EL REENCANTAMIENTO DEL MUNDO Una ética para nuestro tiempo Michel Maffesoli Prólogo a esta edición La ética inmoralista y el espíritu del neotribalismo En el paisaje actual de la sociología contemporánea, Maffesoli tiene un lugar muy singular: se encuentra lejos de cualquier moda intelectual y a contrapelo de las corrientes dominantes, lo que naturalmente le confiere una relativa soledad. Esa singularidad resulta paradójica: a pesar de nutrir el centro de su reflexión sobre fuentes indudablemente sociológicas, predica en el desierto como un profeta alejado de la comodidad institucional de la disciplina.
Gastrocol.comCase Report of Eosinophilic Gastroenteropathy and a
Sandra Roberto A,1, Rómulo Bonilla G, MD,2 Gabriel Pérez G, MD.3 1 Fourth year medical student at the Hospital Universitario de Santander of the Universidad Introduction: Eosinophilic gastroenteropathy is a rare disease characterized by infiltration of eosinophils into one
Industrial de Santander in Bucaramanga, Colombia or more layers in different parts of the gastrointestinal tract especially the stomach and the duodenum. Although 2 Surgeon, Gastroenterologist and Adjunct Professor in most cases it presents with abdominal pain, vomiting, diarrhea, ascites and weight loss may also appear. Case
at the Hospital Universitario de Santander of the report: The patient was a 41 year old man with a clinical picture of 9 months of sudden, intermittent abdominal pain
Universidad Industrial de Santander in Bucaramanga, Colombia (predominantly mesogastric pain which radiated to the lumbar region). He had been treated with antispasmodics but 3 Medical Pathologist and Adjunct Professor at had not improved. Eleven years earlier he had had a right nephrectomy because of hydronephrosis. Three years the Hospital Universitario de Santander of the earlier he had been diagnosed and treated for hypochromic microcytic anemia with hypereosinophilia. Two years Universidad Industrial de Santander in Bucaramanga, Colombia earlier he had had an acute myocardial infarct, although angiography showed healthy coronary arteries. Seven months earlier he developed acute appendicitis. The pathology report at that time showed eosinophilic infiltrates, This case was presented at the XXVII International and a bone marrow biopsy revealed eosinophilia. Physical examination showed normal vital signs, but his bowel Scientific Congress (XXVII Congreso Científico Internacional – FELSOCEM) in Santiago, Chile sounds were more intense and frequent (40/min) than normal, and he suffered mesogastric pain on palpation. There from the 25th to the 29th of September, 2012. The were no masses or organomegaly. Laboratory tests revealed anemia and 16% eosinophilia. Diagnostic images poster's name was Gastroenteritis Eosinofilica. showed esophageal and gastric ileitis with microscopic evidence of eosinophil infiltration in all samples. Eosinophilic Reporte de un Caso y Revisión de la Literatura (Case Report of Eosinophilic Gastroenteropathy and a gastroenteropathy was diagnosed, and the patient was started on a hypoallergenic diet and treated with prednisone. Literature Review) Up to 25% of patients with hypereosinophilic syndrome may have gastrointestinal infiltration. Eosinophilic gastroen- teropathy should be suspected in any patient with abdominal pain and peripheral eosinophilia. However, peripheral eosinophilia is not always present, and histopathological diagnosis is necessary.
Received: 23-04-14 Accepted: 05-11-14 Gastroenteropathy, eosinophilic gastroensteritis, hypereosinophilic syndrome.
in 100,000 patients treated (3, 4). Our review found only three cases reported in Colombia since 2007 which con- Eosinophilic gastrointestinal disorders are quite rare and firms this entity's rarity (5).
