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.