| Abstract|| |
Eosinophilic enteritis is an uncommon disease characterized by eosinophilic infiltration involving any layer of the bowel wall. It can affect any area of gastrointestinal tract although stomach and small intestine are sites most frequently involved. It is important to recognize this disease and institute the necessary treatment at the earliest in order to avoid its complications. We present a case where the patient presented with features of subacute intestinal obstruction due to distal ileal strictures and enteroliths. Histopathologic examination of the resected specimen revealed characteristic features of eosinophilic enteritis.
Keywords: Enterolith, eosinophilic enteritis, subacute intestinal obstruction, ileo-cecal resection
|How to cite this article:|
D'souza C, Bhagavan K R, Sunil H, Mohan R. Unusual case of subacute intestinal obstruction due to eosinophilic enteritis with enteroliths. Ann Trop Med Public Health 2010;3:83-5
|How to cite this URL:|
D'souza C, Bhagavan K R, Sunil H, Mohan R. Unusual case of subacute intestinal obstruction due to eosinophilic enteritis with enteroliths. Ann Trop Med Public Health [serial online] 2010 [cited 2018 Nov 17];3:83-5. Available from: http://www.atmph.org/text.asp?2010/3/2/83/77198
| Case Report|| |
A 42-year-old female was admitted with complaints of colicky abdominal pain and bilious vomiting of 1 day duration. On examination, her vital parameters were within normal limits. Abdominal examination showed a distended abdomen with sluggish bowel sounds. Her hematological parameters were within normal limits. An erect and supine X-ray of her abdomen revealed few air fluid levels involving the small bowel. There were multiple radiopaque shadows seen in the pelvis [Figure 1]. Ultrasonography of the abdomen showed small bowel loops with sluggish peristalsis and a single gall bladder calculi of 15 mm. A computed tomography (CT) scan with i.v. and oral contrast was done to rule out gall stone ileus. CT scan revealed features of subacute intestinal obstruction along with enteroliths in the lumen of the small bowel and cholelithiasis [Figure 2]. Patient was kept nil by mouth and started on intravenous fluids. A Ryle's tube was inserted and the patient was monitored without any surgical intervention. The patient showed significant improvement on the next day. On the third day, the patient was started on oral feeds with which her symptoms recurred. With a suspicion of gall stone ileus, the patient underwent a surgical exploration. Intraoperative findings showed gall bladder with calculi. There was no demonstrable communication found between the gall bladder and the bowel. Four large calculi were found in the ileum [Figure 3]. Stricture was noticed in the distal ileum near the ileo-cecal junction. She underwent cholecystectomy, ileo-cecal resection and extraction of stones with end to end anastomosis of the distal ileum with the ascending colon. Histopathologic examination showed chronic cholecystitis and chronic nonspecific eosinophilic enteritis with impacted stone in ileum [Figure 4]. The patient recovered uneventfully and was discharged on the ninth postoperative day. She was thereafter reviewed at weekly intervals for the next 1 month during which she remained asymptomatic.
|Figure 1: Erect X-ray abdomen showing dilated small bowel loops with enteroliths.|
Click here to view
| Discussion|| |
Esinophilic enteritis is a rare, poorly understood condition presenting with a bizarre spectrum of unexplained symptoms mimicking any other acute abdominal condition.  Kaijser is credited with the first description of eosinophilic gastroenteritis, which dates back to 1937. , This usually presents from third to fifth decade and is almost unheard of in children.  Eosinophilic enteritis usually involves the gastric antrum or proximal small bowel. It is very rarely found to affect the distal small bowel.  About 85% of cases are associated with eosinophilia. ,
Eosinophilic gastrointestinal (GI) disorders may be primary or secondary in nature. Primary eosinophilic GI disorders are defined as disorders that selectively affect the GI tract with eosinophil-rich inflammation in the absence of known causes for eosinophilia (e.g. drug reactions, parasitic infections, and malignancy).  These disorders include eosinophilic esophagitis, eosinophilic gastritis, eosinophilic gastroenteritis, eosinophilic enteritis, and eosinophilic colitis and are occurring with increasing frequency.  Eosinophilic gastritis, enteritis and gastroenteritis are grouped together because they are clinically similar and there is a paucity of information available concerning their pathogenesis. However, it is likely that they are indeed distinct entities in most patients. These diseases are characterized by the selective infiltration of eosinophils in the stomach, small intestine, or both, with variable involvement of the esophagus, large intestine, or both.  Eosinophilic intestinal inflammation can occur secondarily in the GI tract in inflammatory bowel disease, autoimmune diseases, reactions to medications, infections, hypereosinophilic syndrome and after solid organ transplantation. 
