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

Signs and Symptoms of Eosinophilic Esophagitis and Gastroenteritis

Eosinophilic Esophagitis

In adults, dysphagia and food bolus obstruction are the hallmark presenting symptoms of eosinophilic esophagitis, occurring in 29-100% and 25-100% of cases respectively. 1

Adult Presentation

• Dysphagia to solid foods is the predominant symptom, often intermittent and progressive 1, 2
• Food impaction occurs in 33-54% of adults and may be the acute manifestation of chronic dysphagia; EoE accounts for approximately 50% of all esophageal food impaction cases 1, 2
• GERD-like symptoms (heartburn, regurgitation) occur in 7-100% of adults, though these are typically unresponsive or only partially responsive to acid suppression therapy 1
• Chest pain presents in 1-58% of adults 1
• Abdominal pain occurs in 3-25% of adults 1
• Weight loss and diarrhea are reported in some patients 1
• Insidious compensatory behaviors develop over time, including food avoidance (particularly bread and meat), excessive chewing, and drinking large volumes of water with meals, which often delays diagnosis 1, 2

Pediatric Presentation (Age-Dependent)

Symptoms in children are non-specific and vary dramatically by age, making symptom-based diagnosis alone not feasible. 1, 2

Infants and Toddlers (Under 6 Years)

• Feeding difficulties and feeding refusal (median age 2.8 years) 1, 2
• Failure to thrive (5-19% of cases) 1, 2
• Vomiting (median age 5.1 years; range 8-100% across studies) 1
• Diarrhea (median age 6-7 years; range 1-24%) 1

School-Age Children (6-12 Years)

• Abdominal pain becomes more prominent (median age 9.0 years; range 5-68% across studies) 1
• Vomiting remains common 1
• GERD-like symptoms (heartburn, regurgitation) occur in 5-82% of children 1

Adolescents (Over 12 Years)

• Dysphagia becomes the predominant symptom (median age 11.1 years; range 16-100%), mirroring the adult pattern 1, 2
• Food impaction increases with age (median age 12 years; range 10-50%) 1
• Chest pain occurs in 17-20% 1

Critical Diagnostic Considerations for EoE

• Symptoms are typically unresponsive or only partially responsive to proton pump inhibitors when EoE is the primary diagnosis 1
• Many adults have long-standing symptoms with diagnosis delayed an average of 4.6 years (range 0-17 years) 1
• Atopic history is common, as EoE occurs predominantly in atopic males 2
• Up to 15% of all patients presenting with dysphagia to endoscopy units have EoE 2

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Eosinophilic Gastroenteritis

Eosinophilic gastroenteritis presents with vague, nonspecific gastrointestinal symptoms including abdominal pain, nausea, vomiting, and diarrhea, often accompanied by peripheral eosinophilia. 3, 4, 5

Core Symptoms

• Abdominal pain (crampy or epigastric) is the most common presenting symptom 3, 6, 4, 5, 7
• Nausea and vomiting (including postprandial vomiting and cyclical vomiting patterns) 3, 6, 4, 5, 7
• Diarrhea (including watery diarrhea) 3, 4, 5
• Weight loss is frequently reported 3, 6, 4, 5

Additional Manifestations

• Malabsorption 3, 4
• Ascites 3, 4
• Gastrointestinal bleeding 4, 5
• Dysphagia 6, 7
• Anorexia and bloating 6
• Ankle edema 6
• Melena 6
• Extreme weakness and cachexia in severe cases 6

Symptom Patterns Based on Layer Involvement

The clinical presentation depends on which layers of the gastrointestinal wall are involved 4, 7:

• Mucosal involvement: Abdominal pain, nausea, vomiting, diarrhea, malabsorption, protein-losing enteropathy 4
• Muscular involvement: Obstructive symptoms, gastric outlet obstruction 4, 7
• Serosal involvement: Ascites, peritoneal eosinophilia 3, 4

Associated Features

• Peripheral blood eosinophilia is typically present but may be absent in patients on concurrent corticosteroid treatment 3, 7
• Prior history of atopy or allergic diseases is common 5, 7
• Biliary tract involvement (cholecystitis, cholangitis with recurrent cholestasis) is rare but reported 7
• Acute pancreatitis can occur as an unusual concurrent manifestation 3

Natural History Patterns

Three distinct evolutionary patterns exist 4:

• Single outbreak with resolution
• Recurrent course with episodic symptoms
• Chronic persistent disease

Common Pitfall

The gastrointestinal involvement is patchy in distribution, so multiple endoscopic examinations with biopsies from different sites may be necessary to establish the diagnosis 7. Full-thickness biopsy (surgical or CT-guided) may be required when muscular or serosal involvement is suspected 7.