unusual diseases which are characterized by excessive Although its cause and pathogenic mechanism are not infiltration of the bowel wall. Kaijser first described this yet clear, up to 75% of these patients have allergies to entity in 1937 in two patients who had syphilis and who medicines and/or foods and/or have atopic diseases such were allergic to neoarsphenamine (1). Between that time as asthma (5-8). This condition can affect any area of the and 2008 more than 300 cases have been reported (2). Of gastrointestinal tract although the stomach and small intes- the 4 mil ion patients estimated to have been treated at the tine are the most frequently compromised. The symptoms Mayo Clinic between 1950 and 1987, only forty were diag- of eosinophilic gastroenteropathy (GE) are not specific nosed with eosinophilic gastroenteritis: an incidence of 1 to this condition and vary according to the histologically 2014 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología 410 affected layer (9). We present a case of hypereosinophilic sisted of a hypoallergenic diet which eliminated all wheat, syndrome in a patient with chronic abdominal pain with no milk, soy, peanuts, seafood and eggs, and administration of history of allergy or atopic reactions.
25 mg of prednisone each day. A week after implementa- tion of treatment, the patient reported significant improve- CASE DESCRIPTION
ments of symptoms.
The patient was a forty-one year old man who had suffe- red chronic abdominal pain for nine months. He had seen several physicians for sudden onset of intermittent pain of Eosinophils in the gastrointestinal tract are responsible moderate intensity (9/10 on a subjective scale of pain). for innate immunity to parasites, regulation of lympho- The pain was located predominantly in the mesogastric cytes, antigen presentation and protection against tumors. region but radiated to the lumbar region and was associated Nevertheless, over-stimulation of eosinophils generates with fatigue, weakness and pallor. This condition had been excessive degranulation which can lead to severe inflam- managed with antispasmodics without complete resolution mation, production of neurotoxins and reactive oxygen of symptoms. The patient stated that he had had no fever, species which are responsible for the typical symptoms of diarrhea or vomiting. His medical history showed that eosinophilic gastroenteropathy (10, 11). Apparently aller- 11 years earlier he had undergone a retroperitoneoscopic gic processes in which there are excessive release of mast nephrectomy because of hydronephrosis. Four years before cel s and eosinophils and excessive TH2 cell responses to we examined him, he had been diagnosed with gastritis and allergens bear a significant relationship with this uncontro- a biopsy showed eosinophilic infiltrates. The following year lled activation. An association with Interleukin 5 has also he was diagnosed with hypochromic microcytic anemia been reported because it induces proliferation, growth, with hypereosinophilic for which he had required a total of differentiation, activation and apoptosis of eosinophils (5).
12 transfusions of packed red blood cel s and continuous Depending on the location of the compromised tis- administration of ferrous sulfate and folic acid. Two years sue, eosinophilic gastroenteropathy may be identified as before we examined him he had suffered an acute myo- esophagitis, gastritis, duodenitis or colitis. The last is excep- cardial infarct although angiography showed that he had tionally rare and only a few cases have been reported since healthy coronary arteries. Seven months prior to our exa- 1979. It has a very non-specific symptoms of fever, diarr- mination of the patient, he underwent an appendectomy. hea, abdominal pain and weight loss (12). The pathology report stated that the diagnosis was, "acute In 1970, Klein classified this disease according to the fibrinopurulent appendicitis with eosinophilic infiltration". depth of involvement (13): The patient stated that he had no type of atopy or allergic • The Mucosal Form (25% to 100%) most often affects
reaction to medications or food.
the stomach and is manifested by anemia, fecal blood The patient had lost 20 kg which was associated with loss and weight loss.
hyperoxia. Physical examination showed normal vital • The Muscular Form (13% to 70%) manifests through
signs, generalized mucocutaneous paleness, loud and fre- nausea, vomiting, diarrhea, abdominal cramps, and quent bowel sounds (40/min), a soft abdomen which was painful upon deep palpation in the mesogastric region, and • The Serosal Form (12% to 40%) manifests through
no masses or organomegaly.
eosinophilic ascites, high levels of peripheral eosino- Laboratory reports showed hemoglobin of 5.8 g/dL, philia and severe inflammation (3, 5, 9, 10).
