. In case 2, a 34-year-old man with end-stage kidney disease received kidney transplantation and was put on tacrolimus combined with mycophenolate mofetil and prednisolone as the anti-rejection regimen. Twelve weeks after the operation, the patient presented with hematochezia and severe anemia. Colonoscopy revealed multiple large ulcers in the ileocecal valve and distal ileum, with massive accumulation of fresh blood. The bleeding ceased after treatment with intravenous somatostatin and oral thalidomide. Tacrolimus was withdrawn at the same time. Colonoscopy at week 4 of follow-up revealed remarkable healing of the ulcers, and there was no recurrence of bleeding during 1 year of follow-up. No lymphoma, tuberculosis, or infection of cytomegalovirus, Epstein-Barr virus, or fungus wasfound in either patient. In post-transplantation cases with ulcers in the distal ileum and ileocecal valve, sirolimus or tacrolimus should be considered a possible risk factor, and withdrawing them or switching to another immunosuppressant might be effective to treat these ulcers.