What is the management of eosinophilic colitis?

Management of Eosinophilic Colitis

The management of eosinophilic colitis should follow a stepwise approach, starting with topical corticosteroids for at least 8-12 weeks before evaluating histological response, with dietary elimination therapy as an alternative or complementary approach under dietitian supervision. 1

Diagnostic Confirmation

• Diagnosis requires histological evidence of eosinophilic infiltration in the colon wall in symptomatic patients, with exclusion of secondary causes 2
• Threshold of >40 eosinophils per high-power field in at least two different colonic segments is suggested as diagnostic criteria 3
• Secondary causes that must be ruled out include:
  • Food allergies
  • Parasitic infections
  • Drug-induced reactions
  • Inflammatory bowel disease
  • Connective tissue disorders 4

First-Line Treatment Options

Pharmacological Therapy

• Corticosteroids are the mainstay of treatment with a recommended duration of at least 8-12 weeks 1
  • Prednisone is the most commonly used systemic steroid 5
  • Budesonide may be considered for its better safety profile in cases requiring prolonged treatment 3
• Proton pump inhibitors (PPIs) may be used as complementary therapy:
  • Recommended dose: omeprazole 20 mg twice daily for 8-12 weeks 1

Dietary Management

• Dietary elimination therapy should only be conducted under supervision of an experienced dietitian 6
• Recommended approach is a two-food elimination diet (TFED) stepping up to more restrictive diets if needed 6
  • Start with elimination of milk +/- wheat or egg for 8-12 weeks 6
  • If no response, proceed to four-food elimination diet (milk, wheat, egg, soya) 6
  • If still no response, consider six-food elimination diet (milk, wheat, egg, soya, fish/shellfish, tree nuts/peanuts) 6
• Endoscopic and histological assessment should be performed between 8-12 weeks after each dietary change 6

Treatment Monitoring and Follow-up

• Endoscopy with biopsy is recommended while on treatment to evaluate histological response 1
• Symptoms do not always correlate with histological activity, making histological assessment crucial 1
• If symptoms recur during treatment, repeat endoscopy for evaluation and obtain additional histology 1

Second-Line and Alternative Treatments

• For steroid-dependent or refractory cases, consider:
  • Leukotriene inhibitors 5, 4
  • Antihistamines and mast cell stabilizers 5, 4
  • Azathioprine as a steroid-sparing agent 5, 7
• Novel biologics used in other allergic conditions (dupilumab, cendakimab, benralizumab) show promise but evidence specific to eosinophilic colitis is limited 1
• Anti-TNF and anti-integrin monoclonal antibodies are not recommended as routine treatment 1

Special Considerations

• Refractory cases should be jointly managed by a gastroenterologist and allergist specialist 1
• The disease may be self-limiting in some patients, with spontaneous resolution occurring without treatment 7
• The psychological impact of dietary therapy should be discussed with patients 6
• Anxiety and depression related to persistent symptoms and social restrictions should be addressed 6

Prognosis

• Eosinophilic colitis often follows a chronic relapsing course requiring maintenance therapy 5
• Some cases (particularly in middle-aged adults) may be self-limiting with mild clinical course not requiring medication 7
• Long-term follow-up shows variable outcomes:
  • Spontaneous resolution without treatment in some patients
  • Mild persistent symptoms not requiring therapy in others
  • Need for ongoing medical treatment in a subset of patients 7