What is the recommended treatment for a patient with Eosinophilic gastroenteritis?

Treatment for Eosinophilic Gastroenteritis

Start with pharmacological monotherapy using corticosteroids for 8-12 weeks, as this is easier to implement than dietary restriction and provides effective symptom control and histological improvement. 1

First-Line Treatment Approach

Corticosteroids (Primary Recommendation)

Systemic corticosteroids are the most effective first-line treatment for eosinophilic gastroenteritis, with dramatic therapeutic efficacy in achieving both clinical and histological remission. 2, 3

• Dosing: Use 1-2 mg/kg/day of prednisone (maximum 60 mg daily) for patients requiring urgent symptom relief or those with severe symptoms including significant weight loss, dehydration, or obstruction 4
• Duration: Treat for at least 8-12 weeks before evaluating histological response with repeat endoscopy and biopsy 1
• Monitoring: Endoscopy with biopsy while on treatment is mandatory to assess response, as symptoms do not always correlate with histological activity 1, 4

Important caveat: While corticosteroids are highly effective, their use results in substantial toxicity with long-term use, including growth abnormalities, bone abnormalities, mood disturbances, and adrenal axis suppression 4, 2. This makes them ideal for induction but problematic for maintenance.

Proton Pump Inhibitors (Adjunctive Therapy)

• Consider omeprazole 20 mg twice daily for 8-12 weeks as complementary therapy 1
• PPIs may provide additional benefit, though evidence is primarily extrapolated from eosinophilic esophagitis data 5

Second-Line Treatment: Dietary Management

Dietary elimination should only be pursued under supervision of an experienced dietitian and is reserved for patients who fail pharmacotherapy or have identified food allergies as triggers. 1, 4

Dietary Approach Algorithm

• Initial elimination: Remove milk +/- wheat or egg for 8-12 weeks (two-food elimination diet) 1
• Escalation if needed: Progress to more restrictive diets (four-food or six-food elimination) based on response 5
• Assessment timing: Perform endoscopy with biopsy 8-12 weeks after each dietary change to evaluate effectiveness 1
• Reintroduction protocol: Systematically reintroduce eliminated foods one at a time while monitoring symptoms and eosinophil counts to identify causative foods 6, 7

Critical pitfall: Do NOT use allergy testing (skin prick, specific IgE, patch testing) to guide dietary elimination, as eosinophilic gastroenteritis is not an IgE-mediated disease and allergy-directed diets have the lowest histological remission rates 8

Practical Considerations for Dietary Therapy

• Requires motivation, multiple endoscopies, and access to a specialist dietitian 8
• Discuss psychological impact including anxiety, depression, and social restrictions 1, 4
• Particularly challenging in children and during transition from pediatric to adult care 8

Combination Therapy (Reserved for Treatment Failure)

Combining corticosteroids with elimination diets is NOT routinely recommended but can be considered in cases of monotherapy failure. 8

• Combination therapy showed 80% histological remission in pediatric studies versus 50% for steroids alone and 60% for diet alone 8
• In adults with prior monotherapy failure, combination therapy improved symptoms in 88% but did not significantly reduce eosinophil counts 8
• Requires access to a multiprofessional team including gastroenterologist, dietitian, and potentially allergist 8

Treatments NOT Recommended

• Immunomodulators and monoclonal antibody therapies (anti-TNF, anti-integrin): Not recommended as routine treatment 1, 4
• Omalizumab (anti-IgE): Showed no benefit in controlled trials 8
• Sodium cromoglycate, montelukast, antihistamines: Not recommended for eosinophilic gastroenteritis itself, though may have role in concomitant atopic disease 5

Emerging Therapies for Refractory Cases

• Novel biologics (dupilumab, cendakimab, benralizumab) show promise but have limited evidence specific to eosinophilic gastroenteritis 1
• Consider for patients refractory to standard therapies under joint management by gastroenterologist and allergist 1, 4

Surgical Intervention

Surgery should be avoided as far as possible and limited only to solving complications such as bowel obstruction or perforation. 9, 3

Follow-Up Protocol

• Repeat endoscopy with biopsy at 8-12 weeks after initiating treatment to confirm histological response 1, 4
• Target histological threshold: <15 eosinophils per high-power field (though some sources use >30 eosinophils per high-power field as diagnostic threshold) 5, 9
• If symptoms recur during treatment, repeat endoscopy immediately for evaluation 1, 4
• Do not rely on symptom improvement alone—always confirm histological response 5