Microscopic Colitis
Eosinophilic enterocolitis – Example

This 43-year-old white male patient was admitted for work-up of chronic diarrhea. The history reached back over ten years. The clinical picture had, however, worsened significantly over the past several weeks with signs of malassimilation, such as weight loss, hypocalcemia, tetany and secondary hyperparathyroidism. The blood count was remarkable for the high number of eosinophilic granulocytes (14%) with otherwise normal leukocyte count (about 6,000/mm³). A work-up for chronic diarrhea had already been performed ten years previously: Gastroscopy and colonoscopy at that time were both unremarkable.
The current gastroscopy returned findings of erosive duodenitis. Histology revealed eosinophilic duodenitis. Biopsies of the gastric antrum and corpus were unremarkable. Colonoscopy revealed mucosal changes extending from the terminal ileum to the sigmoid colon. Changes decreased in severity from proximal to distal. The mucosal membrane was granulated and vascularity was no longer recognizable. The macroscopic picture resembled that of villous atrophy in sprue. Biopsies from the terminal ileum and entire colon showed infiltration with eosinophilic granulocytes, which was most pronounced in the terminal ileum and became less severe moving distally from the cecum. There was no thickening of the basal membrane.

The videoclip begins in the terminal ileum. There is thickened mucosa with granulated to polypoid surface. Ulcerations or bleeding secondary to tissue friability are not seen. The mucosa appears similar to the terminal ileum as the instrument is withdrawn from the cecum to the splenic flexure. Vascularity is not recognized. Beginning at the splenic flexure, the severity of the changes again begins to decline. Normal mucosa is again seen in the sigmoid colon and rectum. Vascularity is again recognizable.

Abdominal ultrasound showed the small bowel to be filled with fluid with somewhat more prominent small bowel wall but unremarkable wall structure. Similar changes are seen with malabsorption. There were a number of enlarged, oval mesenteric lymph nodes up to 17 mm in diameter.
Eosinophilic gastroenteritis is a rare disorder. It is sometimes diagnosed in patients with chronic diarrhea but macroscopically normal mucosa. Macroscopic changes are hardly ever seen at colonoscopy. It is presumed that, in this patient, the disorder had already persisted for many years. Hardly any macroscopic findings are reported in the literature. It must, therefore, remain open whether the macroscopic changes observed in this patient are in fact typical for eosinophilic enterocolitis. Treatment with budesonide (Budenofalk®) at a dose of 9 mg per day resulted in resolution of the diarrhea within one week. After four weeks, the budesonide dose was reduced to 6 mg per day. Detailed history revealed that, 15 years previously, a skin biopsy had returned findings of cutaneous mastocytosis. These skin lesions were still to be seen at present. Biopsies from all areas of the gastrointestinal tract, however, failed to detect any mast cells. The final diagnosis was “eosinophilic enterocolitis with cutaneous mastoc
tosis”.

Talley NJ. Eosinophilic gastroenteritis. In: Feldmann M, Friedman LS, Sleisenger MH (Editors). Sleisenger and Fordtran`s gastrointestinal and liver disease: Pathophysiology/diagnosis/management. 7th ed., WB Saunders Company 2002