Horta, D

Lourenço, L

Reis, J

GE Portuguese Journal of Gastroenterology

Repositório do Hospital Prof. Doutor Fernando Fonseca

E-Mail karger@karger.com Images in Gastroenterology and Hepatology  GE Port J Gastroenterol 2017;24:206–208  DOI: 10.1159/000453363  Eosinophilic Ascites: Uncommon Presentation of Eosinophilic Gastroenteritis in a Young Adult Male  Luís Carvalho Lourenço    David Valadas Horta    Jorge Reis   Gastroenterology Department, Hospital Professor Doutor Fernando Fonseca,  Amadora , Portugal g/dL), erythrocyte sedimentation rate (1 mm), and liver enzymes were within normal ranges. Abdominal ultrasound confirmed moderate ascites, and com-puted tomography enterography ( fig. 1 ) showed diffuse thickening of the gastric and proximal small bowel wall (arrowheads) and peritoneal fluid (arrow). Ascitic fluid analysis after an abdominal tap revealed a serum-ascites albumin gradient <1.1 g/dL and sig-nificant eosinophilia ( fig. 2 , inset).  Esophagogastroduodenoscopy did not reveal significant endo-scopic findings; however, transendoscopic gastric biopsies showed marked eosinophilic infiltration (>25 eosinophils/high-power-field magnification) ( fig. 2 ). Esophageal biopsies did not show cri-teria for eosinophilic esophagitis. Imaging and pathology findings were, therefore, consistent with eosinophilic gastroenteritis (EGE). Differential diagnosis including food allergy, parasitic infec-tions, inflammatory bowel diseases, malignancy, and other eosino-philic disorders (such as Churg-Strauss syndrome and hypereo-sinophilic syndrome)  [1] were taken into account. Extensive inves-tigation (including allergen-specific serum IgE, skin-prick tests, stool examinations, colonoscopy with ileoscopy and biopsies, ab-dominal and thoracic CT-scan, peripheral blood smear, serum protein electrophoresis, electrocardiography, echocardiography and troponin levels, as well as consultations with hematology, im-muno-allergology and ear, nose and throat doctors) ruled out these conditions. Treatment with a course of oral prednisolone (40 mg/day for 7 days, then tapered by 5 mg/week) resulted in peripheral blood eo-sinophil count normalization within 24 h and symptom resolution after 4 days. Since the patient was an adult, no food allergy was  Keywords  Eosinophilic gastroenteritis · Ascites · Abdominal pain  Ascite Eosinofílica: Forma de Apresentação Incomum de Gastroenterite Eosinofílica num Adulto Jovem  Palavras Chave  Gastroenterite eosinofílica · Ascite · Dor abdominal  Case Report  A 27-year-old male presented with diffuse abdominal pain and distention for 2 weeks. His medical history was notable of atopic asthma, rhinitis, and dust mite allergy. He was medicated with in-haled fluticasone 100 μg (twice/day). He denied edema of the lips, tongue or palate, dysphagia, odynophagia, vomiting, diarrhea, or weight loss. There was no history of previously known food allergy, recent travelling abroad, or new medication.  His physical examination was significant for moderate ascites, and laboratory workup demonstrated leukocytosis (14,600/μL) with peripheral blood eosinophilia (4,100/μL) and elevated serum IgE (154 IU/mL). C-reactive protein was only slightly elevated (0.39 mg/dL). His values of hemoglobin (14.5 g/dL), albumin (3.9  Received: September 26, 2016  Accepted after revision: November 10, 2016  Published online: December 21, 2016  Luís Carvalho Lourenço  Gastroenterology Department  Hospital Professor Doutor Fernando Fonseca, E.P.E., IC 19  PT–2720-276 Amadora (Portugal)  E-Mail luisclourenco   @   gmail.com  © 2016 Sociedade Portuguesa de GastrenterologiaPublished by S. Karger AG, Basel  www.karger.com/pjg Th is article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes as well as any dis-tribution of modifi ed material requires written permission. Eosinophilic Ascites  GE Port J Gastroenterol 2017;24:206–208 DOI: 10.1159/000453363207found, and the criteria for eosinophilic esophagitis were not met. After a consultation with an immuno-allergology doctor, no di-etary restrictions were advised. The patient remains asymptom-atic after 2 years of follow-up. Discussion  EGE is a rare, chronic inflammatory disease character-ized by eosinophilic infiltration of the digestive tract. The etiology is unknown, but a personal or family history of food allergies and atopic disorders can be found in up to 50% of the cases  [1] .  