What are the diagnostic criteria and recommended management for eosinophilic gastroenteritis?

Eosinophilic Gastroenteritis: Diagnostic Criteria and Management

Eosinophilic gastroenteritis requires endoscopic biopsies showing ≥30 eosinophils per high-power field (or ≥15 eosinophils/0.3 mm² for esophageal involvement) with corresponding gastrointestinal symptoms, after excluding secondary causes of eosinophilia, and corticosteroids remain the first-line treatment for achieving clinical remission. 1, 2

Diagnostic Criteria

Clinical Presentation

The symptoms vary by anatomical location and layer of involvement:

• Mucosal disease (most common): Abdominal pain (78.6%), nausea/vomiting (28.6%), diarrhea (25%), weight loss, and gastrointestinal bleeding 3, 2
• Muscular layer disease: Obstructive symptoms, gastric outlet obstruction 1, 2
• Subserosal disease: Abdominal bloating, ascites with dramatic steroid response 2

Laboratory Findings

• Peripheral eosinophilia: Present in 85.7% of cases, but absence does not exclude diagnosis 3, 2
• Elevated serum IgE: Found in 71.4% of patients 3
• History of atopy: Reported in 39-50% of patients 3, 4

Histological Criteria

The diagnostic threshold is >30 eosinophils per high-power field in at least five high-power fields, with signs of eosinophil degranulation extending to the muscularis mucosa or submucosa. 1

For eosinophilic esophagitis specifically (which may coexist), the threshold is ≥15 eosinophils/0.3 mm² 5

Endoscopic Approach

• Take at least 6 biopsies from different anatomical sites within affected areas 5
• Endoscopic findings are often non-specific but may include: small patchy mucosal erythema/erosions (75%), mucosal fold thickening (17.9%), submucosal nodules (21.4%), small ulcers (14.3%) 3, 4
• Critical pitfall: Endoscopic biopsies miss the diagnosis in approximately 12.5% of cases due to patchy disease distribution, so repeat endoscopy should be considered if clinical suspicion remains high 2

Exclusion of Secondary Causes

Before confirming eosinophilic gastroenteritis, exclude:

• Parasitic infections (particularly in travelers—obtain detailed travel history) 6
• Food allergies and celiac disease 5
• Medication-induced eosinophilia 6
• Inflammatory bowel disease 5

Management Algorithm

First-Line Treatment: Corticosteroids

Prednisolone 1-2 mg/kg/day (maximum 60 mg) is the most effective treatment, with clinical improvement typically within 7 days and histological improvement within 4 weeks. 7, 3

• Response rate: 89% of patients respond clinically to prednisolone 3, 4
• Treatment duration: Initial course of 3 weeks, then taper 8
• Relapse rate: 25-50% of patients relapse during tapering and require maintenance therapy 3, 4

Alternative and Adjunctive Therapies

Dietary elimination therapy can achieve remission in select patients:

• Six-food elimination diet results in higher histological remission rates but requires dietitian support throughout elimination and reintroduction 5
• Five of 8 patients (62.5%) achieved clinical resolution with dietary modification, loratadine, and proton pump inhibitors 3

Proton pump inhibitors should be considered as complementary therapy:

• Omeprazole 20 mg twice daily for 8-12 weeks 7
• May be particularly useful when gastroesophageal reflux disease coexists 5

Monitoring Response

Repeat endoscopy with biopsy at 8-12 weeks while on treatment is mandatory, as symptoms do not correlate reliably with histological activity. 5, 7

• Clinical symptoms may resolve while histological disease persists 7
• Remission is defined as <15 eosinophils/0.3 mm² for esophageal disease 5
• Regular clinic visits to assess compliance and adverse effects are essential 7

Refractory Cases

For patients who fail corticosteroids and dietary therapy:

• Joint management by gastroenterologist and allergist is recommended 7
• Novel biologics (dupilumab, benralizumab, mepolizumab) show promise in eosinophilic disorders 7
• Montelukast has shown benefit in isolated case reports 4

Critical Pitfalls to Avoid

• Do not rely on peripheral eosinophilia alone: 15% of patients with confirmed eosinophilic gastroenteritis have normal peripheral eosinophil counts 3, 2
• Do not accept negative initial biopsies in high-suspicion cases: Patchy distribution means multiple endoscopic examinations may be necessary 3, 2
• Do not stop treatment based on symptom resolution alone: Histological confirmation of remission is required to prevent complications 7
• Monitor for Candida esophagitis when using corticosteroids, which should be treated with topical antifungals while continuing steroids 7
• Consider subserosal disease in patients presenting with ascites and very high eosinophil counts, as these patients show dramatic steroid responses 2

Natural History and Long-Term Management

The disease follows three evolutionary patterns:

• Single outbreak with complete resolution
• Recurrent course requiring intermittent treatment
• Chronic disease requiring maintenance therapy 1

Maintenance corticosteroid therapy reduces recurrence risk in patients with relapsing disease, though optimal dosing and duration remain individualized based on response 5, 4