S6026 Small Bowel Eosinophilia With Eosinophilic Ascites

Introduction: Eosinophilic gastrointestinal diseases (EGIDs) are inflammatory disorders of aberrant eosinophil abundance that can manifest anywhere along the gastrointestinal lumen. Non-esophageal EGIDs including eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC) often present with nonspecific symptoms with no formalized guidelines for their diagnosis or treatment. Case Description/Methods: A 71-year-old man with untreated HCV, asthma, and allergic rhinitis presented to the emergency room with 3 weeks of postprandial abdominal pain, decreased appetite, 5 pound weight loss, and abdominal swelling. He had recent travel to Cuba and worked as a chef. Vitals were notable for heart rate of 112. Physical examination showed mild LLQ tenderness and mild abdominal distention. Abdominal computed tomography showed abdominopelvic ascites, hepatic surface nodularity, thickening of the gastric body, and diffuse small bowel wall thickening. Labs were notable for moderate peripheral eosinophilia and elevated IgE. The patient underwent esophagogastroduodenoscopy with pathology showing duodenal mucosa with >50 eosinophils/HPF. He was discharged after his symptoms improved and repeat esophagogastroduodenoscopy 8 weeks later was normal. He was successfully treated for hepatitis C. Four months later the patient was again hospitalized with worsening abdominal pain and 30 pound weight loss. He again had moderate peripheral eosinophilia and computed tomography enterography showed mild thickening of jejunal loops. Push enteroscopy to mid-jejunum demonstrated erosions and erythema in the gastric antrum and duodenum along with inflammation and ulcerations in the jejunum. Pathology showed a maximum of 83 eosinophils/HPF in the lamina propria of the duodenum and jejunum. Infectious disease and oncologic workup ruled out parasitic infections and malignancy, respectively, and a diagnosis of EoN was agreed upon. The patient's symptoms improved with initiation of oral prednisone and he was discharged to outpatient follow-up, where he was tapered off prednisone to budesonide. Discussion: This patient case underscores the need for better understanding of the mechanisms underlying EGIDs. The vast differential diagnoses involving peripheral eosinophilia and nonspecific systemic symptoms made a definitive diagnosis challenging in this patient, especially with inconsistent endoscopic biopsy results. Development and validation of criteria that can specifically diagnose EGIDs will allow for faster treatment of these often debilitating disorders.