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EOSIN

PILYA

OBJECTIVES
To determine the cause of recurrent
diarrhea in a 49 y.o. male
To discuss the diagnostic approach on
patient presenting with this condition
To discuss management done on this case

IDENTIFYING DATA
J.M.
49 y.o.
Male
Catholic
Filipino
Caloocan City

CHIEF COMPLAINT
HEMATOCHEZIA

Initial onset of diarrhea and hematochezia


Video gastroscopy and Video colonoscopy
7 months were done
Prescribed with Omeprazole 40 mg tab
OD, Ribamepide tab TID
2 days later, still noted with diarrhea and
hematochezia
Admission
Fecalysis revealed E. Histolytica cyst and
troph
Discharge with diagnosis of amoebic colitis

VIDEO GASTROSCOPY
Erosive Gastritis, Antrum: Gastric Ulcer,
Antrum, Forrest 3

VIDEO COLONOSCOPY
Non-Specifi c Pancolitis

Recurrence of diarrhea and hematochezia


2 months Fecalysis was done which showed
unremarkable results
Another recurrence of diarrhea and
hematochezia
WBC, Eosinophils
1 month CBC was done
Given Salofalk granules 1.5 gm TID


WBC

01/28/20
15
8.3
0.62

06/26/20
15
8.1
0.59

07/16/20
15
13.7
0.69

0.18

0.27

0.14

0.10

0.08

0.12

0.10

0.05

0.05

Neutroph
ils
Lymphoc
ytes
Monocyte
s

Noted feeling of discomfort on his anus,


sometimes pain
5 days
No consult done

Noted an episode of diarrhea and


hematochezia
5 hours No abdominal pain, no fever, no consult
done

Another episode of hematochezia


2 hours
Associated now with periumbilical pain,
colicky, non-radiating

Admissiom

MEDICAL HISTORY
Patient claims to be non-hypertensive
and diabetic. He denies any history of
allergies to drugs and foods

FAMILY HISTORY
- Hypetension
- DM
- Malignancy
- Bronchial Asthma

PERSONAL HISTORY
Denies smoking and ilicit drug use but
occasionally drinks alcoholic beverages
Non-promiscuous

REVIEW OF SYSTEM
General: (+) weight loss, (-) chills, (+)
malaise
Skin: (-) rash (-) discoloration, (-) pallor (-)
cyanosis
HEENT: (-) epistaxis (-) colds
Respiratory: (-) cough, (-) hemoptysis
CVS: (-) Chest pain (-) palpitations (-) PND

REVIEW OF SYSTEM

GUT: 9-911 (-) hematuria , (-) dysuria (-) anuria

Hematology: (-) easy bruising, (-) epistaxis

GIT: (-) abdominal pain, (-) vomiting, (-) diarrhea, (-)


melena

Endocrinology: (-) polyphagia (-) polydipsia (-)


polyuria (-) heat intolerance

Neurologic: (-) loss consciousness, (-) seizure

PHYSICAL EXAMINATION

General Survey: Conscious, coherent,


ambulatory, not in CR distress.

Vital signs:
BP = 170/90mmHg (sitting)
CR = 89 BPM RR = 19 T = 36.7C
Weight = 69 Kg
Height = 54
BMI = 26.3 (Obese)

Skin: (-) macular rash on both lower legs;


(-) pallor

HEENT: Pink palpebral conjunctiva,


anicteric sclera, no palpable cervical
lymphadenopathies
Chest/Lungs: symmetrical chest
expansion, (-) retractions, equal tactile
fremitus on both sides, vesicular breath
sounds, no rales

CVS: No neck vein distention, adynamic


precordium, apex beat is at 5 th LICS
MCL, normal S1 and S2, no S3 or S4, no
murmurs, no bruit
GIT: abdomen is fl abby, umbilicus
inverted normoactive bowel sounds, no
bruit, soft but tender on deep palpation,
no mass, liver and spleen not palpable,
tympanitic on percussion, Traubes
space not obliterated

Extremities: (-) bipedal edema,


no digital clubbing, peripheral
pulses equal and bounding

ADMITTING IMPRESSION

Lower Gastrointestinal
Bleeding secondary to Amebic
Colitis
Rule out Inflammatory Bowel
Disease and Colorectal CA

ON ADMISSION
IVF: PNSS 1L x KVO
Low salt, low fat die
Diagnostics
CBC
Urinalysis
Fecalysis
Serum electrolytes, Crea
SGPT

Medications
1) Pantoprazole 40 mg IV
2) Racecadotril 100 mg cap, 1 cap
OD

DAY 1 OF ADMISSION
S

Problem:

VS:
BP 160/90
HR 89
RR 19
Temp. 36.7

CBC presence
of eosinophilia

Resume Salofalk
granules 1.5 gm
TID

Hematochezi
a
Diarrhea
Abdominal
pain

Unremarkable
Physical
Examination

Fecalysis: No
ova or parasite
seen
Rule out
Amoebic Colitis
T/C Eosinophilic
Colitis

