What are the signs and symptoms of eosinophilic gastritis and esophagitis?

Signs and Symptoms of Eosinophilic Gastritis and Esophagitis

Eosinophilic Esophagitis (EoE)

The clinical presentation of eosinophilic esophagitis varies substantially by age, with adolescents and adults primarily experiencing dysphagia and food impaction, while children present with less specific symptoms including feeding problems, vomiting, and failure to thrive. 1

Adults and Adolescents

• Dysphagia (difficulty swallowing) is the predominant symptom 1
• Food impaction requiring emergency intervention 1
• Retrosternal burning sensation (heartburn-like symptoms) 2
• Chronic reflux symptoms that may not respond to acid suppression 2
• Nausea and vomiting 2

Children

• Feeding problems and food refusal 1
• Failure to thrive 1
• Vomiting 1
• Heartburn 1
• Abdominal pain or epigastric discomfort 1
• Nausea 1

Endoscopic Findings

• Rings (corrugated or trachealized esophagus) 1
• Linear furrows (vertical lines in the esophageal mucosa) 1
• White plaques or exudates 1
• Edema or decreased vascularity 1
• Strictures or luminal narrowing 1
• Crepe-paper mucosa (fragile mucosa that tears easily) 1

Associated Features

• 50-80% of patients have concurrent atopic conditions including allergic rhinitis, asthma, eczema, or food allergies 3
• More common in white males 1
• Peripheral eosinophilia is present in only 10-50% of adults and 20-100% of children, and is usually modest (2-fold elevation) 3

Eosinophilic Gastritis (EoG) and Gastroenteritis (EGE)

Eosinophilic gastritis and gastroenteritis present with non-specific gastrointestinal symptoms that vary based on the layer of the GI tract involved (mucosal, muscular, or subserosal), making diagnosis challenging without a high index of suspicion. 4, 5

General Symptoms

• Abdominal pain (most common presenting symptom) 4, 5
• Nausea and vomiting 4, 5
• Diarrhea 4, 5
• Weight loss 4, 5
• Early satiety 4
• Bloating 4

Symptoms by Layer of Involvement

Mucosal Type (Most Common):

• Melena (black, tarry stools) 6
• Hematochezia (bloody stools) 6
• Protein-losing enteropathy 4
• Malabsorption 4
• Iron deficiency anemia 4

Muscular Type:

• Obstructive symptoms 4
• Gastric outlet obstruction 4
• Intestinal obstruction 4

Subserosal Type:

• Ascites (fluid accumulation in the abdomen) 4, 6
• Eosinophilic ascitic fluid 4

Laboratory and Endoscopic Features

• Peripheral eosinophilia is present in approximately 77% of cases 4, 6
• Endoscopy may appear completely normal in up to one-third of patients 4
• When abnormal, findings include mucosal erythema, nodularity, erosions, or ulcerations 4, 5
• Multiple GI sites are frequently involved simultaneously 6

Associated Features

• History of atopy or food allergies in many patients 4, 7
• More common in young men 6
• Can involve stomach alone, small intestine alone, or multiple sites 5, 7

Critical Diagnostic Distinctions

A key pitfall is that endoscopic appearance alone cannot distinguish between these conditions and other causes of esophageal or gastric inflammation—histologic confirmation with biopsies is mandatory. 1, 4

When to Suspect Systemic Disease

• Peripheral eosinophilia >1,500 cells/μL suggests hypereosinophilic syndrome (HES) rather than isolated EoE, as peripheral eosinophilia is rare in isolated EoE 1, 3
• Screen for multi-organ involvement (skin, lung, heart, neurologic) if hypereosinophilia is present 1
• Consider eosinophilic granulomatosis with polyangiitis (EGPA) if there is a history of asthma, allergic rhinitis, and systemic vasculitis 1

Differential Considerations

• Rule out GERD, which affects 10-20% of the population and can coexist with EoE 1, 8
• Exclude Crohn's disease, which can cause esophageal eosinophilia with granulomatous inflammation 1, 8
• Consider drug-induced esophagitis (NSAIDs, bisphosphonates, tetracyclines) 8
• Exclude infectious causes, particularly Candida esophagitis in immunocompromised patients 8, 9
• Rule out parasitic infections as a cause of eosinophilia 3