hematocrit at 19.9%, and 16% eosinophilia. Endoscopy identified gastritis, duodenitis, terminal ileitis, colitis and Hypereosinophilic syndrome is a rare disorder defined aphthoid ulcers in the rectum. Biopsies of all samples by a peripheral eosinophilia greater than 1,500 cel s/mL showed edema and congestion of the lamina propria and for more than six consecutive months, the absence of an the mucosa with a mixed leukocyte influx that was predo- underlying cause of hypereosinophilia and the presence of minately eosinophilic (up 22 per high power field). There organ damage or dysfunction associated with hypereosino- were no signs of H. pylori in the glandular apical surface. philia. The most frequently affected organs are the heart, Also, a bone marrow biopsy revealed greater than usual lungs, central nervous system, kidneys and skin (7, 14).
number of eosinophils.
In this case the patient had suffered peripheral eosinophi- When all patient data, records and examinations were lia for three years with the involvement the appendix and correlated a diagnosis of eosinophilic gastroenteropathy gastrointestinal tract which are both very infrequent sites in the context of hypereosinophilic syndrome was made. for hypereosinophilic syndrome (14). It is also important A treatment plan was developed and implemented. It con- to highlight that this patient had undergone a myocardial Case Report of Eosinophilic Gastroenteropathy and a Literature Review 411 infarct event though he had healthy coronary arteries. This could be attributed to eosinophilic infiltration although confirmation of this diagnosis would require a heart biopsy which is not available in our area. Consequently, the exact cause of the heart attack remains unknown.
Diagnosis of eosinophilic gastroenteropathy is based on three criteria: gastrointestinal symptoms, eosinophilic infiltration in one or more areas and exclusion of other causes of intestinal eosinophilia such as tuberculosis and Helicobacter pylori infections which are very frequent in our environment (3, 4).
Diagnosis of 80% of these patients is done through upper digestive tract endoscopy of the stomach and small intestine. In most cases, macroscopic study of the gastroin- testinal mucosa shows normal mucosa, slight edema and congestion, and even ulcers or lesions with nodular confi- gurations (15).
Microscopic examination will find dense, predominantly eosinophilic, inflammatory infiltrate in which there can be up to 20 eosinophils per high-power field (Figure 1). This infiltrate is distributed in the lamina propria and may also be accompanied by formation of aggregates in crypt abs- cesses that permeate the glandular epithelium. These can be distributed in diffuse or nodular patterns and can be accompanied by outbreaks of ulceration of the glandular epithelium with regenerative alterations and severe edema. Tissue damage may extend beyond the mucosa into the muscle and serous layers (Figure 2). In addition, up to 10% the study of mucosal biopsies may show no changes (Figures 3 and 4). At least six biopsies may be required to Figure 2. Eosinophilic compromise of the cecal appendix
reach a diagnosis of one segment (15-17).
Figure 3. Macroscopically normal gastric antrum
A large group of diseases must be considered in differen- tial diagnosis. These include parasites such as roundworms and hookworms; reactions to drug such as enalapril, car- Figure 1. Colonic mucosa and reactive changes with predominance of
bamazepine, and clotrimazole; connective tissue diseases including scleroderma, dermatomyositis and lupus; vas- Rev Col Gastroenterol / 29 (4) 2014 culitis syndrome (Churgstrauss Disease and poliarteririts REFERENCES
nodosa); celiac disease; eosinophilic leukemia; Crohn's disease and ulcerative colitis (2, 3, 5).
1. Kaijser R. Zur Kenntnis der allergischen Affektionen des Verdawungskanal vom standpunkt desi Chirugen aus. Arch Klin Chir 1937; 188: 36-64.
2. Famularo G, Prantera C, Nunnari J, Gasbarrone L. Eosinophilic gastroenteritis in a young man. CMAJ 2011; 183(1): E65-7.
3. Gamarra V, Nova A, Herrera A. Gastroenteritis eosi- nofílica con ascitis: presentación de un caso clínico. Rev Gastroenterol Perú 2011; 31(2): 173-7.
