Approach Considerations
Most patients with eosinophilic gastroenteritis respond to conservative measures, empiric dietary elimination of six foods or an elemental diet, and oral glucocorticosteroids. [11] Patients can be monitored every 6 months. Biologic therapy with humanized IL-5 treatment has been associated with a reduced eosinophil count but not with improved clinical symptoms. [15] Treatment with omalizumab has shown a reduction in eosinophil count as well as clinical improvement of symptoms; however, the results were not clinically significant. [16] A 2016 case report showed treatment with clarithromycin resulted in both improvement in clinical symptoms and a decrease in eosinophil count. [17]
Avoid surgery if at all possible, unless it is necessary to relieve persistent pyloric or small bowel obstruction. Reoccurrence is possible, even after surgical excision. [18]
Consultations
Refer patients with persistent abdominal symptoms and peripheral eosinophilia to a gastroenterologist for workup, endoscopy, and biopsies.
Refer patients to an allergy/immunology specialist for food skin testing and evaluation of eosinophilia and high IgE levels.
Medical Care
Elimination of foods implicated by skin testing has variable effects, but resolution of symptoms can sometimes be achieved with amino acid based elemental diets. Supportive treatment with pharmacotherapy, mainly oral glucocorticosteroids, (20-40 mg per day) followed by a rapid taper, is indicated for those with obstructive symptoms.
Patients with mucosal layer involvement may benefit from anti-inflammatory medications (eg, oral glucocorticoids, oral cromolyn) and/or diet elimination therapy, particularly if they report a history of food intolerance or allergy.
Drugs, such as montelukast, ketotifen, suplatast tosilate, and mycophenolate mofetil (inosine monophosphate dehydrogenase inhibitor), and alternative Chinese medicines have been advocated but are generally not successful.
Dietary considerations
Educate patients to avoid foods that they cannot tolerate and to seek medical care when needed. Initially, a trial elimination diet that excludes milk, eggs, wheat and/or gluten, soy, and beef may be helpful. RAST or skin testing can identify food hypersensitivity. If a prohibitive number of food reactions are found, an amino–acid-based diet or elemental diet may be considered.
Diet
The strong association of eosinophilic gastroenteritis with food allergies has prompted the use of restrictive or elemental diets. [11] However, there is a lack of good, high-quality clinical data regarding the efficacy of dietary interventions. [19]
On the basis of the available studies, an attempt may be made with an empiric elimination of six foods, including milk, soy, wheat, egg, peanuts/tree nuts, and fish/shellfish.
The American Partnership For Eosinophilic Disorders (APFED) provides educational resources and support for patients and caregivers. For additional patient education resources, see Digestive Disorders Center, as well as Gastroenteritis.
The absolute eosinophil count can be checked 4-6 weeks after implementation of empiric dietary treatment. A reduction of 50% in the peripheral eosinophil count can be considered a response to treatment. Although food hypersensitivity plays a role in eosinophilic gastroenteritis pathophysiology, no food allergy test has been shown to effectively identify specific culprit foods leading to clinical improvement in these patients’ symptoms.
Long-Term Monitoring
No official guidelines for long-term follow-up exist in patients with eosinophilic gastroenteritis (EGE) because the disease evolution is so variable. Patients may present with a single outbreak, intermittent flares, and/or prolonged a protracted disease course. Yearly follow-up may be of benefit. The American Partnership For Eosinophilic Disorders (APFED) established an online patient database registry that may have the potential to provide more insights to the disease course.
Endoscopy and radiologic findings in EGE may reveal a normal appearance. These may be used for follow-up on a case-by-case basis.
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Biopsy specimen of eosinophilic gastroenteritis.
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Biopsy specimen of eosinophilic gastroenteritis.
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Biopsy specimen of eosinophilic gastroenteritis.
