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Eosinophilic Gastroenteritis Workup

  • Author: MyNgoc T Nguyen, MD; Chief Editor: Julian Katz, MD  more...
Updated: Dec 29, 2015

Approach Considerations

The evaluation starts with a comprehensive history and physical examination. The diagnosis of eosinophilic gastrointestinal conditions, including eosinophilic gastroenteritis, is one of exclusion and requires the presence of gastrointestinal symptoms, the presence of gastrointestinal eosinophilia on biopsy specimens, and the exclusion of other known causes of tissue eosinophilia.[1, 10]


Laboratory Studies

General workup includes a complete blood cell (CBC) count and differential. Peripheral blood eosinophilia is found in 20-80% of cases. The average count is 2000 eosinophils (eos)/µL in patients with mucosal layer involvement, 1000 eos/µL in patients with muscular layer involvement, and 8000 eos/µL in patients with serosal involvement.

Mean corpuscular volume measurements may reveal iron-deficiency anemia, and serum albumin levels may be low, especially in patients with mucosal layer involvement.

Also note the following:

  • Although usually unnecessary, fecal protein loss can be measured by measuring alpha1-antitrypsin in a 24-hour feces collection. This test is used to identify the inability to digest and absorb proteins in the GI tract. The normal value is 0-54 mg/dL. Patients with eosinophilic gastroenteritis have elevated alpha1-antitrypsin in their feces. Obtain a stool sample (minimum 2-g portion), and keep it refrigerated.
  • Protein loss also can result in a low level of quantitative immunoglobulins.
  • The erythrocyte sedimentation rate (ESR) and serum IgE level can be elevated.
  • Obtain 3 separate stool specimens to rule out parasitic infection. Perform a wet mount or stain smear.
  • Mild-to-moderate steatorrhea is present in approximately 30% of patients. This can be measured by qualitative and quantitative stool tests.
  • Skin prick tests to inhalant allergens and food help identify sensitization to specific allergens.
  • The diagnosis of eosinophilic gastroenteritis depends on microscopic evaluations of endoscopic biopsy specimens. Examine specimens from each intestinal segment with particular attention to the following: (1) eosinophil quantification; (2) the location of eosinophils especially if present in the intraepithelial, superficial mucosal, and intestinal crypts; (3) the presence of extracellular eosinophilic granules; (4) associated pathologic abnormalities; and (5) the absence of other primary disorders (ie, vasculitis).

Imaging Studies


Radiographically, eosinophilic gastroenteritis does not have a pathognomic appearance. Radiographic changes are variable, nonspecific, and/or absent in at least 40% of patients.

  • Gastric folds can be enlarged, with or without nodular filling defects.
  • Valvular conniventes may be thickened and flattened. Strictures, ulceration, or polypoid lesions may occur.
  • In eosinophilic gastroenteritis involving the muscle layer, localized involvement of the antrum and pylorus may occur, causing narrowing of the distal antrum and gastric retention. The small intestine also may be dilated, with an increase in the thickness of the folds. Prominent mucosal folds also may be observed in the colon.
  • Rarely, diffuse esophageal narrowing or achalasialike motor abnormalities may occur.

Ultrasonography and computed tomography (CT) scanning

Abdominal ultrasonographic imagesy and CT scans may show thickened intestinal walls and, sometimes, localized lymphadenopathy.[11]  Ascitic fluid usually is detected in patients with serosal layer involvement.



Endoscopy and biopsy

Note the following:

  • When eosinophilic gastroenteritis is suspected, obtain biopsy samples from the gastric antrum and duodenum.[12, 13] It is not recommended that biopsy samples be placed in Bouin preservative, as this can cause difficulty in identifying eosinophils.[13]
  • Because of possible sampling error, when performing endoscopy, obtain at least 6 biopsy specimens from normal and abnormal areas of the bowel.
  • Grossly prominent mucosal folds, hyperemia, ulceration, or nodularity may be apparent.
  • In patients with esophageal or colonic symptoms, obtain additional biopsy specimens from the relevant sites to aid in the diagnosis. Gastroesophageal reflux can cause tissue eosinophilia in the distal esophagus. See the images below.
    Biopsy specimen of eosinophilic gastroenteritis. Biopsy specimen of eosinophilic gastroenteritis.
    Biopsy specimen of eosinophilic gastroenteritis. Biopsy specimen of eosinophilic gastroenteritis.


Patients with serosal disease present with ascites. Abdominal paracentesis demonstrates a sterile fluid with a high eosinophil count. Pleural effusion also may be present. Laparoscopy may show hyperemia and/or nodularity of the GI wall.


Exploratory laparotomy may be indicated, especially in patients with serosal eosinophilic gastroenteritis.


Histologic Findings

Histopathology usually demonstrates increased numbers of eosinophils (often >50 eos per high-power field) in the lamina propria. Large numbers of eosinophils often are present in the muscularis and serosal layers. The localized eosinophilic infiltrates may cause crypt hyperplasia, epithelial cell necrosis, and villous atrophy. The gross appearance of eosinophilic gastroenteritis upon endoscopy shows erythematous, friable, nodular, and, often, ulcerated mucosa. Diffuse enteritis with complete loss of villi, submucosal edema, infiltration of the GI wall, and fibrosis may be apparent. Mast cell infiltrates and hyperplastic mesenteric lymph nodes infiltrated with eosinophils may be present. Because of errors in sampling or to mucosal sparing, 10% of mucosal biopsies are not helpful to establish a diagnosis.