Start Prednisone
5 mg tab, 1 tab
TID

COMPLETE BLOOD COUNT


Exam

Results
(08/04/16)
10,2

Results
(08/06/16)
9.1

Neutrophils

0.69

0.60

5.00-10.00
10^9/L
0.40-0.60

Lymphocytes

0.16

0.26

0.20-0.40

Monocytes

0.11

0.10

0.02-0.08

Eosinophils

0.04

0.04

0.01-0.03

Basophils

0.00

0.00

0.00-0.02

Hgb

140

135

123.00-152 g/L

Hct

0.42

0.41

0.37-0.42

Platelet

411

409

150.00-450.00

WBC

Normal values

Absolute eosinophilic count = 368


FECALYSIS
Color

Dark Red

Consistency

Watery

WBC

None seen

RBC

TNTC

Fat Globules

None seen

Yeast Cells

None seen

Ova/Parasite

No Ova or
Intestinal Parasite
Seen

Occult Blood

Positiv


URINALYSIS
Color
Transparency
RBC
Pus Cells
Bacteria
Epithelial Cells

Light Yellow
Slightly turbid
0-2/HPF
0-2/HPF
Few
Few


Creatinine

BUN

Potassium

Sodium

Chloride

SGPT

8/4/2016
Normal
68.20 umol/L Values

45.00-84.00
mmol/L

2.60 mmol/L
2.14-7.14

mmol/L

3.56 mmol/L
3.30-5.10

mmol/L

141.00
136.00-145.00
mmol/L
mmol/L

101.80
98.00-107.00
mmol/L
mmol/L

27.50 U/L
0.00-41.00 U/L

Result

ESR
21 mm/hr

DAY 2 OF HOSPITAL STAY


S

Problem:
1. Hematoch
ezia x1
episode
2. Less
abdominal
pain

VS:
BP 140/80
HR
RR
Temp.

Eosinophilic
Colitis

Continue with
present
medications

No rashes
No signs of
dehydration
Abdomen:
soft,
NABS,nontender

Hypertension
controlled

DAY 3 OF HOSPITAL STAY


S

No episode of
hematochezia

VS:
BP 130/80

Eosinophilic
Colitis

No abdominal
pain

No rashes

Hypertension
controlled

Refer to
dietician
regarding
hypoallergenic
diet

No signs of
dehydration
Abdomen:
soft,
NABS,nontender

DAY 4 OF HOSPITAL STAY


S

No subjective
complaints

VS:
BP 130/80
HR 76
RR 18
Temp. 36.8

Eosinophilic
Colitis

For discharge
Home meds
1. Salofalk
granules 1.5
gm, BID
2. Prednisone
5 mg tab, 1
tab TID after
meals
3. Omeprazole
40mg tab, 1
tab OD
Follow up after 2
weeks with
repeat CBC,
SGPT, SGOT,
Crea, ESR and
fecalysis

No rashes
No signs of
dehydration
Abdomen:
soft,
NABS,nontender

Hypertension
controlled

FINAL DIAGNOSIS

Eosinophilic Colitis

FOLLOW UP
S

No subjective
complaints

Unremarkable

Eosinophilic
Colitis,
improved
clinically with
steriod

Continue
prednisone on
tapering
dosages

No recurrence
of diarrhea
and
hematochezia

Hypertension
controlled

DISCUSSION

Eosinophilic
Gastrointestinal
Disease

INTRODUCTION
Disorders that selectively affect
GI tract
Eosinophil-rich inflammation in the
absence of known causes for
eosinophilia

Rothenberg ME. Middleton's Allergy ; 8th edition. 2014. p. 1095-1106

Rothenberg ME. Middleton's Allergy ; 8th edition. 2014. p. 1095-1106

EOSINOPHIL BACKGROUND
constitute 13% of the granulocyte pool
absolute eosinophil count of ,350 per
ml
Following a brief half-life of 812 h,
eosinophils traffi c to specifi c tissues,
particularly the gastrointestinal tract,
where they reside for at least a week
Eosinophil function can be benefi cial or
detrimental

Eosinophils are present at low levels in


numerous tissues
In biopsy and autopsy specimens,
organs that normally demonstrate
tissue eosinophils at substantial levels
are
- GI tract
- Lymph nodes
- Spleen
- Thymus
DeBrosse CW, Case JW, Putnam PE, Collins MH, Rothenberg ME. Quantity and
distribution of eosinophils in the gastrointestinal tract of children. Pediatric and
developmental pathology : the official journal of the Society for Pediatric Pathology and

Triggering of eosinophils by
engagement of receptors for cytokines,
immunoglobulins, and complement can
lead to the generation of a wide range
of infl ammatory cytokines

Yousefi S, Gold JA, Andina N, Lee JJ, Kelly AM, Kozlowski E, et al. Catapult-like release of
mitochondrial DNA by eosinophils contributes to antibacterial defense. Nature

ETIOLOGY
A non- IgEassociated disease
Some studies point to a T lymphocyte
mediated process.
Exact immunologic mechanisms
responsible for this condition have not
been identifi ed.

Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.