4. Liao W, et al. A rare case of spontaneous resolution of eosi- nophilic ascites in a patient with primary eosinophilic gas- troenteritis. Chang Gung Med J 2012; 35(4): 354-9.
5. Rocha N, Aponte D, Huertas S, Sabbagh LC. Gastroenteritis eosinofílica: reporte de caso y revisión de la literatura. Rev Medica Sanitas 2011; 14 (2): 8-11.
Figure 4. Macroscopically normal distal esophagus
6. Rodríguez R, Bohórquez M, González I, Torregroza G. Desórdenes eosinofílicos gastrointestinales (DEGI): presenta- ción de dos casos. Rev Col Gastroenterol 2007; 22(2): 138-148.
Steroids are the cornerstone for treatment of eosinophi- 7. Alnaser S, Aljebreen AM. Endoscopic ultrasound and histo- lic gastroenteropathy. The most commonly recommended pathologic correlates in eosinophilic gastrienteritis. Saudi J is prednisone at a dosage of 1-2 mg/kg/day for eight weeks. Gastroenterol 2007; 13(2): 91-4.
Improvement usually occurs within two weeks. Budesonide 8. Busoni V, et al. Gastroenteropatía eosinofílica: una serie has also been widely used, but it does not have enough high pediátrica. Arch Argent Pediatr 2011; 109(1): 68-73.
impact studies to be recommended (18). Nevertheless, 9. Martinez D, et al. Colitis eosinofílica. Rev cubana med relapses are common with these drugs. When they occur 2012; 51(1):91-8.
repeated or longer maintenance therapy at low doses is 10. Baig M, Qadir A, Rasheed J. A Review of Eosinophilic required (3-6, 10). Gastroenteritis. J NatI Med Assoc 2006; 98: 1616-9.
Although not enough studies have been done about 11. Hepburn IS, Sridhar S, Schade RR. Eosinophilic ascites, an making dietary modification a part of the established unusual presentation of eosinophilic gastroenteritis: A case therapy, a prospective study of adults with eosinophi- report and review. World J Gastrointest Pathophysiol 2010; 1(5): 166-170.
lic gastroenteropathy conducted by Gonsalves et al. has 12. Alfadda AA, Storr MA, Shaffer EA. Eosinophilic colitis: epi- demonstrated clinical remission with dietary elimination demiology, clinical features, and current management. Ther in six weeks. In that study, significant reductions in symp- Adv Gastroenterol 2010; 4(5): 301-9.
toms, complete histological resolution and endoscopically 13. Klein NC, Hargrove RL, Sleisenger MH, et al. Eosinophilic verifiable normalization of peripheral eosinophilia was gastroenteritis Medicine (Baltimore) 1970; 49(4): 299-319.
achieved in six weeks for three of the seven adults who 14. Roufosse FE, Goldman M, Cogan E. Hypereosinophilic participated in an empirical food elimination diet. The diet syndromes. Orphanet J Rare Dis. 2007; 2: 37.
eliminated wheat, corn, eggs, milk, peanuts, fish and sea- 15. Bhattacharya B. Chapter 3. Non-Neoplastic disorders food (19). Other drugs which have been used in various of the stomach. Lacobuzio-Donahue CA, Montgomery studies include cromolyn sodium (20, 21), ketotifen (22, E. Gastrointestinal and liver pathology. Second edition. 23), montelukast (24, 25) and omalizumab (26), but these Philadelphia: Elsevier; 2012. p. 105-107.
16. Talley NJ, Shorter RG, Phil ips SF, Zinsmeister AR. drugs have not been shown to have greater efficacy than Eosinophilic gastroenteritis: a clinicopathological study of prednisone (10).
patients with disease of the mucosa, muscle layer, and subse- This case demonstrates how correlation of signs, symp- rosal tissues. Gut 1990; 31(1): 54-8.
toms, history and an appropriate clinical approach make 17. Lee JH, Rhee PL, Kim JJ, Koh KC, Paik SW, Han JH, Ree diagnosis of a rare disease possible. This is reflected in HJ, Rhee JC. The role of mucosal biopsy in the diagnosis of the absolute remission of a chronic condition suffered by chronic diarrhea: value of multiple biopsies when colonos- the patient. It should be noted that the prevalence of this copic finding is normal or nonspecific. Korean J Intern Med disease is increasing and proper guidance can completely 1997; 12(2): 182-7. change the prognosis for these patients if we are well infor- 18. Prussin C. Eosinophilic Gastroenteritis and Related med about this entity.
