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Abstract:
We describe a case of eosinophilic gastritis (EG) presenting as pyloric stenosis. A 62 year woman presented with vomiting and weight loss. Upper endoscopy revealed pyloric stenosis. Biopsies revealed severe chronic antral gastritis with eosinophilia. EUS showed pyloric wall thickening to 7mm with loss of five layer echopattern. Patient was treated with slow steroid taper with improvement. Her prior episodes of EG were treated with 4-6 weeks of steroids, but had symptom recurrence. She declined surgical full thickness biopsy, so EUS was a less invasive method compared to surgery for evaluating disease extent. The findings provided useful information and guided management.
Key words:
Endoscopic ultrasound (EUS), eosinophilic gastritis, pyloric stenosis
Introduction:
Eosinophilic gastritis may be difficult to diagnose since the exact disease mechanism is not clearly understood.1 The diagnosis of eosinophilic gastritis is based on clinical history and biopsy findings of increased eosinophils, after exclusion of other etiologies of eosinophilic disorders.2, 3 We describe a case of eosinophilic gastritis presenting as pyloric stenosis. Endoscopic ultrasound (EUS) was used to aid in assessing the extent of disease infiltration and guiding further management.
Case report:
A 62-year-old woman presented with vomiting solids and liquids immediately after eating. She reported a 40 pound weight loss. Her only medication was sertraline. Physical exam was unremarkable. Laboratory tests including a CBC with differential, electrolytes, liver panel, IgE were normal; stool studies revealed no ova or parasites. Upper endoscopy revealed pyloric stenosis (Figure 1) and a TTS balloon dilation to 10mm for 60 seconds was done with some heme in the pyloric area post dilation. Biopsies revealed severe chronic antral gastritis with eosinophilia without Helicobacter pylori. No eosinophils were noted on small bowel or esophageal biopsies. Her symptoms persisted despite multiple pyloric dilations; therefore treatment with 4-6 weeks of tapering doses of oral steroids was started. Initially she responded to the treatment, but had recurrence of symptoms once steroids were tapered.
Patient declined surgical full thickness biopsy to evaluate extent of disease but agreed to EUS. A 2.4 mm 12 MegaHertz EUS miniprobe was passed through the channel of an upper endoscope and was inserted into the stenotic pyloric channel for high frequency ultrasound imaging. No dilation of the pylorus was performed immediately prior to the EUS so that dilation would not affect EUS findings. EUS demonstrated hypoechoic pyloric wall thickening to 7mm with loss of layer echopattern as well as loss of definition of the muscularis propria(the muscularis propria was distinctly visible only in 1/4th of the circumference of the pylorus) that would be consistent with full thickness involvement of the pylorus with eosinophilic gastritis (Figure 2). The wall of the body and antrum appeared normal with an intact layer pattern. Based on the EUS findings, patient was treated with a slow but longer steroid taper (over 6 months instead of over 4-6 weeks) with gradual but persistent improvement in symptoms.
Discussion:
Eosinophilic gastrointestinal diseases include a spectrum of illnesses including
esophagitis, gastritis, gastroenteritis, enteritis and colitis. The presentation can vary based on location of symptoms. Eosinophilic gastritis is even more complex to diagnose due to the presence of baseline eosinophils. Eosinophilic gastritis can involve the mucosa, muscularis or serosa. Patients with mucosal involvement can present with vomiting, pain, anemia, and malabsorption symptoms. Infiltration of eosinophils into the muscularis can cause wall thickening, resembling pyloric stenosis. Serosal involvement presents with ascites.1 Eosinophilic gastritis is generally treated with a short course of steroids.4 Our patient's prior episodes of pyloric stenosis had been treated with 4-6 weeks of steroids. She presented with recurrence of symptoms; therefore we wanted to assess extent of eosinophilic involvement. Since she declined surgical full thickness biopsy, EUS in our patient served as a less invasive method compared to surgery for evaluating the extent of disease infiltration. The findings provided us useful information regarding disease extent, guiding further management. There may be a role for EUS in eosinophilic gastrointestinal
disorders for evaluating the extent of disease.5 As illustrated in the above case, EUS may be a less invasive alternative to full thickness surgical biopsy in patients with difficult to manage eosionophilic gastrointestinal disorders.
References
1. Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). J Allergy Clin Immunol 2004;113:11-28; quiz 29.
2. Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH. Eosinophilic gastroenteritis. Medicine (Baltimore) 1970;49:299-319.
3. Talley NJ, Shorter RG, Phillips SF, Zinsmeister AR. Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues. Gut 1990;31:54-8.
4. Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS, et al. Eosinophilic gastroenteritis: 10 years experience. Am J Gastroenterol 1993;88:70-4.
5. Andriulli A, Recchia S, Valente G, Pera A, Verme G. Endoscopic ultrasonography in eosinophilic infiltration of gastric wall. Ital J Gastroenterol 1990;22:129-32.
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