The clinical features of EG vary depending on the loca-tion, extent, and depth of infiltration of the gastrointesti-nal wall. Eosinophilic ascites is an unusual form of pre-sentation of EGE  [2] . It is characteristic of the predomi-nantly subserosal pattern of the disease (the least common, followed by the intramural and the mucosal types) and is rare in young males  [3] . However, even in the predomi-nantly subserosal type, there is frequently significant mu-cosal and submucosal eosinophilic infiltration  [1] , which allows for the diagnosis to be obtained through transen-doscopic biopsies in most cases. The radiological appearance, the eosinophilic infil-trate, and frank improvement after steroid therapy con-firm the diagnosis.  The clinical course of EG is variable. Some patients have no recurrences, while others experience recurrent symptoms and require repeated or long courses of steroid therapy. In these patients, other therapies (mast cell in-hibitors, antihistamines, or leukotriene receptor antago-nists) may be considered  [4] . According to previous stud-ies, the predominantly serosal pattern of EG seems to have a good prognosis, with excellent response to steroids and presenting mainly with a single flare and no chronic course  [5] . Authors’ Contribution  L.C. Lourenço collected data and wrote the manuscript. D.V. Horta was responsible for the interpretation of data and manu-script editing. J. Reis was responsible for study supervision and manuscript reviewing. Statement of Ethics  Patient consent was obtained for the publication of the case details. Disclosure Statement  The authors have no conflicts of interest to disclose.  Fig. 1. Computed tomography enterography showing diffuse thickening of the gastric and proximal small bowel wall (arrow-heads) and ascites (arrow).  Fig. 2. Gastric biopsy specimen (hematoxylin and eosin, ×400) showing intense eosinophilic infiltration (>25 eosinophils/high-power-field magnification).  Inset Ascitic fluid analysis revealing significant eosinophilia (Wright-Giemsa stain, ×600).  Lourenço/Horta/Reis  GE Port J Gastroenterol 2017;24:206–208 DOI: 10.1159/000453363208 References  1 Talley NJ, Shorter RG, Phillips SF, et al: Eo-sinophilic gastroenteritis: a clinicopathologi-cal study of patients with disease of the mu-cosa, muscle layer, and subserosal tissues. Gut 1990; 31: 54–58.  2 Zhang MM, Li YQ: Eosinophilic gastroenteri-tis: A state-of-the-art review. J Gastroenterol Hepatol 2016, Epub ahead of print.  3 Durieu I, Nove-Josserand R, Cathebras P, Du-rand DV, Rousset H, Levrat R: Eosinophilic ascites. 2 new case reports (in French). Rev Med Interne 1992; 13: 446–448.  4 Straumann A: Idiopathic eosinophilic gastro-intestinal diseases in adults. Best Pract Res Clin Gastroenterol 2008; 22: 481–496.  5 Pineton de Chambrun G, Gonzalez F, Canva JY, et al: Natural history of eosinophilic gas-troenteritis. Clin Gastroenterol Hepatol 2011;  9: 950–956.  

Eosinophilic Ascites: Uncommon Presentation of Eosinophilic Gastroenteritis in a Young Adult Male.

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Eosinophilic Ascites: Uncommon Presentation of Eosinophilic Gastroenteritis in a Young Adult Male.

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