S4464 Bloody Eosinophils! Upper Gastrointestinal Bleed and Ulceration Unresponsive to Proton Pump Inhibitors in a Young Man With Eosinophilic Gastrointestinal Disease

Introduction: Eosinophilic gastrointestinal disease (EGID) is characterized by eosinophil infiltration in the gastrointestinal tract without secondary causes. Eosinophilic gastroenteritis, a subtype affecting the stomach and small intestine, predominantly affects adults aged 30-50, with a prevalence of 22-28 cases per 100,000 persons in the U.S. Although commonly linked to allergic conditions, this article presents a rare and significant case of eosinophilic gastroenteritis manifesting as upper gastrointestinal bleeding (UGIB) in a 35-year-old man without typical atopic disorders, underscoring the importance of considering EGID in the differential diagnosis of acute UGIB. Prompt recognition can prevent complications and significantly improve patient outcomes. Case Description/Methods: A 35-year-old man with a history of gastric ulcers, hypertension, and pre-exposure prophylaxis presented with hematemesis, coffee-ground emesis, and melena, accompanied by fatigue, jaw pain, and intermittent reflux symptoms. His medications included pre-exposure prophylaxis, amlodipine, citalopram, and naproxen. Past procedures included an esophagogastroduodenoscopy (EGD) in 2006 for a gastric ulcer and normal colonoscopies in 2009 and 2010. Initial laboratory findings demonstrated hemoglobin of 14.0 g/dL and leukocytosis. EGD showed gastric and duodenal ulcers with a visible vessel treated by cautery; biopsies were deferred due to active bleeding. The patient had no further bleeding episodes and was discharged with hemoglobin of 9.4 g/dL. Eight weeks later, a repeat EGD revealed non-bleeding ulcers, and biopsies confirmed eosinophilic esophagitis and gastritis. Treatment consisted of fluticasone and high-dose proton pump inhibitors (PPIs). Discussion: This case emphasizes a rare presentation of EGID as UGIB and highlights the clinical necessity of considering EGID in patients with unexplained gastric and duodenal ulcers. Diagnosis typically relies on histological evidence of elevated eosinophils (>30 eosinophils/HPF in the stomach, >52 in the duodenum). Although peripheral eosinophilia occurs in approximately 70% of cases, diagnosis can be complicated when active bleeding prevents biopsies. Pathogenesis involves IgE-dependent and Th2 cell-mediated allergic responses resulting in eosinophil infiltration and subsequent tissue damage. Standard treatments include corticosteroids and PPIs, with PPIs notably effective in reducing eosinophil-driven inflammation. This case reinforces the critical importance of early recognition and management of EGID to optimize patient outcomes.