What are the causes and treatment options for pancreatitis in patients with a history of basophilia and eosinophilia?

Causes of Pancreatitis with History of Basophilia and Eosinophilia

Eosinophilic gastroenteritis with pancreatic involvement is the most likely cause of pancreatitis in patients with basophilia and eosinophilia, requiring corticosteroid therapy as first-line treatment.

Eosinophilic Disorders as Causes of Pancreatitis

• Eosinophilic gastroenteritis (EGE) is a rare disorder characterized by eosinophilic infiltration of the gastrointestinal tract that can extend to the pancreas, causing eosinophilic pancreatitis 1, 2
• EGE typically presents with abdominal pain, nausea, vomiting, and diarrhea, and can be complicated by acute pancreatitis when there is duodenal involvement causing pancreatic duct obstruction 3
• Hypereosinophilic syndrome, a systemic condition with persistent eosinophilia affecting multiple organs, can also involve the pancreas and cause pancreatitis 1
• Basophilia often accompanies eosinophilia in these conditions, particularly in allergic disorders, as both cell types are involved in type 2 immune responses 4

Diagnostic Considerations

• Peripheral blood eosinophilia (>500 eosinophils/mm³) is present in approximately 17.2% of patients with chronic pancreatitis, suggesting an immunologic component to some cases 5
• Endoscopic evaluation with biopsy is essential for diagnosis, looking for eosinophilic infiltration (≥15 eosinophils per high-power field) in the gastrointestinal tract, particularly the stomach and duodenum 4
• Imaging findings may include duodenal thickening, pancreatic changes, and ascites, which can mimic pancreatic neoplasms 1, 3
• Secondary causes that must be ruled out include:
  • Drug-induced pancreatitis (various medications can cause both pancreatitis and eosinophilia) 6
  • Parasitic infections (which can cause both eosinophilia and pancreatitis)
  • Other autoimmune disorders affecting the pancreas 4

Treatment Approach

• Systemic corticosteroids are the first-line treatment for eosinophilic pancreatitis, with prednisone 1-2 mg/kg/day (maximum 60 mg) recommended for severe cases 7
• Clinical symptoms typically improve within 7 days of starting corticosteroid therapy, with histological improvement within 4 weeks 7
• The duration of treatment should be at least 8-12 weeks before evaluating the histological response 8, 7
• Proton pump inhibitors (PPIs) may be used as complementary therapy, with omeprazole 20 mg twice daily for 8-12 weeks recommended 8

Dietary Management

• Dietary elimination therapy should be considered when food allergies are identified as triggers 8, 7
• A dietitian's support is crucial during the process of elimination and reintroduction of foods 8
• The initial approach typically involves eliminating common allergens such as milk, wheat, or eggs for 8-12 weeks, with subsequent adjustments based on response 8

Treatment for Refractory Cases

• For patients with refractory disease, joint management by a gastroenterologist and an allergist specialist is recommended 8, 7
• Novel biologics used in other allergic conditions, such as dupilumab, cendakimab, and benralizumab, have shown promising results in eosinophilic disorders 8
• Immunomodulators, anti-TNF, and anti-integrin therapies are not recommended as routine treatment for eosinophilic disorders 8, 7

Monitoring and Follow-up

• Endoscopy with biopsy is recommended while the patient is on treatment to evaluate the histological response, as symptoms do not always correlate with histological activity 8, 7
• If symptoms recur during treatment, endoscopy should be repeated for evaluation 8, 7
• Patients should be monitored for potential complications of corticosteroid therapy, including Candida infections, which should be managed with topical antifungals while continuing steroids 7