Eosinophilic recruitement into the inflammatory tissue is thought to be a complex process regulated by IL-3, IL-5 and granulocyte macrophage colony stimulating factor (GM-CSF). ,,
The symptoms depend on the site of infiltration and the layers affected. , Eosinophilic enteritis can be asymptomatic or symptomatic. The clinical presentations of eosinophilic enteritis depend on the level of involvement. The mucosal form is the most common form and presents with vomiting, diarrhea, abdominal pain, anemia, and protein loosing enteropathy. Involvement of the muscularis is characterized by eosinophilic infiltration mainly in the muscular layer, leading to thickening of the bowel wall, resulting in obstructive symptoms. The serosal involvement occurs only in a minority of the patients and is characterized by exudative ascites with higher peripheral eosinophilic counts as compared to other forms. ,,,
CT scan may show nodular and irregular thickening of the foregut which may mimic other conditions like Crohns disease, tuberculosis or lymphoma. Since either layer of the GI tract can be involved, endoscopic biopsy can be normal in patients with the muscularis subtype, serosal subtype, or both. Despite all the clinical features, definitive diagnosis can only be made based on presence of increased eosinophils in biopsy specimens from the GI tract wall, the infiltration of eosinophils within intestinal crypts and gastric glands, the lack of involvement of other organs, and the exclusion of other causes of eosinophilia . ,, The histological characteristic is edema and an inflammatory cell infiltrate composed of eosinophils, which may appear in clumps . 
The endogenous foreign bodies or the enteroliths were first described by Pfahler and Stamm in 1915. True enteroliths of the small intestine are of three main types: (1) those consisting mainly of bile acids; (2) those consisting mainly of calcium oxalate; and (3) those consisting mainly of phosphate. Bile acid enteroliths are made up mainly of choleic acid.  In general, enteroliths rarely form within the GI tract, except in certain pathologic conditions like Crohn's disease or blind loop syndrome. In humans, enteroliths are rare and may be difficult to distinguish from gall stones. Most enteroliths are not apparent and cause no complications. However, any complications that do occur are likely to be severe. Of these, bowel obstruction is most common, followed by ileus and perforation
Steroids have a role in the management of patients with non-allergic eosinophilic enteritis. Serosal disease responds dramatically to steroids. Low-dose maintenance therapy to maintain remission is advocated. Immunosuppressive therapy with azathioprine can be used as an adjunct to steroids. If in acute exacerbations steroids are unable to control the morbidity, then sodium cromoglycate may be employed. It prevents the release of mast cell toxic mediators and can also reduce absorption of antigens by the small bowel. Chromoglycate has also been used to treat milk allergy and other gastrointestinal allergic reactions in children.  Surgery should be considered in patients with localized disease, who present with obstruction, and if treatment with steroids is unsuccessful.
The mortality related to eosinophilic gastroenteritis itself is rare. However, progressive weight loss leading to profound cachexia unresponsive to treatment can occur.  Eosinophilic gastroenteritis does not predispose a patient for GI malignancy.
Although known to cause intestinal obstruction, association of enteroliths and ileal stricture with eosinophilic enteritis has only once been reported so far in the literature, to the best of our knowledge. Eosinophilic enteritis is a diagnostic dilemma and the clinical presentation and investigations are only contributory. Surgeons must be aware of this rare cause of acute abdomen.
| References|| |
|1.||Kshirsagar AY, Jagtap SV, Kanojiya RP, Langade YB, Shinde SL, Shekhar N. Eosinophilic enteritis presenting as a rare cause for ileo-ileal intussusception. World J Gastroenterol 2007;13:6444-5. |
|2.||SA Malik, MA Yasin, G Nasreen. Eosinophilic Enteritis presenting as acute intestinal obstruction. Internet J Surg 2008;15:1528-8242. |
|3.||Karande T, Oak SN, Trivedi A, Karmarkar S, Kulkarni B, Kalgutkar A. Proximal jejunal obstruction due to eosinophilic gastroenteritis. J Postgrad Med 1996;42:121-3. |
|4.||Shivathirthan N, Maheshwari G, Kamath D, Haldar P. Enterolithiasis complicating eosinophilic enteritis: A case report and review of literature World J Gastrointest Surg 2009;1:68-70. |
|5.||Alnaser S, Aljebreen MA. Endoscopic Ultrasound and histopathologic correlates in eosinophilic gastroenteritis. Saudi J Gastroenterol 2007;13:91-4. |
|6.||Khan S, Orenstein SR. Eosinophilic gastroenteritis. Gastroenterol Clin North Am 2008;37:333-48. |
|7.||Clegg-Lamptey JN, Tettey Y, Wiredu EK, Kwawukume EY. Eosinophilic enteritis - a diagnostic dilemma. West Afr J Med 2002;21:258-9. |
Department of General Surgery, K S Hegde Medical College, Deralakatte, Mangalore - 574 160, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]