Case Report
A 66-year-old man presented with a 15-day history of persistent upper abdominal pain and distension. The pain located in the middle and right upper abdomen. It was aggravated by drinking or eating. He had normal flatus and defection. No fever, vomiting, or hematemesis was reported. An unintentional weight loss of 2 kg in the last 15 days was reported. He reduced his food intake and took pantoprazole 40 mg per day for three days. However, his condition did not improve. Therefore, he presented to the physicians of the local primary hospital because of unremitting distended pain. He was a farmer without a significant past medical history or a family history of malignancy. Physical examination was significant for slight distension in the upper middle and right abdomen, with normal bowel sounds and slight tenderness in the upper abdomen, especially in the right quadrant. No rebound was found. Laboratory studies showed a white blood cell (WBC) count of 14.5x109/L, with 78.5% neutrophils, 7.5% eosinophils, a hemoglobin level of 13.4g/dL, and a C-reactive protein (CRP) concentration of 48.3 mg/L. Serum biochemical analyses, including glucose level, liver function, renal function, amylase, lipase, cardiac markers, and tumor markers, showed no abnormalities. Esophagogastroduodenoscopy (EGD) demonstrated diffuse thickening, focal mucosa erosions, hyperemia, and swelling of the antrum (Figure 1). Biopsies from the antrum showed mild chronic inflammation with some lymphocytes. Abdominal ultrasonography showed cholecystolithiasis (full gallstone) (Figure 4). Subsequently, cholecystectomy was performed successfully with the strong recommendation and insistence from his daughter who is a surgeon in the general department of the local hospital. The pathology showed chronic cholecystitis with some lymphocytes (Figure 5). The patient was observed overnight in the local hospital and was sent home the next morning.
However, the patient complained of more severe pain and distension after the surgery. The pain was gradually correlated with slight diarrhea with mucus and blood and tenesmus. Ten days after the surgery, the patient was seen in the emergency department of our hospital for progressive unremitting pain and distension. On physical examination, the abdomen was moderately distended, with active bowel sounds approximately 8-9 times per minute, diffuse tenderness without rebound and moderate ascites. Laboratory studies showed the following: hemoglobin level of 13 g/dL; PLT of 163 x109/L; WBC of 12.3x109/L; 45.5% eosinophils; and albumin (ALB) 3.2 g/dL. Feces were positive for occult blood and negative for parasite ova.
Computer tomography (CT) of the abdomen showed thickening of the gastric antrum and sigmoid wall and a small amount of ascites in the pelvis (Figure 6). Colonoscopy showed diffuse thickening of mucosa, focal erythema and erosion (Figure 1), and biopsies showed eosinophilic infiltration of mucosa with more than 40 cells/HPF (Figure 3). Since obvious eosinophilic infiltration was found from the colonic mucosa, we doubted about the previous pathologic result of the EGD. So we rechecked the antrum biopsies which showed heavy infiltration of eosinophils: >60 cells/HPF (Figure 2). Ultrasound-guided diagnostic paracentesis showed a large number of eosinophilic granulocytes without malignant cells seen in punctate. For the evaluation of malignancy, the patient also underwent bone marrow aspiration and biopsy, the results of which were negative. Thus, the constellation of clinical presentation and histopathological findings were suggestive of eosinophilic gastroenteritis.
Subsequently, the patient received oral prednisone treatment at an initial dose of 40 mg/day, combined with dietary restrictions, proton-pump inhibitors and mucosal protective agents. One week later, the patient noticed a marked improvement in his symptoms. The dosage of prednisone was gradually tapered off over an 8-week period. After the completion of the steroids, the patient’s abdominal pain was completely relieved, and a peripheral blood count revealed an absolute normal eosinophil count level. Furthermore, CT imaging of the abdomen and pelvis showed a complete resolution of the gastric antrum and sigmoid thickening as well as ascites. Six months have elapsed since treatment, and the patient remains asymptomatic on no medications.