Histologic analysis of the small intestine reveals increased deposition of extracellular major basic proteins (MBPs) and eosinophilic cationic proteins (ECPs).

Contributor Information and Disclosures

MyNgoc T Nguyen, MD Clinical Associate Professor, Department of Pediatrics, University of California, San Francisco, School of Medicine

MyNgoc T Nguyen, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology

Disclosure: Nothing to disclose.


Jean-Luc Szpakowski, MD 

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Ronnie Fass, MD, FACP, FACG Chief of Gastroenterology, Head of Neuroenteric Clinical Research Group, Southern Arizona Veterans Affairs Health Care System; Professor of Medicine, Division of Gastroenterology, University of Arizona School of Medicine

Ronnie Fass, MD, FACP, FACG is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Neurogastroenterology and Motility Society, American Society for Gastrointestinal Endoscopy, Israeli Medical Association

Disclosure: Received grant/research funds from Takeda Pharmaceuticals for conducting research; Received consulting fee from Takeda Pharmaceuticals for consulting; Received honoraria from Takeda Pharmaceuticals for speaking and teaching; Received consulting fee from Vecta for consulting; Received consulting fee from XenoPort for consulting; Received honoraria from Eisai for speaking and teaching; Received grant/research funds from Wyeth Pharmaceuticals for conducting research; Received grant/research funds f.


Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

  1. Uppal V, Kreiger P, Kutsch E. Eosinophilic gastroenteritis and colitis: a comprehensive review. Clin Rev Allergy Immunol. 2015 Jun 9. [Medline].

  2. Mehta P, Furuta GT. Eosinophils in gastrointestinal disorders: eosinophilic gastrointestinal diseases, celiac disease, inflammatory bowel diseases, and parasitic infections. Immunol Allergy Clin North Am. 2015 Aug. 35 (3):413-37. [Medline].

  3. Ito J, Fujiwara T, Kojima R, Nomura I. Racial differences in eosinophilic gastrointestinal disorders among Caucasian and Asian. Allergol Int. 2015 Jul. 64 (3):253-9. [Medline].

  4. Kim NI, Jo YJ, Song MH, et al. Clinical features of eosinophilic gastroenteritis [in Korean]. Korean J Gastroenterol. 2004 Oct. 44(4):217-23. [Medline].

  5. Chen MJ, Chu CH, Lin SC, et al. Eosinophilic gastroenteritis: clinical experience with 15 patients. World J Gastroenterol. 2003 Dec. 9(12):2813-6. [Medline].

  6. Venkataraman S, Ramakrishna BS, Mathan M, et al. Eosinophilic gastroenteritis--an Indian experience. Indian J Gastroenterol. 1998 Oct-Dec. 17(4):148-9. [Medline].

  7. Tien FM, Wu JF, Jeng YM, Hsu HY, Ni YH, Chang MH, et al. Clinical features and treatment responses of children with eosinophilic gastroenteritis. Pediatr Neonatol. 2011 Oct. 52(5):272-8. [Medline].

  8. Zhang L, Duan L, Ding S, Lu J, Jin Z, Cui R, et al. Eosinophilic gastroenteritis: clinical manifestations and morphological characteristics, a retrospective study of 42 patients. Scand J Gastroenterol. 2011 Sep. 46(9):1074-80. [Medline].

  9. Lecouffe-Desprets M, Groh M, Bour B, Le Jeunne C, Puechal X. Eosinophilic gastrointestinal disorders associated with autoimmune connective tissue disease. Joint Bone Spine. 2015 Dec 18. [Medline].

  10. Cianferoni A, Spergel JM. Eosinophilic esophagitis and gastroenteritis. Curr Allergy Asthma Rep. 2015 Sep. 15 (9):58. [Medline].

  11. Savino A, Salvatore R, Cafarotti A, Cecamore C, De Sanctis S, Angelucci D, et al. Role Of Ultrasonography in the Diagnosis and Follow-Up of Pediatric Eosinophilic Gastroenteritis: a Case Report and Review of the Literature. Ultraschall Med. 2011 Dec 9. [Medline].

  12. [Guideline] Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011 Jul. 128(1):3-20.e6; quiz 21-2. [Medline].

  13. [Guideline] Sharaf RN, Shergill AK, Odze RD, Krinsky ML, Fukami N, Jain R, et al. Endoscopic mucosal tissue sampling. Gastrointest Endosc. 2013 Aug. 78(2):216-24. [Medline]. [Full Text].

  14. Lucendo AJ, Serrano-Montalban B, Arias A, Redondo O, Tenias JM. Efficacy of dietary treatment for inducing disease remission in eosinophilic gastroenteritis. J Pediatr Gastroenterol Nutr. 2015 Jul. 61 (1):56-64. [Medline].

  15. Prussin C. Eosinophilic gastroenteritis and related eosinophilic disorders. Gastroenterol Clin North Am. 2014 Jun. 43 (2):317-27. [Medline].

  16. Elliott JA, McCormack O, Tchrakian N, et al. Eosinophilic ascites with marked peripheral eosinophilia: a diagnostic challenge. Eur J Gastroenterol Hepatol. 2014 Apr. 26 (4):478-84. [Medline].

  17. Gupta N, Aggarwal A, Gupta R, Sule S, Wolf DC. The management of eosinophilic gastroenteritis. Scand J Gastroenterol. 2015. 50 (11):1309-14. [Medline].

Biopsy specimen of eosinophilic gastroenteritis.
Biopsy specimen of eosinophilic gastroenteritis.
Biopsy specimen of eosinophilic gastroenteritis.
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