What is the management approach for eosinophilic gastritis?

Management of Eosinophilic Gastritis

Corticosteroids are the mainstay of treatment for eosinophilic gastritis, with prednisone being first-line therapy for symptomatic patients, while dietary elimination under dietitian supervision serves as an alternative or adjunctive approach. 1, 2, 3

Diagnostic Confirmation Required Before Treatment

Before initiating therapy, confirm the diagnosis by meeting three essential criteria: 1

• Clinical symptoms (abdominal pain, nausea, vomiting, diarrhea, weight loss, or anemia depending on affected GI layer) 1, 2
• Histologic evidence of eosinophilic infiltration (>20 eosinophils per high-power field in gastric/duodenal biopsies) 2, 3
• Exclusion of other causes including parasitic infections, drug reactions, inflammatory bowel disease, connective tissue disorders, and malignancy 1, 2

Obtain at least 5-6 random biopsies from each site (stomach and duodenum) since endoscopic appearance may be normal in up to 30% of cases. 3

First-Line Pharmacological Treatment

Corticosteroids remain the definitive first-line therapy: 1, 2, 3

• Prednisone 20-40 mg/day for initial treatment 1, 4
• Treatment duration of 8-12 weeks before evaluating histological response 5
• Expect clinical improvement within 2 weeks and histological remission within 2 months 4
• Corticosteroids are highly effective with rapid symptom resolution in most patients 2, 3

For mild-to-moderate disease, consider budesonide as an alternative with better safety profile for long-term use, though evidence is limited to case series. 1

Dietary Management

Dietary elimination therapy should be conducted under supervision of an experienced dietitian: 5, 6

• Identify and eliminate specific food allergens if IgE testing or clinical history suggests food hypersensitivity 1, 2
• Many patients have elevated serum IgE levels and allergies to multiple foods 4
• Two-food elimination diet (milk and wheat/egg) is a practical starting approach for 8-12 weeks 5
• Elemental diets are highly effective but impractical for most patients 6
• Risk of nutritional deficiencies requires dietitian monitoring 6

Disease Course and Maintenance Therapy

Spontaneous remission occurs in 30-40% of cases, but most patients require ongoing treatment: 2, 3

• Some patients experience no recurrences after initial treatment 2
• Others have relapsing disease requiring maintenance therapy 1, 3
• For relapsing disease, prolonged steroid use carries significant adverse effects, necessitating steroid-sparing strategies 1

Steroid-Sparing and Alternative Agents

When long-term corticosteroids are needed or contraindicated, consider: 1, 3

• Leukotriene receptor antagonists (montelukast) 1, 3
• Mast cell stabilizers (cromolyn sodium) 1, 3
• Antihistamines as adjunctive therapy 1, 3, 4
• Azathioprine for steroid-sparing maintenance 1
• Proton pump inhibitors (omeprazole 20 mg twice daily for 8-12 weeks) may provide complementary benefit 5

These agents are supported only by case reports and small case series, not randomized trials. 1

Refractory Disease Management

For steroid-refractory or severe cases: 3, 4

• Increase prednisone dose to 40 mg/day if initial response inadequate 4
• Consider biological agents including anti-IL-4, anti-IL-5, anti-TNFα, anti-integrin α4β7, and anti-IgE monoclonal antibodies 3
• Joint management by gastroenterologist and allergist specialist is recommended for optimization 5, 6
• Novel agents like AK002 (anti-siglec antibody) show promise in clinical trials 3

Monitoring and Follow-Up

Endoscopy with biopsy is required to evaluate treatment response: 5, 6

• Perform repeat endoscopy at 8-12 weeks after treatment initiation 5
• Symptoms do not reliably correlate with histological activity 5, 6
• If symptoms recur during treatment, repeat endoscopy immediately 5
• Monitor for candida infection in patients on topical steroids (though this applies more to esophageal disease) 6

Important Caveats

The psychological burden of dietary restrictions is significant and should be discussed with patients, including risks of social isolation, anxiety, and depression related to persistent symptoms and food limitations. 7, 6 This is particularly important in children and adolescents where quality of life impacts are substantial. 7

Unlike eosinophilic esophagitis, standardized diagnostic criteria and treatment algorithms for eosinophilic gastritis are lacking, making management more challenging and requiring individualized clinical judgment based on disease severity and distribution. 3