Eosinophilic gastroenteritis

SUMMARY Analysis of the heights and weights of about 85% of school entrants in Leeds in 1982 and 1983 showed that the distribution at a mean of 5-3 years is similar to the accepted standard centiles and confirms the appropriateness of the use of these standards at this age.

SUMMARY We report two children with eosinophilic gastroenteritis-a 14 month old atopic boy with persistent vomiting and aspiration pneumonitis illustrates the mucosal variety of the disorder, and a 9 year old boy with eosinophilic ascites typifies serosal involvement.
Eosinophilic infiltration of the gut wall may affect the mucosa, muscularis layer, or the serosa. Each has a distinctly different clinical presentation and the two children we now report illustrate some features of the clinical spectrum.
Case reports Case 1. This boy was fully breast fed and thrived until he was 6 months old. Two weeks after introducing cows' milk and various solid foods he developed persistent vomiting and subsequent poor weight gain. Physical examination, chest radiograph, and urine culture were normal. Barium meal at the age of 11 months showed mild gastrooesophageal reflux but no obstruction. Neither milk exclusion nor 'Gaviscon' improved his vomiting. At age 14 months he collapsed after vomiting and at bronchoscopy food material was removed from both main bronchi. Mechanical ventilation, together with antibiotics and hydrocortisone, were required to treat his aspiration pneumonitis. On reintroducing a normal diet, vomiting recurred. Further questioning revealed two previous episodes of wheeze after vomiting and also facial and lip swelling after certain foods (apple, rhubarb, baked beans, and egg). His mother and maternal grandmother have asthma.
A peripheral eosinophilia (3-09x 109/l) was present on hospital admission and persisted. His serum IgE concentration was 1890 IU/l (normal less than 10), and specific IgE antibodies to milk, egg copyright. white and yolk, wheat, nuts and beans were present. Duodenal biopsy showed a considerable infiltration of eosinophils in the lamina propria, and no parasites.
Vomiting continued despite chlorpheniramine and cimetidine but stopped once a hypoallergenic diet excluding milk, beef, eggs, chicken, salicylates, dyes, and preservatives was introduced. He remains well six months later but challenge with egg induced vomiting, and with milk, vomiting and wheeze. Case 2. A 9 year old Caucasian boy presented with 10 days' central abdominal pain and distension, and diarrhoea for one day. There was no history of atopy, foreign travel, nor medication except Asilone for two days. His height and weight were on the third centile. Ascites was present and tenderness was detected on deep abdominal palpation.
Investigation showed a peripheral eosinophilia (13-9x 109/l). The following tests were normal: blood urea and electrolytes, liver function tests; blood culture; chest radiograph; electrocardiograph; M mode echocardiogram; urine microscopy and culture; urinary vanillyl mandelic acid screen; serum immunoglobulins; and blood T cell, T subset, and B cell numbers. His total IgE concentration was 15 IU/ml (normal less than 10), and radioallergosorbent tests to rye grass, house dust mite, aspergillus fumigatus, dog hair, cat fur, milk protein, egg white, fish, and wheat were all negative. Antinuclear factor and autoantibodies to smooth muscle, mitochondria, and parietal cells were absent. Culture for  enteric bacteria was negative as were serological tests for aspergillus fumigatus, toxocara, fasciola, yersinia, hydatid, and trichinella. Abdominal ultrasound confirmed ascites; abdominal computed tomogram and barium meal were normal. The ascitic fluid was bloody, rich in eosinophils and protein (44 gm/l), and sterile on bacterial, tuberculous, and fungal culture. Laparotomy excluded abdominal malignancy but ascites, fibrinous exudate on the serosa, and mesenteric lymph node enlargement were found. Mesenteric node biopsy and bone marrow both showed eosinophilia. Prednisolone (2 mg/kg per day) resulted in rapid resolution of symptoms and ascites. The eosinophil count fell to nil but rose again on stopping treatment (Figure). This and two subsequent relapses showed the need for maintenance steroid treatmentcurrently 5 mg on alternate days.

Discussion
Eosinophilic gastroenteritis, an infiltration of parts of the gastrointestinal wall with eosinophils and a peripheral blood eosinophilia, was first described by Kaijser in 1937. It affects young adults predominantly,1 and is rare in childhood.
Gut involvement is mainly proximal, the clinical features depending on which layer is predominantly affected. Mucosal involvement (33%) causes vomiting, diarrhoea, and blood loss with resultant anaemia, malabsorption, protein losing enteropathy, and subsequent weight loss or, in children, growth retardation. Infiltration of the muscularis layer (50%) results in thickening of the gut wall and subsequent obstruction. Serosal involvement (10 to 20%) causes an exudative ascites rich in eosinophils and protein.
Although allergic features occur in less than half of the reported cases,2 our first child clearly shows an atopic aetiology. The absence of eczema and staphylococcal skin infection make the hyper-IgE (Job's) syndrome very unlikely. Colon et aP report a boy aged 4 months with pyloric obstruction due to submucosal eosinophilic gastroenteritis. Obstruction was excluded in our patient by barium studies, and his persistent vomiting was probably associated with the duodenitis seen at endoscopy. His presentation with an acute, life threatening respiratory collapse emphasises the need for earlier recognition of this entity. Indiscriminate use of exclusion diets is to be avoided. Where food antigens are clearly implicated immunologically, however, as in this patient, a strict exclusion diet is indicated. Steroids have been used successfully.' In some cases, especially those with copyright. on 2 May 2019 by guest. Protected by http://adc.bmj.com/ atopic features, oral disodium cromoglycate has induced remission. A 16 year old boy with mucosal disease showed no improvement with combined disodium cromoglycate and cimetidine treatment. 2 The serosal variant, illustrated by case 2, is rare in childhood but has been reported in an 18 month old boy4 and two girls aged 2 years5 and 15 years.6 The differential diagnosis includes vasculitic disorders such as polyarteritis nodosa, abdominal lymphoma, long term peritoneal dialysis, or rupture of a hydatid cyst. Despite its sinister presentation, it responds readily to steroid treatment, although continued low dosage may be needed to maintain remission as in case 2.
Eosinophilic gastroenteritis carries a good long term prognosis.
We thank Dr C J F Spry, Dr A C Campbell, and Dr A Edwards of Fisons Ltd for their helpful comments.