ABDOMINAL PAIN AND DIARRHEA - IT S NOT (ALWAYS) WHAT YOU THINK. Yakov Wainer, MD Gastroenterology and Hepatology Meir Medical Center

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1 ABDOMINAL PAIN AND DIARRHEA - IT S NOT (ALWAYS) WHAT YOU THINK Yakov Wainer, MD Gastroenterology and Hepatology Meir Medical Center

2 1 ST ADMISSION y/o female Abdominal pain, diarrhea - intermittent since 2014 PE: no fever, vital signs normal, no abnormal findings Medical history: asthma, smoking Ambulatory workup - negative Stool test: C. Diff - negative Culture/parasites - negative

3 DISCHARGED

4 Persistent recurrent symptoms + weight loss - 10 kg WBC 21k, CRP 0.7, amylase 1800, lipase 1700 C. Diff - negative CT: thickened colonic wall ( pancolitis ), small amount of peritoneal fluid Treated with metronidazol + Ceftriaxone Improvement of pain but diarrhea continues Discharged home 2 ND ADMISSION weeks later- Returns to hospital Diarrhea continues no leukocytosis

5 40 yo female Diarrhea and abdominal pain for >3 years Weight loss Three admissions Pancolitis on CT Celiac screen negative C. Diff - negative Fecal cultures and Parasites - negative Charcot-leyden crystals SUMMARY What s Next?

6 ENDOSCOPY Sigmoidoscopy without preparation (patient refusal): normal colonic mucosa- no stool in bowel! Pathology: eosinophilic colitis

7 REVISION OF BLOOD WORK

8 EOSINOPHILIC ENTERITIS - EPIDEMIOLOGY Prevalence (in the US) 22 to 28/100,000 Affect patients of any age Typically 3 rd -5 th decades Peak age of onset 3 rd decade Slight male predominance

9 CLINICAL MANIFESTATION 50% of patients history of atopy: asthma, food sensitivities, eczema, rhinitis etc. Symptoms depend on affected part and layer of GI tract Most common GI involvement: Stomach, SB, Colon Might be part of systemic illness

10 CLINICAL MANIFESTATION (cont.) Mucosal infiltration: Abdominal pain, nausea, vomiting, diarrhea Malabsorption, protein-losing enteropathy, weight loss. Infiltration of muscle layer: Symptoms of intestinal obstruction Dysphagia, early satiety, regurgitation Perforation or obstruction Sub-serosal: Ascites

11 LABORATORY Peripheral eosinophilia: 80% of patients range from 5-35 % average absolute count 1000 cells/microl Iron deficiency ESR normal IgE elevated

12 DIAGNOSIS Eosinophils normaly occur in parts of the GI-mucosa no clear cutoff for diagnosis exist

13 DIAGNOSIS (cont.) Elevated eosinophils in biopsy (in comparison with normal levels) Infiltration within intestinal crypts and gastric glands Exclusion of other causes of tissue eosinophilia (Infections, IBD ) Gastric micronodules (and/or polyposis)

14 DIAGNOSIS (cont.)

15 WORKUP EOSINOPHILIC INFLAMAION ON BOPSY NORMAL EOSINOPHIL COUNT R/O: INFECTION CELIAC IBD DRUGS HIGH EOSINOPHIL COUNT R/O OTHER ORGAN INVOLVEMENT : ECHOCARDIOGRAM CXR BONE MARROW BIOSY FIP1L1-PDGFRA FUSIONGENE ANALYSIS

16 TREATMENT Dietary therapy: elimination diet Steroids: budesonide 9 mg/d or prednison Motelukast - leukotriene antagonist Omalizumab - anti-ige monoclonal antibody Mepolizumab IL5- Antagonist patients FIP1L1-PDGFRA fusion gene - imatinib

17 BACK TO OUR PATIENT Received 3 courses of budesonide for flare-ups (each for 2 weeks) Prompt response of symptoms within the first 24 hours of treatment FIP1L1-PDGFRA fusion gene- negative Echocardiogram and bone marrow normal Recurrent symptoms and asthma exacerbation Started treatment with mepolizumab

18 TAKE HOME MESSAGES should be suspected in patients with eosinophilia >500 Recurrent/chronic diarrhea, abdominal pain, vomiting with no obvious cause The endoscopic picture might be normal Workup should include other organ systems Multidisciplinary FU for other affected organs

19 THANK YOU!