What is the management approach for eosinophilic gastroenteritis?

Management of Eosinophilic Gastroenteritis

The management of eosinophilic gastroenteritis (EGE) should begin with systemic corticosteroids as first-line therapy, followed by a step-up approach to dietary interventions and other pharmacological options for refractory cases. 1

Diagnostic Confirmation

Before initiating treatment, confirm diagnosis with:

• Presence of gastrointestinal symptoms
• Dense eosinophilic infiltration on GI biopsies (>30 eosinophils/high power field)
• Exclusion of other causes of gastrointestinal eosinophilia

First-Line Treatment Options

Pharmacological Management

1. Corticosteroids

   • Systemic corticosteroids (prednisolone) are the mainstay of treatment 1, 2
   • Dosing: Typically prednisolone 20-40mg daily for 2-4 weeks, then taper
   • Efficacy: 89% of patients respond clinically to prednisolone 3
   • Caution: 50% of patients may relapse following steroid tapering 3

2. Proton Pump Inhibitors (PPIs)

   • Recommended as adjunctive therapy 1
   • Dosing: Omeprazole 20mg twice daily for at least 8-12 weeks
   • Assessment: Repeat endoscopy with biopsies while still on treatment to evaluate response

Second-Line and Refractory Disease Management

Dietary Interventions

For patients who fail or cannot tolerate corticosteroids, or as adjunctive therapy:

1. Elimination Diet Approach 4, 1

   • Should be conducted under supervision of an experienced dietitian
   • Step-up approach:
     • Start with 2-food elimination diet (typically milk +/- wheat or egg) for 8-12 weeks
     • If no response, progress to 4-food elimination (milk, wheat, egg, soy) for 8-12 weeks
     • If still no response, progress to 6-food elimination diet (milk, wheat, egg, soy, fish/shellfish, tree nuts/peanuts) for 8-12 weeks
   • Assess response with repeat endoscopy and biopsies after each dietary phase
   • Reintroduce foods one at a time with 8-12 week intervals and repeat endoscopy

2. Elemental Diet

   • Consider for severe refractory cases 1
   • High efficacy but poor compliance due to palatability issues

Alternative Pharmacological Options

For steroid-dependent or refractory cases:

1. Leukotriene Receptor Antagonists

   • Montelukast can be effective as a steroid-sparing agent 5, 3
   • Particularly useful for maintaining remission after steroid induction

2. Biologic Therapies (for refractory cases)

   • Vedolizumab (anti-integrin α4β7): Showed clinical and histological improvement in 3/4 steroid-refractory patients 2
   • Other biologics under investigation: anti-IL-4, anti-IL-5, anti-TNFα, and anti-IgE antibodies 6

3. Topical Steroids

   • Non-enteric-coated budesonide may be considered for localized disease 7

Treatment Assessment and Follow-up

• Repeat endoscopy with biopsies is essential to assess treatment response 1
• Perform while still on treatment (typically at 8-12 weeks)
• If symptoms recur, repeat endoscopy to guide treatment adjustments

Special Considerations

• Maintenance Therapy: Consider for patients with frequent relapses
• Multidisciplinary Management: Refractory cases should be jointly managed by gastroenterologists and allergists 1
• Psychological Impact: The psychological impact of dietary therapy should be discussed with patients 4

Common Pitfalls and Caveats

1. Diagnostic Challenges:

   • EGE can mimic common GI disorders like IBS, dyspepsia, or even appendicitis
   • Endoscopic findings are often non-specific
   • Multiple biopsies from different GI segments are necessary (at least 5-6 random biopsies from each site)

2. Treatment Monitoring:

   • Clinical improvement alone is insufficient to assess response
   • Histological assessment is the best criterion for response

3. Relapse Management:

   • Up to 50% of patients may relapse after steroid tapering
   • Long-term low-dose maintenance therapy may be required
   • Consider steroid-sparing agents for maintenance (montelukast, immunomodulators)

By following this structured approach to management, most patients with EGE can achieve clinical and histological remission, though ongoing monitoring and treatment adjustments may be necessary for this chronic condition.