FEBRUARY,

1966

EOSINOPHILIC
By H. JOACHIM

(ALLERGIC)
BURHENNE,
SAN

GASTROENTERITIS*
and JOHN V. CARBONE, M.i).
CALIFORNIA

M.D.,
FRANCISCO,

E OSINOPHILIC
the been given roentgenologic
The disorders.

gastroenteritis has not sufficient consideration in diagnosis of small bowel

description of this entity did

not appear in the radiologic literature until I 964, probably because the roentgenologic
appearance in the small bowel is similar to

appearance of an extramucosal, intramural filling defect. It has been described in the stomach,2 and in the small6 and large bowel, but has not been related to the eosinophilic granuloma of bone or lung. Blood eosinophilia, as that i n eosinophilic
gastroenteritis, is not seen in

eosinophilic

that of regional enteritis. The eosinophilic form

is characterized by a wall,

granuloma of gastroenteritis
thickened in one tract by

of

the

gastrointestinal
OF CASES woman was

tract.

REPORTS CASE I. A 31
year

or several regions of the alimentary a diffuse infiltrate ofpredominantly mature eosinophils. The review of the literature by Ureles et al.7 in 1961 revealed 25 cases of
this in disease 1964, entity. Edelman and March,3

old

admitted

to

the

University
because

of

California

Hospital,
with

San

Francisco,

6 weeks duration. bouts ofdiarrhea

of abdominal Associated and constipation,

symptoms of these were intermittent

philic stances
reported

accepted gastroenteritis of their

material.

diagnosis as correct own and of

The largest

the

of eosinoin 24 inpreviously
individual

cramping, ing, and

history of

diffuse supra-umbilical aggravation by laxatives.

allergic rhinitis,

pain, She

vomitgave a
from

particularly

of McCune, Gusack, and Newman,8 in 1955, with 3 cases. We believe that eosinophilic gastroenteritis is more common than initially believed. Now that instruments for biopsy of the small bowel are available, the diagnosis of eosinophilic gastroenteritis should be made more readily and frequently. We have seen the typical clinical and roentgenologic manifestations of eosinophilic gastroenteritis in 7 patients. The diagnosis was proved histologically in 4 and these patients are the subject of this report. For diagnostic data relating to diseases of the bowel, the clinician depends on the roentgenologist. The roentgenologist, therefore, should be aware of the clinical and roentgenologic criteria necessary to establish the diagnosis of eosinophilic gastroenteritis. This presentation is not concerned with the so-called eosinophilic granuloma of the gastrointestinal tract, a circumscribed polypoid lesion with the roentgenologic
*

report

is that

weeds and grasses. On physical examination the abdomen was moderately distended and a shifting dullness was noted. Abdominal paracentesis revealed
ascites ratory mm. stool containing data eosinophils. 11,000 white cent eosinophils. were Significant blood cells laboper cu. were 36 per

with

The
for

results
ova

of
and

examinations

negative

parasites. The roentgenologic

appearance

of the

small

on admission enteritis (Fig. i).

Exploration of ascitic submucosa eosinophilic logic 2). One diagnosis year later fluids. cells of the Small

bowel

was interpreted
abdomen bowel all yielded biopsy

as regional
1,500 cc.

revealed

the

to be edematous through was the eosinophilic patient

with
layers.

an infiltrate
The entenitis was re-admitted histo(Fig.

of

for evaluation of dysunia which had been present for 4 weeks. An excretory urogram showed marked thickening, up to about 3 cm., of the

entire

bladder

wall

of the stroma with eosinophils was noted. The presence of eosinophilic cystitis in this patient was reported previously.0

eosinophilic tion dense

cystitis. infiltration

(Fig. On

3).

A biopsy

revealed examina-

microscopic

The

white

blood
School

cell count
of Medicine, San

was
Francisco,

27,000

per
California.

cu.

From the

Departments

of Radiology

and

Medicine,

University

of California

332

Voi..

96,

No.

Eosinophilic

(Allergic)

Gastroenteritis

333

.3

Ii;.

i. Case i. showed irregular with thickening

Small l)owel studs narrowing of loops and rigidity of wall.

on admission of small bowel

mill.

with
of the

pet urine

cent showed

eosinophils.

The
5

examinablood
eosinophils.

