A Patient with Eosinophilic Gastroenteritis Presenting with Acute Pancreatitis and Ascites
A 68-year-old woman was admitted with abdominal pain, nausea, vomiting, and watery diarrhea after eating a high protein and fat diet ("Chueotang" which is loach in hot bean paste soup) 1 day ago. She had a history of recurrent epigastric pain and nausea for the past 3 years. There was no history of drug allergy, bronchial asthma, allergic rhinitis or hepatitis except for hypothyroidism. She had been taking levothyroxine, cimetidine, and rebamipide for 2 years and had not taken a new medicine recently. She was not consuming alcohol or any illicit drug. Physical examination was unremarkable except for mild epigastric tenderness. Laboratory investigations indicated a white blood cell count of 6,800/mm3 with high percentage of eosinophils (18.4%). The serum biochemistry showed an aspartate aminotransferase of 50 IU/L, alanine aminotransferase of 39 IU/L, amylase of 253 U/L, lipase of 478.71 U/L, and triglycerides of 66 mg/dL. Serum immunoglobulin E (IgE) and immunoglobulin G4 (IgG4) levels were in the normal range. Antinuclear antibody was negative. Abdominopelvic computed tomography (CT) was performed under the diagnosis of acute pancreatitis. It revealed diffuse wall thickening in the duodenum at the 2nd and 3rd portions, mild edema of small bowel loops and a moderate amount of ascites. However, there was no evidence of gallstones, abnormality of the pancreas or peripancreatic fluid collection (). We diagnosed her as Balthazar grade A of acute pancreatitis based on the elevated amylase/lipase and normal pancreas on CT. Esophagogastroduodenoscopy (EGD) was performed to examine the duodenal wall thickening found on CT. EGD findings showed mild erythematous mucosal change with atrophy on the antrum but the duodenum was unremarkable. Bowel rest and supportive care including intravenous fluids and acid-reducing agents were initiated. The level of amylase and lipase decreased to the normal range on the following day and her abdominal pain gradually decreased within a week. However, mild epigastric pain persisted and subsequent laboratory examination on the 7th hospital day showed that blood eosinophils had increased to 39.8% and the eosinophil count was 3.5×103/µL (normal, 0.04-0.5×103/µL). Stool examination for ova and parasites was negative. Allergen skin prick test was also negative. At that time, we thought of the possibility of EGE because her GI symptoms continued even after treatment and the eosinophilia was more aggravated without any other obvious cause. So we decided to perform EGD and colonoscopy again to take a biopsy from the GI tract. The 2nd look-EGD revealed aggravated linear mucosal erythema of the antrum and multifocal patchy erythematous mucosal lesions on the 2nd portion of the duodenum, which were not observed in the initial EGD (). However, there was no evidence of papillitis. Colonoscopy revealed erythematous mucosal changes of the terminal ileum. Multiple biopsies were obtained from the normal mucosa to the erythematous lesions on the stomach, duodenum and ileum. Histological examination indicated chronic inflammation with increased eosinophils in the lamina propria from the duodenal erythematous lesion (). The patient was treated with 30 mg of prednisolone and 10 mg of montelukast for 1 month. Her symptoms improved immediately and the eosinophil count normalized within 2 weeks. Prednisolone was tapered over 8 weeks and montelukast was used 4 more months. The follow-up EGD after 8 months showed normal antral and duodenal mucosa (). One year after presentation, her symptoms recurred, with elevated levels of amylase, lipase and blood eosinophil counts. The patient was treated with oral prednisolone and montelukast again, and then her upper abdominal pain resolved and the eosinophil count normalized.