Gastric Outlet Obstruction due to Eosinophilic Gastroenteritis

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(1)대한외과학회지：제 75 권 부록 II Vol. 75, Suppl. II, December, 2008. □ 증 례 □. Gastric Outlet Obstruction due to Eosinophilic Gastroenteritis Division of Gastro-enterologic Surgery, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea. Ho Goon Kim, M.D., Mi Ran Jung, M.D., Hyo Kang, M.D., Oh Cheong, M.D., Jae Kyun Ju, M.D., Young Kyu Park, M.D., Seong Yeob Ryu, M.D., Dong Yi Kim, M.D., Young Jin, M.D., Shin Kon Kim, M.D. Despite of its rarity, eosinophilic gastroenteritis (EG) needs to be recognized by the clinician because this disease can masquerade as irritable bowel syndrome and it may be misdiagnosed in clinical practice. We report here on a female patient with gastric outlet obstruction that was due to EG, and we review the relevant literature for either an association or a causality of EG. (J Korean Surg Soc 2008;75:447-450) Key Words: Eosinophilic gastroenteritis, Obstruction obstruction of the upper gastrointestinal tract. She had no other specific disease history. On admission, she had a. INTRODUCTION. pulse of 88 beats/min, blood pressure of 120/80 mmHg, Eosinophilic gastroenteritis (EG) is a disease charac-. respiratory rate of 18/min. Laboratory studies revealed. terized by marked eosinophilic infiltration of the gast-. hemoglobin, 11.5 g/dl; hematocrit 34.7%; platelets 420,000/. rointestinal tract. The entire gastrointestinal tract from. mm3, serum albumin 3.0 g/dl; AST 35 U/L; ALT 40 U/L. esophagus to colon, including bile duct, can be af-. alkaline phosphatase 120 U/L. A peripheral eosinophilia. fected.(1-4) Kaijser first described three patients with EG. of 14% to 25% was noticed repeatedly, with the total. in 1937(5) and Klein classified this disease into three types:. eosinophilic count raging from 1,300 to 3,900/mm3.. mucosal, muscle layer, and subserosal disease.(6) The signs. (normal, 40∼400/mm3) with a normal white cell count of. and symptoms of EG are related to the layers and extent. 8,500/mm3. Serum immunoglobulin E (IgE) concentration. of bowel involved with eosinophilic infiltration. The pre-. was elevated (30 IU/ml; normal 1∼12 IU/ml). Upper. valence of each subtypsoe is unknown because of reporting. gastrointestinal endoscopy showed distal esophageal ery-. and referral biases. Surgical series report a predominance. thema and diffuse antral thickening with duodenal. of muscular disease with obstruction.(7) We describe a. narrowing (Fig. 1). A biopsy from the stomach showed. female patient with gastric outlet obstruction due to EG.. extensive eosinophilic infiltration of the antrum. Upper gastrointestinal series revealed marked gastric distension due to tapered narrowing of gastric antrum (Fig. 2). The. CASE REPORT. abdominal CT scan yielded normal findings. A 75-year female patient was admitted to our unit. She exhibited vomiting and abdominal pain for several. because of vomiting for 7 days. It was compatible with. days. The patient underwent a laparotomy with the following findings: an overdistended stomach with antral wall thickening and gastric outlet obstruction (Fig. 3).. Correspondence to: Dong Yi Kim, Division of Gastro-enterologic Surgery, Department of Surgery, Chonnam National University Medical School, 671, Jebong-ro, Dong-gu, Gwangju 501-757, Korea. Tel: 062-220-6456, Fax: 062-227-1635, E-mail: [email protected] Received March 18, 2008, Accepted May 28, 2008. Distal gastrectomy and gastrojejunostomy were performed. Histologic examination revealed mucosal ischemia, sub-. 447.