11G.

tion

3 to

white

cells

of

Case i. Excretory urogram showed thickening of the entire bladder

up to wall.

cm.

per high power field lhe results of stool negative examillatioll showed turned On mission, that to normal re-examination tile pattern for ova of (ortisone

with

occasional

examinations was small

intestillab

were

again
and nelater readcontinued unmnars to be normal complaints (Fig. were ). No elicited.

atid Pitnitsites. adnlmnmstered tile the

therapy

bowel

3 months
pattern

sears

after

the

original

intestinal on At present, admission, the pa-

had the
first

(Fig.

4).

5 sears
of the

after
small

bowel

lI(,.

2. Case

i.

Photomicrograph

of small bowel. A dense infiltrate seen throughout all layers.

of biopsy specimen of eosinophils

FiG.

is

4. Case i. Re-examination of the small bowel 3 months after continued prednisone therapy showed intestinal pattern returned to normal.

334

H.

Joachim

Burhenne

and

John

V. Carbone

IE

BRI\RY,

19(6

16
11G. . Case i. Small bowel re-examined after years of prednisone therapy showed a normal roentgenologic pattern.

tient and

continues is free of

to take symptoms.

mg.

ofprednisone

daily

JIG. 6. Case ii. Upper gastrointestinal study showed an irregular infiltrate along the distal half of tile greater curvature and of tile antral portion of tile lesser curvature. Pronounced pylorospasm.

CASE

II.

ihis the

55
University

sear

old of

woman California

was

re-

submucosa dominantls distributed tologic diagnosis patient

and of in

musculanis
eosinophils.

consisting

prewas

ferred

to

Hos-

lhe

infiltrate Ihe

pital,
quadrant tion. asthma

San
For for
results

Francisco,
abdominal the bs many
of

with
pain 2 weeks

a history
of 6 pain

of left
months

lower
dura-

a penivascular
WaS

pattern. with

his-

eosinophilic

gastritis.
instructions

last

companied

diarrhea. years and

the The house

limits.

had
a history

patient dust.
examination Laboratory

been achad had

of an were data

The

was

discharged

gave

allergy The
entirels

to feathers
the within

and
normal

physical

showed #{231}o white blood cells per Cu. mm. with io per cent eosinophils. The results of stool examinations on 3 occasions were positive for guaiac reaction, but negative for ova and parasites. On gastric analysis, free acid was present only after stimulation with histalog. Roentgenobogic study of the upper gastrointestinal tract gave evidence of an irregularity in the antrum, consistent with carcinoma. Pronounced pybonospasm was noted (Fig. 6). A diagnosis of carcinoma was made. Pliability and penistalsis were present, however, by cinefluorography and polygraphy (Fig. 7). The small bowel study showed no abnormality. Gastroscopy confirmed an infiltrative process in the distal stomach. At surgery, the gastric wall was thickened to more than i cm. The
distal stomach biopsy revealed appeared to be infiltrated. The

cellular

infiltration

in

the

FIG. 7. Case (polygraph). tion.

H.

Three
Penistalsis

exposures along

on the

area

roentgenogram of infiltra-

\oi.

96,

No.

Eosinophilic cortisone. Roentgenograms

(Allergic) re-

Gastroenteri

tis

335

to

continue

petted i sear later showed the gastrointestinal tract to l)e completely normal (lig. 8). lor the past 4 years the patient has been of intestinal symptoms during which

free time

cortisone Csi
the
iii.

thera)y

has

1)een old

continued. man was admitted San Franchildhood, and of histors to

A 57 s!ear

I niversits

cisco,
chronic allergy mission abdominal

with

of California Hospital, a history of allergs since

resulting

in
bronchitis.

severe A

unticaniab strong

reaction

family

was

obtained. Three months severe paroxvsms of asthma, bloating, the cramping, abdomen

before adrecurrent and

meteorism,

diarrhea developed. On examination

was studies

distended.
revealed Stool ova

The

laboratory
per gave

moderately of the blood

power results studies field. for of

eosinophils examinations parasites.

high negative transit,

l1(i. 9. Case of several

sall.

iii. Small bowel studs loops and thickening

showed of tile

distention
intestinal

the

and small

Roentgenobogic slow thickening biopsy of of as prescribed, present, symptoms.

bowel
loops ).

showed
and

dilatation to pain

CASE the

iv.

