S3791 Eosinophilic Gastrointestinal Disorders (EGID): A Case of Eosinophilic Ascites

Introduction: Eosinophilic (Eos) gastrointestinal (GI) disorders (EGID) are characterized by Th2 immune response to foods and environmental exposures with Eos infiltration of the GI tract. A history of (h/o) atopy and genetic predisposition has been well described. We present an interesting case of EGID with Eos ascites. Case Description/Methods: A 22 year old man with h/o allergic rhinitis presented with nausea, vomiting and post prandial right lower quadrant abdominal pain 1 week after a road-trip dirt biking and eating from a farm. Initial labs noted WBC 8.0 K/uL, Hgb 15.0 g/dL, platelets 202 K/uL, absolute eosinophil count 2.0 × 1000/uL. liver function test’s, lipase, and creatinine were normal. Computed tomography abdomen and pelvis revealed distal esophageal wall thickening, gastritis, jejunal submucosal edema, hepatosplenomegaly, and small-moderate ascites. A diagnostic paracentesis demonstrated low serum-ascites-albumin-gradient, high protein and Eos (2700 eosinophils) ascites. Stool enteric PCR, ova/parasite, giardia/cryptosporidium ag, and fecal calprotectin were negative. Serum ascaris/toxocara/Strongyloides serologies, HIV ag/ab, tryptase, quantitative immunoglobulins, ANA, and ANCA were negative. EGD showed normal esophagus and erythematous mucosa in the gastric body/antrum, and duodenum. Biopsies (bx) demonstrated eosinophil-rich esophagitis (>40 eosinophils per high-powered field) and were normal in the stomach and duodenum. Ileocolonoscopy was grossly normal with unrevealing bx in the terminal ileum. Numerous aggregate forming eosinophils with preserved architecture were found throughout the colon on bx. EGID with Eos ascites was diagnosed. Discussion: EGIDs are a group of chronic immune mediated conditions characterized by GI symptoms and Eos infiltration of any layer of the GI tract: mucosa (70% of cases), muscularis (20% of cases), and serosa (10% of cases). Three diagnostic criteria are proposed: GI symptoms, bx proven Eos infiltration (alongside peripheral eosinophilia or Eos ascitic fluid), and exclusion of other secondary causes including parasitic infections, IBD and hypereosinophilic syndrome. This rare case underscores the importance of maintaining a high level of suspicion for EGIDs in patients with unexplained ascites and GI symptoms as making diagnosis can often be challenging. Early recognition and accurate diagnosis are critical to initiate appropriate therapy and prevent prolonged morbidity and long term complications related to this chronic inflammatory disorder.