What is the management approach for eosinophilic colitis?

Management of Eosinophilic Colitis

Eosinophilic colitis (EC) should be treated with corticosteroids as first-line therapy, with budesonide showing efficacy in the vast majority of cases. 1

Diagnostic Approach

Eosinophilic colitis is a rare inflammatory condition characterized by abnormal eosinophilic infiltration of the colonic wall in symptomatic patients. Before initiating treatment, a proper diagnosis must be established:

• Endoscopy with biopsy is essential for diagnosis
• Histological criterion: >40 eosinophils per high-power field (×400) in at least two different colonic segments 1
• EC is a diagnosis of exclusion - rule out secondary causes:
  • Food allergens
  • Parasitic infections
  • Drug-induced allergic reactions
  • Inflammatory bowel disease
  • Connective tissue disorders 2, 3

Treatment Algorithm

First-Line Therapy

1. Corticosteroids

   • Systemic corticosteroids (prednisone) for moderate to severe cases
   • Budesonide has demonstrated efficacy in most cases 1

2. Dietary Therapy (particularly in cases with suspected allergic component)

   • Consider elimination diet under dietitian supervision
   • Note: Less effective in adults than in children 1

Second-Line Options

1. 5-Aminosalicylic acid (5-ASA) compounds 4

2. Immunomodulators

   • Azathioprine for maintenance therapy in steroid-dependent cases 4

3. Antihistamines and Leukotriene Inhibitors

   • May be used as steroid-sparing agents 2

4. Biologics

   • Consider in refractory cases 2

Monitoring and Follow-up

• Repeat endoscopy with biopsy to assess treatment response
• Monitor for symptom resolution (abdominal pain, diarrhea)
• Assess for potential complications

Clinical Course and Prognosis

EC is often a self-limiting disease in adults, with many patients experiencing spontaneous resolution without treatment 4:

• In a population-based study, 3 out of 7 patients had spontaneous resolution
• 2 patients continued with mild symptoms not requiring therapy
• Only 2 patients required medical treatment 4

Special Considerations

• Allergic component: In cases with suspected allergic etiology, consider:

  • Allergy testing (though limited value in adults)
  • Consultation with allergist
  • Elimination diets under dietitian supervision 1

• Refractory disease: For patients not responding to standard therapy:

  • Consider combination therapy
  • Evaluate for missed secondary causes
  • Consider biologics 2

• Maintenance therapy: May be required in a minority of patients with chronic or relapsing disease 4

Pitfalls to Avoid

• Failure to exclude secondary causes of eosinophilic infiltration
• Over-treating self-limiting cases
• Inadequate follow-up to assess treatment response
• Neglecting nutritional status in patients on long-term elimination diets

While EC shares some similarities with eosinophilic esophagitis, management approaches differ, and treatment guidelines specific to EC are less established due to its rarity and limited research evidence.