Eosinophilic gastroenteritis with refractory ulcer disease and gastrointestinal bleeding as a rare manifestation of seronegative gastrointestinal food allergy

Abstract

Gastrointestinal bleeding and iron deficiency anaemia may cause severe symptoms and may require extensive diagnostics and substantial amounts of health resources.This case report focuses on the clinical presentation of a 22 year old patient with recurrent gastrointestinal bleeding from multilocular non-healing ulcers of the stomach, duodenum and jejunum over a period of four years. Extensive gastroenterological and allergological standard diagnostic procedures showed benign ulcerative lesions with tissue eosinophilia, but no conclusive diagnosis. Multiple diagnostic procedures were performed, until finally, endoscopically guided segmental gut lavage identified locally produced, intestinal IgE antibodies by fluoro-enzyme-immunoassay.IgE antibody concentrations at the intestinal level were found to be more-fold increased for total IgE and food-specific IgE against nuts, rye flour, wheat flour, pork, beef and egg yolk compared with healthy controls.Thus, a diet eliminating these allergens was introduced along with antihistamines and administration of a hypoallergenic formula, which resulted in complete healing of the multilocular ulcers with resolution of gastrointestinal bleeding. All gastrointestinal lesions disappeared and total serum IgE levels dropped to normal within 9 months. The patient has been in remission now for more than two years.Eosinophilic gastroenteritis (EG) is well known to induce refractory ulcer disease. In this case, the mechanisms for intestinal damage and gastrointestinal bleeding were identified as local gastrointestinal type I allergy. Therefore, future diagnostics in EG should also be focused on the intestinal level as identification of causative food-specific IgE antibodies proved to be effective to induce remission in this patient.

A Case of Proton Pump Inhibitor–Resistant Multiple Gastric Ulcers Caused by Eosinophilic Gastroenteritis

“…In recent reports, patients were diagnosed and treated successfully with prednisolone [1][2][3] or food elimination. 4 In this case, ulcer healing was confirmed after prednisolone, and recurrence was observed after cessation. Low-dose prednisolone maintenance therapy may be needed.…”

“…In this case, mild peripheral eosinophilia was observed, however, the serum IgE level was normal and radioallergosorbent test results were negative. Raithel et al 4 reported increased intestinal foodspecific IgEs in a case in which serum food-specific IgEs were negative. Therefore, food allergy cannot be eliminated completely in this case.…”

The management of eosinophilic gastroenteritis

“…Elimination diets are more successful if a limited number of food allergies are identified in the patient [21]. However, standard allergy testing is not always predictive of the food triggers [22,23]. Despite strict adherence to the diet, patients may still have symptoms.…”

Excretion of urinary histamine and N-tele methylhistamine in patients with gastrointestinal food allergy compared to non-allergic controls during an unrestricted diet and a hypoallergenic diet

“…Thus, urine samples collected after 6 p.m. and their mediator values obtained reflect more precisely the endogenous 12-hour histamine production overnight than exogenous histamine intake [ 13 - 15 , 20 ]. In addition, further standardisation was achieved by expression of all mediator excretion rates in relation to renal function and body surface area [ 12 - 15 , 21 , 22 ]. Finally, the results reported here arise from a cohort of fully confirmed GMA, since usual allergy tests were refined by search for intestinal IgE and proven by BPCFCs [ 4 , 7 , 9 , 11 , 12 , 16 , 21 ].…”

“…However, UMH excretion was found to be highly significantly enhanced in both IgE- and non-IgE type of GMA patients than in controls under both diet forms, showed lower rates of intraindividual variation and it has been reported to reflect more precisely alterations of the histamine metabolism than histamine itself [ 12 - 14 , 21 , 22 ]. UMH presents as a possible indicator of systemic histamine production and it was found to increase in urine during early and late phase allergic asthmatic reactions [ 12 , 19 , 21 - 23 ]. The distribution of individual UMH levels in GMA and controls showed a considerable overlap, but in controls most patients (86.4%) were found to have UMH excretion rates lower than 6.2 (mean + 1SD).…”