Q:

5/8/2014
Do you know if there any allergy or GI clinics in the U.S. that have a special interest in eosinophilic GI diseases that are NOT eosinophilic esophagitis? I am seeing a 58 yo BF with Past. Med Hx. only of HTN and high cholesterol and IgE -mediated crustacea allergy with 3 yrs of episodic indigestion/UGI pain, who recently has undergone three EGDs, and biopsies show "up to 70 eosinophils per HPF and up to 130 mast cells per HPF" in the stomach, and this mucosa was also grossly friable and bleed a lot when poked during the EGD. Her esophagus is totally normal, and no h/o sx to suggest EoE. She does not have any signs/sx of mastocytosis, and no LGI sx, and her colonoscopy is totally normal.

The pathologist said that the bx findings "are not entirely typical of eosinophilic gastritis". She has no h/o hay fever or asthma. She does have a h/o IgE mediated allergy to shrimp and lobster. Food skin prick panel of 80 foods was all negative (shrimp, lobster, and crab revealed flares and mild itching, but wheal size not large-enough to call positive, so I ordered in-vitro IgE to shellfish). She has not been able to correlate any certain foods/food groups with triggering of her sx. I have ordered a CBC to check for peripheral eosinophilia

Any help or advice on how to further work-up this pt. would be greatly appreciated. Her GI dr. just started her on Entocort (budesonide) and placed her on PPI one month ago.

A:

Thank you for your inquiry.

Eosinophilic gastritis is a reasonably rare condition; I have no personal experience with it and I am not personally aware of any center that deals specifically with this disorder. However, there are several institutions in the United States which have published on eosinophilic gastroenteropathies. The two that come to mind are:

1. The Digestive Health Institute, Section of Pediatric Gastroenterology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital, Denver, Colorado.

Also there has been an influx of pediatric allergists interested in food allergy in this department including Drs. Dan Atkins and David Fleischer. I am not sure, however, whether they would be willing to see an adult at this institution.

2. There have been publications on eosinophilic gastroenteropathies from the Mayo Clinic in Rochester, Minnesota, from the Department of Internal Medicine. I think that you might also consider this institution.

Finally, as you know, Dr. Marc Rothenberg is an internationally known expert in eosinophilic esophagitis. Although you have clearly stated that this condition is not eosinophilic esophagitis, Dr. Rothenberg may know of other centers in the United States because of his interest in eosinophilic disorders in general. Therefore I am asking Dr. Rothenberg to let us know whether or not there are other institutions to be considered. When I receive his response, I will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

Below is the response we received from Dr. Marc Rothenberg. Thank you again for your inquiry and we hope this response is helpful.

Warm Regards
Phil Lieberman MD

Response from Dr. Rothenberg:
EG typically is associated with atopy and peripheral blood eosinophilia. If the patient has none of these, including normal IgE, I would be concerned about another process such as infection, including H pylori. It could also be a drug induced response, underlying malignancy (e.g. lymphoma), collagen vascular disorder, part of IBD, etc.

We do see adult patients with EG, if there is an interest in a second opinion.

Sincerely yours,
Marc E. Rothenberg MD, PhD
Director, Division of Allergy and Immunology Director, Cincinnati Center for Eosinophilic Disorders Professor of Pediatrics Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine

AAAAI - American Academy of Allergy Asthma & Immunology