case presentation 2

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Case Presentation 2
ESIM-9, Sintra
30.08.-06.09.2006
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Department of Gastroenterology
Prof. Dr. Holstege
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46 y/o man

• with
• acute abdominal pain

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History of present illness
4 weeks before admission For the first time
acute abdominal pain - postprandial -
associated with diaphoresis and diarrhea -
completely resolved One day before
admission - severe abdominal pain - diarrhea

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History of present illness (cont.)

• Associated symptoms
• reduced appetite since 4 weeks
• weight loss of 5 kg in this time
• food intolerane ? diarrhea after
  consumption of tomatos or peanuts

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Past medical history

• Asthma
• Allergies
• pollens
• mold
• dust
• cat hair
• Medication
• Inhaler with Budesonid / Formoterol

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Physical examination

• Good general condition, obesity (178 cm 93,8 kg)
  
• BP 130/60 mmHg - HR 88/min RR 15/min - Temp.
  37.0 C
• Abdomen
• no distension
• decreased bowel sounds, no bruits
• soft, no tenderness, no rigidity
• no shifting dullness
• rectal no tenderness, no mass, stool in rectum
• No enlargement of liver and spleen
• No further pathological finding in systemic
  examination

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Laboratory Tests

• CrP 22 mg/dl lt 0,5
• Leucocytes 17.900 /µl - 10.000
• ESR 18 / 42
• Normal
• - Urea, Creatinine, Electrolytes
• LFTs
• Lipase

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Ultrasound
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Paracentesis
Malodorant, purulent exudate ? leucocytes 92
.000 /mcl LDH 1452 protein 6,1
g/dl lipase 9 U/l
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Plan

• Cultures
• Blood (2 x)
• Ascites
• CT-scan
• Antibiotic therapy (Piperacillin, Tazobactam)
• Surgical consultation

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CT scan

• No free air, however suspicion of contained
  perforation
• (Cecum, appendix)
• Pericolic fat inflammation (Cecum, Ascending
  colon)
• Ascites (perihepatic / hypogastric between bowel
  loops)

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Exploratory Laparotomy
No evidence of perforation Irrigation drainage
Appendectomy
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Continuation of the case

• Post-operative course
• Wound drain clearer
• WBC and CRP ?
• Normal bowel function
• Oral nutrition

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Ascites smear
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Ascites smear

Charcot-Leyden-crystals
Charcot-Leyden-crystals formed from the
breakdown of eosinophils ? parasitic disease,
asthma, allergies, eosinophilic pneumonia

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Paracentesis
Malodorant, purulent exudate ?
leucocytes 92.000 /mcl -
neutrophils 13 - eosinophils 67
Cytology No evidence for malignancy
Eosinophils ?
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Laboratory Tests
Leucocytes 17.900 /µl - 10.000 ? Differentia
l WBC neutrophils 26,3 lymphocytes
9,5 monocytes 4,7 basophils 0,2
eosinophils 59,3
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Microbiology

• Cultures
• Blood (2 x) ? No bacterial growth
• Ascites ? - -
• Peritoneum (intraop.) ? - -

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Histology

• Chronic appendicitis
• Inflammation across serosal layer with massive
  infiltration of eosinophils

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Assessment

• 46 y/o man with PMH of
• allergic diathesis
• food intolerane
• Asthma
• presents with acute abdominal pain and diarrhea
• ?
• Eosinophilic ascites

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Differentialdiagnoses
Eosinophilic ascites - Parasitic infection -
Churg-Strauss Syndrome - Lymphoma - Eosinophilic
leucemia - Hypereosinophilic Syndrome - (chronic
peritoneal dialysis)
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Microbiology II
Stool Wormeggs/larvae ? 3 x
negative Cultures ? no pathogenic
intestinal bacteria Serology Echinoc.
multilocularis ? negative Echinoc. granulosus
? lt 116
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Immunology
c-ANCA lt 12 p-ANCA lt 110 IgE 725 U/ml
(atopy likely)
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Bone marrow biopsy
Cytology No evidence for myeloproliferative
syndrome Cyto- / Molecular genetic
Exclusion of clonal eosinophilia or
Hypereosinophilic Syndrome (HES) Immune
Cytology Exclusion of T-Zell Lymphoma
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Gastroscopy

Histology No signs of Celiac or Whipples
disease, massive infiltration with eosinophils
(antrum,corpus)

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Colonoscopy

Histology No pathologic finding.
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Colonoscopy

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Summary

• No evidence for
• Parasitic infection
• Churg-Strauss Syndrome
• Lymphoma
• Eosinophilic leucemia
• Hypereosinophilic Syndrome

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Diagnosis
Eosinophilic Gastroenteritis serosal type
with eosinophilic ascites
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Therapy

• Prednisolone
• 20 mg/d for 5 days
• 10 mg/d for 4 weeks
• further reduction
• Further course
• No complaints anymore after therapy with steroids
  eosinophils ?

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Eosinophilic Gastroenteritis
First described by Kaijser 1937 Definition -
Tissue eosinophilia in any layer(s) of any
segment of GI tract - GI symptoms - No
eosinophilic infiltration in organs outside of GI
tract - No parasitic infection
Epidemiology Any age (mainly 30-50)

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Eosinophilic Gastroenteritis

• Etiology
• ? food intolerance, parasites, toxins are
  discussed
• Classification
• - Mucosal layer ? colicky abd. pain, nausea,
  diarrhea
• - Muscle layer ? intestinal obstruction
• - Serosal layer ? eosinophilic ascites
• Complications
• Intestinal obstruction
• - Malnutrition

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Eosinophilic Gastroenteritis

• Diagnosis
• Blood eosinophilia (80)
• Stool studies ? r/o parasites
• Multiple endoscopic biopsies, duodenal aspirate
• Diagnostic paracentesis
• Laparoscopy (uncertain cases)

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Eosinophilic Gastroenteritis

• Differentialdiagnosis of eosinophilia with GI
  symptoms
• - Parasites
• Drugs
• Vasculitis
• Systemic Mastocytosis
• Lymphoma
• Hypereosinophilic Syndrome
• Addisons disease

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Eosinophilic Gastroenteritis

• Treatment
• - Discontinuation of relevant drugs
• Trial of elimination diet if symptoms follow
  specific food
• Empiric antihelminthics if high risk for
  parasitic infestation
• Sodium Cromoglycate
• Glucocorticoids (initiation 20-40 mg,
  maintenance 5-10 mg/d)
• Surgery in localized disease with obstruction if
  conservative therapy fails

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Eosinophilic Gastroenteritis

• Prognosis
• Good prognosis
• Up to 1/3 self-limited course