A 52 year of

old

woman

was Hospital,

admitted San was

of several wall (Fig. showed sisting

of the intestinal the small bowel of the mucosa eosinophils, enterpatient admiscon-

University

California

Francisco, suspected
Sippy tinued,

with and
regimen however.

a chief
duration.

complaint
l)uodenal

of abdominal
ulcer

a cellular predominantly

infiltration

of 3 months

mature

the
and

patient
antacids. Upper

was

diagnosed histologically itis. Prednisone was

eosinophilic and the i year after

treated by the The pain conroent-

gastrointestinal

was
sion,

discharged. he is without

At

genograms
antrum

revealed
and duodenal (lig. io).

an incomplete
bulb, On 3 of suggestive blood

filling
of cell

of the
duocounts,

denal

ulcer

the
leukocte

number
count

of
two

eosinophils was elevated

occasions.

cent stool

on

other

was normal. The to 9 and 20 per The results of

for ova region and was

examinations were parasites. At operation, thickened formed. and The a partial histologic

negative the pybonic gastrectomy examination

was pershowed

edema
cellular clustered

of the

submucosa The

and
composed

musculanis
primarily were

and

a
of

infiltration around the

eosinophils.

infiltrates small

particularly A histologic

vessels. gastroduodenitis

diagnosis of eosinophilic made (Fig. ii). DISCUSSION

was

Although the
about surfaces
FIG.

the are well

allergic understood,

manifestations little
tivits of the is known internal

of

skin

tissue of

hypersensi

8. Case

It. Follow-up
roentgenobogic site of

study
gastrotomy

1 year

Normal curvature.

appearance

lesser

The curvature.

Figure 7. greater is seen on the

of

after

eosinophilic the strong patients

icance. Tn

the human gastroenteritis

body.

The cause is unknown, of

of but

the

family history with this entity

favor of

of allergy may be

in most signifor an

a hypersensitivity

336

H.

Joachim

Burhenne

and

John

V.

Carbone

IFBRI

RV,

1966

allergic
itis is

reaction in eoSiliophilic gastroenterthe involvement of multiple organs

i). Eosinophilic wi di cysti eosi tis, gastroenteritis nophilic pen tis, toni astis,

(Case
sociated eosinophilic asthma

has
prominent

not as

been high

bronchi reported
as

aiid has
cent in

previously. which
per

The been
eosi

eosinophilia,

reported

63

an

noph ilic gastroen ten tis, also allergic cause. In one of our
i), eosinophilia of distribution

suggests
patients

( Case
noted.
cells.

$o
are

These
Penivascular

eosinophils further
in

per cent was alwass lilature

of the cellu-

bar
..

infiltrates
reaction

favors
eosinophilic

an

ulidenivilig

allergic
.j

gastroen-

ten

tis.5

The
served
gastroentenitis
11G.
1

concentration
histologically
is more

of

eosinophils
i Ii eosi nophilic than

obill

pronounced

a.

Case
incomplete

iv.
was

L pper
filling suggested,

vealed ulcer

gastrointestinal of the antrum.

but rio crater

study rel)uodenal
was seen.

other pathologic emphasized that

component of

states. l.Treles et a/. have eosinophils are a normal

gastrointesti nal tissue7

disease

and
in

Gastric
1110111

ng was delayed. noted incidentally.

eniptyi

1)uodenal

divertic-

are Hodgki

seen ns
8

in amebi

increased disease,2 asis, gastroi

concentration
ti testinal Ii thic with linlited disease, lisperknowleosinopiiilic ilellili eosinophils tile

car-

ci noma,

and

gastric
\Vhen

ulcers.
associating reactions,

sensitivity

edge cell

about must

the be

function taken

of into

the

consideration.