Eosinophilic Disorders. Gastroenterol Clin N Am 2014; 43: Case Report of Eosinophilic Gastroenteropathy and a Literature Review 413 19. Serrano OJ, Bonil a RA. Colitis eosinofílica perforada. Med 24. Bolukbas FF, Bolukbas C, Uzunkoy A, Baba F, Horoz M, UIS 2010; 23: 255-8.
Ozturk E. A dramatic response to ketotifen in a case of eosi- 20. Gonsalves N, Doerfler B, Yang G, Hirano I. A prospective nophilic gastroenteritis mimicking abdominal emergency. clinical trial of six food elimination diet or elemental diet Dig Dis Sci 2004; 49(11-12): 1782-5.
in the treatment of adults with eosinophilic gastroenteritis. 25. Neustrom MR, Friesen C. Treatment of eosinophilic gas- Gastroenterology 2009; 136(5): A280.
troenteritis with montelukast. J Allergy Clin Immunol 1999; 21. Van Dellen RG, Lewis JC. Oral administration of cromolyn 104(2Pt 1): 506.
in a patient with protein-losing enteropathy, food allergy, 26. Quack I, Sel in L, Buchner NJ, et al. Eosinophilic gastroente- and eosinophilic gastroenteritis. Mayo Clin Proc 1994; ritis in a young girl--long term remission under Montelukast. 69(5): 441-4.
BMC Gastroenterol 2005; 5: 24.
22. Pérez-Mil án A, Martín-Lorente JL, López-Morante A, 27. Foroughi S, Foster B, Kim N, et al. Anti-IgE treatment of López-Morante A, Yuguero L, Sáenz- Rayuela F. Subserosal eosinophil-associated gastrointestinal disorders. J Allergy eosinophilic gastroenteritis treated efficaciously with Clin Immunol 2007; 120(3): 594-601.
sodium cromoglycate. Dig Dis Sci 1997; 42(2): 342-4.
23. Melamed I, Feanny SJ, Sherman PM, Roifman CM. Benefit of ketotifen in patients with eosinophilic gastroenteritis. Am J Med 1991; 90(3): 310-4.
Rev Col Gastroenterol / 29 (4) 2014
„Black Caviar" im Gestüt ÖARV-Championat 2013 . 2Veranstaltungskalender . 2Wir gratulieren recht herzlich! . 2ÖARV – Aktuell . 3Mein Freund Ewald . 4FEGENTRI-Generalversammlung, Cannes 15. Februar 2013 . 7FEGENTRI – Cagnes sur Mer, 16. Februar 2013 . 8 Qatar, 27./28. Februar 2013 . 10 Oman, 3./4. April 2013 . 12 Budapest, 21. April . 15 Rom,19. Mai 2013 . 17 USA, 7. bis 10. Juni 2013 . 18 Göteborg, 23. Juni 2013 . 21 Oslo, 6. Juli 2013 . 23 Köln, 13. Juli 2013 . 24H.H. Sheikha Fatima Bint Mubarak Ladies IFAHR Cup Houston, Texas, 9. März 2013 . 26 Casablanca, 12. April 2013 . 28 Toulouse, 9. Juni 2013 . 31 Duindigt, Holland, 23. Juni 2013 . 32Pisa, World Cup of Nations, 24. März 2013 . 35Chantilly, Frankreich, 27. April 2013 . 36Internationales Amateurrennen, Budapest, 20. Mai 2013 . 38Historische Siege für Amateure . 39ÖARV-Sommerfest . 40