Eosinophilic gastrointestinal disorder is a rare disorder characterised by eosinophilic infiltration of the gastrointestinal tract. There are various gastrointestinal manifestations with eosinophilic ascites being the most unusual and rare presentation. Diagnosis requires high index of suspicion and exclusion of various disorders associated with peripheral eosinophilia. There are no previous case reports to suggest an association between eosinophilic gastrointestinal disorder and coeliac disease in adults. We report a case of eosinophilic ascites and gastroenteritis in a 30-year-old woman with a known history of coeliac disease who responded dramatically to a course of steroids.
Eosinophilic gastrointestinal disorder is an unusual inflammatory gastrointestinal disease characterized by eosinophilic gut infiltration [
A 30-year-old Caucasian female presented with a two-week history of central abdominal pain and distension, vomiting, and increased frequency of bowel motion. There had been no weight loss or history of foreign travel. She was known to have coeliac disease diagnosed at age two. She was compliant to gluten-free diet. There was no history of drug allergy, asthma or skin eczema. Abdominal examination showed sign of ascites. There were no stigmata of chronic liver disease. The rest of the systemic examination was also within normal limits. A summary of her laboratory investigations is presented in Table
Summary of laboratory results.
Peripheral eosinophil count | 860 IU/L |
IgE | 98 IU/L |
Tissue transglutaminase IgA | Negative 36.4 IU/L |
Tissue transglutamase antibody IgG | Negative |
HIV, thyroid function | Negative |
Stool | Negative for oval, cysts and parasites |
Parasites serologies (Echinococcus, Entamoeba histolytica, Toxocara, Trichinella) | Negative |
RAST (radioallergosorbent test) egg, peanut, soya, milk, cheese, wheat, cod, mussel, salmon, shrimp, tuna, hazel, Brazil, and almond nuts | Negative tests for allergens |
Ascitic fluid analysis | |
Total protein | 4.5 g/dL |
Albumin | 2.4 g/dL |
SAAG (serum ascitic-albumin |
0.1 g/dL |
Eosinophil count | 6030/mm3 |
Cytology | No evidence of malignant or lymphoma cells |
Computed tomography of abdomen and pelvis showing large amount of ascites and thickened small bowel wall. No pelvis or peritoneal mass identified.
Esophagogastroduodenoscopy showed multiple areas of erythematous patches at the duodenal bulb.
H&E Low power view of second part of duodenal biopsy showing Marsh 3a villous atrophy.
Jejunal mucosa showed dense infiltration of eosinophils on the lamina propria (30/HPF) (Figures
H&E high power view of jejunal biopsy showed increase in lamina propria cellularity with eosinophilic infiltration.
H&E section of jejunal biopsy showed eosinophils infiltration (30/HPF) in the lamina propria.
Laporoscopic examination showed no evidence of underlying intra-abdominal malignancy. After excluding the possibilities of malignancy, parasitic disease and an autoimmune disorder, eosinophilic gastrointestinal disorder was diagnosed. This diagnosis was based on the presence of peripheral eosinophilia, eosinophilic ascites, and eosinophilic infiltration of the proximal duodenum and jejunal mucosa.
The patient was started on intravenous hydrocortisone 100 mg four times a day with rapid resolution of her symptoms and eosinophilia. She received three days of intravenous hydrocortisone and was converted to a reducing dose of oral prednisolone 40 mg per day for four days. This was reduced to 20 mg per day for four days, 10 mg per day for three days, 5 mg per day for five days, then 2.5 mg per day for seven days, and stop.
However, the length of steroid treatment was greatly influenced by the development of steroid-induced psychosis. The patient was eventually admitted for psychiatric treatment following discharge. Her psychosis had resolved upon discontinuation of steroid and did not require long-term antipsychotic treatment. A repeat computed tomography of the abdomen and pelvis three months after discharge from hospital showed resolution of the ascites and small bowel wall thickening (Figures
Computed tomography showing resolution of ascites and small bowel thickening three months after discharge from hospital.
Eosinophilic gastrointestinal disorder is a rare disorder first described in 1937 [
In a retrospective study of 40 patients, the most common symptoms were abdominal pain, nausea, vomiting, and diarrhoea. In this study, the percentages involving mucosal layer, muscle, and subserosal layers were 58%, 30%, and 12% respectively [
Radiological features of eosinophilic gastroenteritis include thickening of mucosal folds on barium study or computed tomography depending on the severity and layer(s) involved [
Both cellular and humoral immunity have been postulated placing eosinophilic gastroenteritis between purely IgE-mediated disorders such as food allergies and non-IgE-mediated disorders such as inflammatory bowel disease and coeliac disease [
The patient in our case report has a childhood history of coeliac disease at the age of two from another hospital. The diagnosis was based on gastrointestinal symptoms of ascites and gastroenteritis, the presence of dense eosinophil infiltration on the lamina propria of duodenal and jejunal biopsies, marked eosinophilia in the ascites, and the rapid response to steroid therapy [
Elevated eosinophils in blood and different tissues have been found in coeliac disease. The coexistences of eosinophilic gastrointestinal disorder and coeliac disease in an adult should be considered when a patient presented with ascites in the absence of liver disease and unexplained gastrointestinal symptoms.