Robbins13
-..I:__,4,.

stated,
to have the potentialities not
in

While
same

these

cells

are

believed phagocvtic they

sponse

chemotactic and as the neutrophil, to the defensive comparable to

leucocvtes. re-

do

contribute any fashion

of tile

the
the

4,J

1$t

contribution They appear

adrenal cortical

neutrophilic

to

be under
horniones,

the

control excess of

of

which

-:.-;

--

.-

brings blood.

about their diSappearance from Speirs14 found that eosinophilia results

alitigefl, He are of antibodies. expressed possibly

the
in

the blood stream jection of a protein

at

once from but only in

the

in-

the
the

Ti:
FIG.

sensitized that eosinophils production

animal.

belief
in

involved

That
it. Case iv. Photomicrograph of biopsy specimen of the thickened gastric wall showed eosinophilic infiltration involving all layers from mucosa (top) to serosa (lower right). intestinal lying

an
etiology

allergic
surfaces

reaction
represents

of

the the when:

gastroundertis

in eosinophilic

gastroeliteri

might

reasonably

be

assumed

(a)

eosinophils

are especially

attracted

the

VOL.

96,

No.

Eosinophilic
reaction ; (b) the

(Allergic)
eosinonon

Gastroenteri
of

tis

337

an tigen-an
phil proved (c) count

ti body

is typically eosi nophilic

high gastroen ofallergy

in patients ten

with tis ; and

a strong history The roentgenologic gastroenteritis suggest the familiar

is obtained.

appearance
is fairly diagnosis with this

in eosinotypical to the entity. and roentMor-

philic should genologist

antral narrowing and eosinophilia alert the roentgenologist to the posSi bili ty of eosinophilic gastroenteri tis. The roentgenologic di iferen tiation between eosi nophilic gastroenteri tis affecting the small bowel only and regional enteritis should
may be
usually rarely

impossible.

With
whereas in both

eosinophilic

gasenter-

troenteri
is itis

tis,

additional
present, occurs

gastric
areas

involvement
regional of the ali-

phologic
usually
antrum.

changes
limited The to
gastric

in
the

the
distal
process

stomach
half or to results

are
the in

infiltrative appearance carcinoma.

an

irregular

outline. is If possible,
gastric

The
that of pliability especially

roenta mass and

from

genographic resembling
peristalsis carcinoma the pearing are

present,

differentiation

mentarv tract. If the roentgenologic appearance indicates that eosinophilic gastroenteri tis is limi ted to the antrum, then other diseases must be considered. These are gastric carcinoma, antral gastritis culosis,
tous

mas
of in

be
the

with
disap-

accompanying syphilis,
gastritis.4

peptic and isolated

ulcer,

tuber-

use

cinefluorography.

Tumor-like
antrum

granuloma-

infiltrations

within

few
delayed

days

ported.6
flected and

Gastric
only by pvlorospasm.

involvement
Involvement

have been ma be
gastric emptying

rerethe

of

stomach was present in all 25 of the patients reviewed by Ureles and associates. The only reports of no gastric abnormality
on roentgenologic
2

examination

are

those

of

our

patients (Cases i and iii). In one patient described by Edelman and March, the additional feature of a proteinlosing enteropathy was present with gastric
involvement. Our patients were not studied

for this phenomenon. The small bowel, in addition to the stomach, was involved in about half the patients reported by Ureles et al. The first reports of involvement of small bowel alone are those of our 2 patients (Cases i and iii). The roentgenologic changes of eosinophilic gastroenteni tis involving the intestine are similar to those of inflammation or granulomatous
Segments

A characteristic clinical feature to remember is the self-limitation of eosinophilic gastroenteritis and its response to cortisone therapy. If the small bowel appears normal after a previous roentgenologic diagnosis of regional enteritis, the diagnosis of eosinophilic gastroenteritis may have been correct. We have seen 3 additional patients with blood eosinophilia and the described roentgenologic changes of either stomach or small bowel. In 2, a biopsy could not be obtained and cortisone therapy was tried before deciding upon exploration. Both patients responded well and the roentgenologic appearance returned to normal after this therapy. In the third patient, the antrum, pylorus, and small bowel were involved. After duodenal intubation and
biopsy, negative results were obtained on

disease,
of

as seen

in regional

enteritis.

ing the

of the lumen. Eosinophilic ily diagnosed

bined involvement gastric,

the small bowel show thickenwall, rigidity, and narrowing of

gastroenteritis

histologic examination. Another biopsy at a more distal intestinal level was refused and the patient was treated with cortisone. On re-examination, the roentgenologic appearance of all 3 areas of the intestinal tract had returned to normal as had the number of eosinophils.
SUMMARY

roentgenologically
pyloric, is present, and particularly

is more readif comsmall bowel

in the

presence
and March3

of

blood
pointed

eosinophilia.
out that the

Edelman
combina-

Four cases of eosinophilic (allergic) gastroenteritis are reported, including the first 2 reports of involvement limited to the small bowel.