CLINICAL PRESENTATION
Present with a constellation of
symptoms that are related to the
degree and area of the GI tract
aff ected
1. Mucosal layer
2. Muscularis layer
3. Serosal layer

Rothenberg ME. Middleton's Allergy ; 8th edition. 2014. p. 1095-1106

CLINICAL PRESENTATION
Mucosal disease
Vomiting
Abdominal pain
Diarrhea
Blood loss in stools
Iron defi ciency anemia
Malabsorption
Protein-losing enteropathy
Failure to thrive

Chehade M, Magid MS, Mofidi S, Nowak-Wegrzyn A, Sampson HA, Sicherer SH. Allergic
eosinophilic gastroenteritis with protein-losing enteropathy: intestinal pathology, clinical
course, and long-term follow-up. Journal of pediatric gastroenterology and nutrition.

CLINICAL PRESENTATION
Muscle layer disease
Bowel wall thickening & Intestinal
obstruction
Cramping & abdominal pain
associated with nausea and vomiting

Rothenberg ME. Middleton's Allergy ; 8th edition. 2014. p. 1095-1106

Ingle SB, Hinge Ingle CR. Eosinophilic gastroenteritis: an unusual type of gastroenteritis.
World journal of gastroenterology : WJG. 2013;19(31):5061-6.

CLINICAL PRESENTATION
Subserosal disease
Eosinophilic exudate ascites
Abundant peripheral eosinophilia
Serosal and visceral peritoneal
infl ammation leads to leakage of fl uids

Rothenberg ME. Middleton's Allergy ; 8th edition. 2014. p. 1095-1106

Ingle SB, Hinge Ingle CR. Eosinophilic gastroenteritis: an unusual type of gastroenteritis.
World journal of gastroenterology : WJG. 2013;19(31):5061-6.

DIFFERENTIAL DIAGNOSIS OF EC

Okpara N, Aswad B, Baffy G. Eosinophilic colitis. World journal of gastroenterology : WJG.

NO STANDARDS EXIST FOR


DIAGNOSIS
Four criteria are required for the diagnosis
1. Presence of
gastrointestinal
symptoms
2. Eosinophilic
infi ltration of
gastrointestinal tract
3. Exclusion of parasitic
disease
4. Absence of other
systemic involvement
Ingle SB, Hinge Ingle CR. Eosinophilic gastroenteritis: an unusual type of gastroenteritis.
World journal of gastroenterology : WJG. 2013;19(31):5061-6.

DIAGNOSTIC EVALUATION
No single test is the gold
standard for diagnosis
Peripheral blood eosinophilia or
eosinophils in the stool suggests
eosinophilic colitis.

Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.

ENDOSCOPIC AND PATHOLOGY


Patchy erythema
Loss of
vascularity,
Lymphonodular
hyperplasia
mostly localized
to the rectum but
might extend to
the entire colon
Gastroenterol Res Pract. 2011

Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.

ENDOSCOPIC AND PATHOLOGY


Patchy erythema
Loss of
vascularity,
Lymphonodular
hyperplasia
mostly localized
to the rectum but
might extend to
the entire colon
Okpara N, Aswad B, Baffy G. Eosinophilic colitis. World journal of gastroenterology : WJG.
2009;15(24):2975-9.
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of
allergy and clinical
immunology. 2004;113(1):11-28.

ENDOSCOPIC AND PATHOLOGY


Overall architecture
of the mucosa is well
preserved
Focal aggregates of
eosinophils in the
lamina propria, crypt
epithelium, and
muscularis mucos.,
Multinucleated giant
cells are occasionally
present in the
submucosa.
Gastroenterol Res Pract. 2011

Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.

TREATMENT
Eosinophilic colitis of older
: Cromoglycate
,Montelukast,Histamine receptor
antagonists : generally unsuccessful
:Aminosalicylates and systemic or
topical glucocorticoids :typically
used and appear to be effi cacious
:Azathioprine or 6-mercaptopurine:
in severe cases

Rothenberg ME. Middleton's Allergy ; 8th edition. 2014. p. 1095-1106

Initiated using prednisone


at 0.4 to 0.8 mg/kg each
morning
+
Solubilized budesonide is
begun at 9 mg orally daily,
taken at bedtime on an
empty stomach

Prednisone is
tapered over the
next 2 or more
weeks
One to 2 months after the
prednisone has been
stopped
Budesonide dose is slowly
tapered over an additional
2 to 4 months to the
minimum required dose.

clinical
symptoms
are
controlled

clinical
symptoms
are
controlled

Prussin C. Eosinophilic gastroenteritis and related eosinophilic disorders. Gastroenterology clinics of


North America. 2014;43(2):317-27.

Initiated using prednisone


at 0.4 to 0.8 mg/kg each
morning
+
Solubilized budesonide is
begun at 9mg orally daily,
taken at bedtime on an
empty stomach

clinical
symptoms
are
controlled

clinical
symptoms
are
controlled

Prednisone is
tapered over the
next 2 or more
weeks

One to 2 months after the


prednisone has been
stopped
Budesonide dose is
slowly tapered over an
additional 2 to 4 months
to the minimum required
dose.

Prussin C. Eosinophilic gastroenteritis and related eosinophilic disorders. Gastroenterology clinics of


North America. 2014;43(2):317-27.