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DOI: 10.1055/s-0030-1256526
© Georg Thieme Verlag KG Stuttgart · New York
Eosinophilic enteritis presenting as a perforated duodenal ulcer
Publication History
Publication Date:
08 November 2011 (online)
Eosinophilic gastroenteritis (EGE) is a rare condition of unknown etiology that is characterized by eosinophilic infiltration in the layers of the gastrointestinal tract [1]. It can affect any part of the gastrointestinal tract but most commonly affects the stomach [1] [2]. This report describes a rare case of EGE presenting as a perforated duodenal ulcer with subsequent duodenal stenosis.
A 26-year-old man was referred to us with duodenal obstruction following a laparotomy for a perforated duodenal ulcer. He had undergone repair of the ulcer and 2 weeks later had presented with vomiting and weight loss. Endoscopy showed gastritis and a duodenal ulcer with stenosis ([Fig. 1]). A barium meal showed narrowing at the first part of the duodenum ([Fig. 2]). He was given treatment for Helicobacter pylori and pantoprazole. A repeat endoscopy 2 months later showed a deformed pylorus, prepyloric nodular mucosa, and an almost circumferential duodenal ulcer with significant narrowing.
Biopsies from the ulcer showed a marked eosinophilic infiltrate diagnostic of EGE ([Fig. 3]). He received prednisolone as a tapered course over 1 month and pantoprazole, after which, there was a marked improvement in his symptoms. A repeat endoscopy showed a healed duodenal ulcer and a postbulbar stricture ([Fig. 4]). Central radial expansion balloon dilation was performed. He received another course of steroids and 1 month later was well and gaining weight with no vomiting.
Fig. 1 Esophagogastroduodenoscopy showing gastritis and a duodenal ulcer with stenosis.
Fig. 2 Barium meal showing a short segment of narrowing in the first part of the duodenum with peripheral ulceration suggesting chronic ulceration with secondary fibrotic changes and subsequent narrowing.
Fig. 3 Biopsies from the duodenal ulcer showing a marked eosinophilic infiltrate, diagnostic of eosinophilic gastroenteritis (EGE).
Fig. 4 Esophagogastroduodenoscopy showing a healed duodenal ulcer and a postbulbar stenosis that was subsequently dilated.
Talley et al. suggested three diagnostic criteria for EGE: (i) gastrointestinal symptoms; (ii) demonstration of eosinophilic infiltration in the gastrointestinal tract, or presence of high eosinophil count in fluid; (iii) no evidence of parasitic or extraintestinal disease [3]. EGE has been classified, depending on the extent of bowel wall involvement, into mucosal, muscular, and serosal [1] [3]. In the past, peptic ulceration accounted for most cases of gastric outlet obstruction. Nowadays, other causes such as malignancy and EGE must be excluded.
EGE may also present acutely [4] [5] as was the case for our patient who presented with peritonitis secondary to a perforated peptic ulcer, with a subsequent stricture that was presumed to be postsurgical but proved to be due to EGE. To the best of our knowledge, this is the first report of EGE presenting as a perforated duodenal ulcer.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC
References
- 1 Khan S, Orenstein S R. Eosinophilic gastroenteritis. Gastroenterol Clin N Am. 2008; 37 333-348
- 2 Chen M J, Chu C H, Lin S C. et al . Eosinophilic gastroenteritis: clinical experience with 15 patients. World J Gastroenterol. 2003; 9 2813-2816
- 3 Talley N J, Shorter R G, Phillips S F, Zinsmeister A R. Eosinophilic gastroenteritis: a clinicopathological study of patients with disease of the mucosa, muscle layer, and subserosal tissues. Gut. 1990; 31 54-58
- 4 Blanco-Guerra C, Cazana J L, Villas F. Ileal perforation due to eosinophilic gastroenteritis. Am J Gastroenterol. 1991; 86 1689-1690
- 5 Maeshima A, Murakami H, Sadakata H et al. Eosinophilic gastroenteritis presenting with acute pancreatitis. J Med. 1997; 28 265-272
A. H. Al-SalemMD
Department of Pediatric Surgery, Maternity and Children Hospital,
Dammam
P.O. Box 61015
Qatif 31911
Saudi Arabia
Email: ahsalsalem@hotmail.com