338

H.

Joachim

Burhenne

and John

V. Carbone

FEBRUARY,

1966

The roentgenologists role in the diagnosis of eosinophilic gastroenteritis is important. This condition should be considered in patients with peripheral eosinophilia and with the described roentgenologic changes in the stomach and small bowel. An allergic reaction of the gastrointestinal surfaces is considered a likely

explanation
H. Joachim
Department

for eosinophilic
Burhenne, M.D. of Radiology

gastroenteritis.

Childrens
3700

Hospital
St. California grateful to 94122 Drs. Phibbip L. Pillsbury

San

California Francisco, are

We

and
case.

Glen

Bell

for permission

to include

their

REFERENCES .
2.

AFENDULIS,
BOCKUS,

T. C. Cited by Ureles, A. L. eta/. H. Gastroenterology. Volume I. W.

Saunders
755. 3.
EDELMAN,

Company,
M. &

Philadelphia,
MARCH,

1944,

B. p.

J., and
AM.
NUCLEAR

T. L. Eosinophibic
ROENTGENOL., RAD.
91,

gastroenteritis.
THERAPY

J.

MED.,

1964,

773-

778.
4. FAHIMI,

H. D., DEREN, J. J., and ZAMCHECK, N. Isolated gastri tis: its relationship

sarcoidosis
tero/ogy, 5.
FAHRLANDER,

and
1963,45,

regional
161-175.

L. S., granubomatous to disseminated enteritis. GastroenGOTTLIEB,

pseudotumor#{246}se allergische Gastri tis. Gastroentero/ogia, I 962, 97, 65-74. 7. HAM, A. W. Histology. J. B. Lippincott Company, Philadelphia, 1950, p. 440. 8. MCCUNE, W. S., GUSACK, M., and NEWMAN, \V. Eosinophilic gastroduodenitis with pyboric obstruction. Ann. Surg., 1955, 142, io-5i8. 9. MCKELVIE, I. J. liosinophilia with visceral manifestations: report of two cases. M. 7. AiisIra/ia, 1965, 2, 6066o8. to. PALUBINSKAS, A. J. Eosinophilic cystitis: case report of eosinophilic infiltration of urinary bladder. Radio/ogy, 1960,75, 589-59 I. ii. PARDO, M. V., and RODRIGUEZ, T. I. Eosinophilic granuloma of colon. Arch. Hosp. Univ. (Habana), 1952,4, 248-253. 12. RIGLER, L. G., BLANK, L., and HEBBEL, R. Granuboma with eosinophils: benign inflammatory fibroid polyps of stomach. Radio/ogy, 1956,66,169-176. 13. ROB BINS, S. L. Textbook of Pathology. Second edition. W. B. Saunders Company, Philadelphia, 1962, p. 66. 14. SPEIR5, R. S. Cited by Castle, W. B. Disorders of blood. In: Pathologic Physiology. Edited by W. A. Sodeman. Second edition. W. B. Saunders Company, Philadelphia, 1956, p. 8o6. 15. SPEIR5, R. S. Cited by Stanworth, D. R. Reaginic antibodies. Adv. Immuno/ogy, 1963, 3, p. 221. i6. UNNEWEHR, F., and OHRT, H. Eosinophiles Granubom des D#{252}nndarms als Ursache f#{252}r einen Ileus. Zentra/bi. Chir., 1954, 79, 91-93. 17. URELES, A. L., ALSCHI BAJA, T., LODIC0, D., and STABINS, S. J. Idiopathic eosinophilic infiltra-

tion

of gastrointestinal

tract,

diffuse

and

cir-

mentelle
Entziindungen /ogia, 1962, 6. HAFTER, E.,

H., and HUBER, F. TierexperiUn tersuchungen #{252}berallergische im D#{252}nndarm. Gastroentero97, 156-187. SIEBENMANN,

i8. R. E. Akute

and

cumscribed: proposed classification and review of literature with two additional cases. Am. 7. Med., 1961,30, 899-909. YOON, I. L. Eosinophil and gastrointestinal carcinoma. Am. 7. Surg., 1959, 97, 195-200.