What is the management approach for eosinophilic colitis?

Management of Eosinophilic Colitis

The management of eosinophilic colitis (EC) should begin with corticosteroids as first-line therapy, followed by dietary elimination approaches in refractory cases, with biological therapies reserved for steroid-dependent or resistant disease. 1, 2, 3, 4

Diagnostic Approach

• EC is diagnosed by the presence of primary eosinophilic infiltrate in the colon wall in symptomatic patients
• Diagnostic criteria: >40 eosinophils per high-power field (×400) in at least two different colonic segments 4
• Rule out secondary causes of colonic eosinophilia:
  • Food allergens
  • Parasitic infections
  • Drug-induced allergic reactions
  • Inflammatory bowel disease
  • Connective tissue disorders

Treatment Algorithm

First-Line Treatment

1. Corticosteroids
   • Systemic corticosteroids (prednisone) for moderate to severe cases
   • Budesonide for milder cases
   • Demonstrated efficacy in the vast majority of cases 4

Second-Line Options

1. Dietary Therapy (if corticosteroid-dependent or allergic component suspected)

   • Elimination diets under supervision of an experienced dietitian
   • Options include:
     • Two-food elimination diet (milk +/- wheat or egg)
     • Four-food elimination diet (milk, wheat, egg, soya)
     • Six-food elimination diet (milk, wheat, egg, soya, fish/shellfish, tree nuts/peanuts)
   • Elemental diet reserved for refractory cases

2. Maintenance Medications

   • 5-Aminosalicylic acid compounds for mild persistent disease 5
   • Azathioprine for steroid-dependent cases 5

3. Adjunctive Therapies

   • Antihistamines (H1 blockers)
   • Leukotriene receptor antagonists (montelukast)

Refractory Disease

1. Biological Therapies
   • Consider novel biologics used in allergic conditions (e.g., dupilumab)
   • Limited evidence but may be considered in steroid-dependent or resistant cases 2

Monitoring and Follow-up

• Endoscopic and histological reassessment to evaluate treatment response
• If symptoms recur while on treatment, repeat endoscopy for assessment and to obtain further histology

Special Considerations

• Many cases (approximately 43%) may resolve spontaneously without treatment 5
• Mild cases with minimal symptoms may be observed without specific therapy
• Joint management by gastroenterologist and allergist for refractory cases or those with significant concomitant atopic disease

Pitfalls and Caveats

• Allergy testing has limited value in adults with EC and should not be used to determine dietary restrictions 4
• EC is a diagnosis of exclusion - thorough evaluation for secondary causes is essential
• Response to restrictive diets is less effective in adults than in children 4
• No consensus guidelines exist specifically for EC management, with most evidence drawn from case reports and small case series 1, 3
• Avoid immunomodulators, anti-TNF, and anti-integrin therapies as first-line treatments due to limited evidence of efficacy

The approach to EC management should be systematic, starting with corticosteroids and progressing to more targeted therapies based on response, with careful monitoring for disease activity through both symptom assessment and histological evaluation.