(2) 448 J Korean Surg Soc. Vol. 75, Suppl. II mucosal edema, and prominent eosinophilic infiltration of the mucosa, and submucosa (Fig. 4).. eosinophilia in approximately 50% of patients.(8) The cause of classical eosinophilic gastroenteritis is. The patient was discharged on postoperative day 15,. unknown, and its diagnosis relies upon gastrointestinal. without complications. At follow-up three months after the. symptoms combined with a marked eosinophilic infiltra-. initial diagnosis, she was clinically well.. tion of the gastrointestinal tract.(2,9,10) The entire gastrointestinal tract from esophagus to colon, including bile. DISCUSSION. duct, can be affected.(1-4) Peripheral eosinophilic counts are usually elevated, ranging between 5 and 35%, but are. Eosinophilic gastroenteritis (EG) is a disease charac-. normal in 20% of patients.(2) The signs and symptoms of. terized by marked eosinophilic infiltration of the gastroin-. EG are related to the layers and extent of bowel involved. testinal tract, an absence of vasculitis, and a peripheral. with eosinophilic infiltration. The gastric antrum is thought to be target organ in EG.(9) Its eosinophilic infiltration and. Fig. 1. Upper gastrointestinal endoscopy shows distal esophageal erythema and diffuse antral thickening with duodenal narrowing.. Fig. 2. Upper gastrointestinal series reveales marked gastric distension due to tapered narrowing of gastric antrum.. Fig. 3. A laparotomy with the following findings: an overdistended stomach with antral wall thickening and gastric outlet obstruction..

(3) Ho Goon Kim, et al：Gastric Outlet Obstruction due to Eosinophilic Gastroenteritis. 449. Fig. 4. Histologic examination reveales mucosal ischemia, submucosal edema, and prominent eosinophilic infiltration of the mucosa, and submucosa.. edema from accompanying inflammation can cause ob-. ful as well as modifiers of leucotriene (monteleucast),. structive symptoms. In our case, the gastric antrum was. stabilizers of mast cells (chromoglicate) and antagonist of. affected and resulted in obstructive symptoms.. 5-HT2 receptor (ketotiphene).(15,16) Surgical treatment is. Radiologic studies have been utilized in the diagnosis of. required for patients with symptoms of gastrointestinal. eosinophilic gastroenteritis but less useful than endoscopy. obstruction.(15,17) Eosinophilic gastroenteritis usually res-. and biopsy. Barium studies may suggest the diagnosis but. ponse to steroids, but there have been no controlled. are neither sensitve nor specific. They typically reveal thic-. trials.(13) The incidence of disease relapse after steroid. kening or nodularity in the antrum.(11) Tuncali et al.(12). tapering is unknown. Kalantar et al.(18) reported that. reported that most radiological techniques had low speci-. disease relapse occurred two out of six cases after steroid. ficities. Diagnosis in our case was made when endoscopic. tapering. Data on the natural history and therapy of. biopsy was obtained. The pathogenesis of eosinophilic. eosinophilic gastroenteritis are limited to case reports.. gastroenteritis is not well understood. Several epidemiolo-. Despite of its rarity, eosinophilic gastroenteritis (EG). gic and clinical features suggest an allergic component.. needs to be recognized by the clinician because this disease. About 50% of patients have allergic disease, such as food. can masquerade as the irritable bowel syndrome and may. sensitivities, asthma, or eczema.(2,13) Some patients have. be misdiagnosed in clinical practice. Early diagnosis is. elevated serum IgE levels and rare patients have IgE. important and upper gastrointestinal endoscopy and mul-. antibodies directed against specific food.(6,13,14) However,. tiple biopsy are recommended for diagnosis.. avoidance of inciting foods in those with an allergic food history has limited or no clinical benefit.(12) Thus, the role. REFERENCES. of allergy as a stimulus for the recruitment of eosinophils to the gastrointestinal tract remains controversial. There have been no prospective, randomized clinical trials regarding therapy. Thus, treatment is empiric. In some cases, the anti-inflammatory medicines were success-. 1) Redondo Cerezo E, Moreno Platero JJ, Garcia Dominguez E, Gonzalez Aranda Y, Cabello Tapia MJ, Martinez Tirado P, et al. Gastroenteritis eosinophilic presenting as colitis with acute abdomen. Gastroenterol Hepatol 2000;23:477-9. 2) Talley NJ, Shorter RG, Phillips SF. Eosinophilic gastroenteritis:.

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