18 F-FDG PET/CT in Lupus Enteritis Presenting With Fever and Abdominal Pain.

ABSTRACT: Systemic lupus erythematosus is a systemic autoimmune disease associated with various manifestations. Here, we report a compelling case of a 42-year-old woman who presented with lupus enteritis as a sole manifestation of systemic lupus erythematosus and underwent 18 F-FDG PET/CT. The resected bowel segment revealed vasculitis, and subsequent workup revealed positive antinuclear and anti-double-stranded antibody levels, confirming lupus enteritis, thus highlighting the diagnostic role of 18 F-FDG PET/CT in reaching the final diagnosis.

Long-term prognosis and its associated predictive factors in patients with eosinophilic gastroenteritis.

BACKGROUND: Eosinophilic gastroenteritis (EGE) is a chronic recurrent disease with abnormal eosinophilic infiltration in the gastrointestinal tract. Glucocorticoids remain the most common treatment method. However, disease relapse and glucocorticoid dependence remain notable problems. To date, few studies have illuminated the prognosis of EGE and risk factors for disease relapse. AIM: To describe the clinical characteristics of EGE and possible predictive factors for disease relapse based on long-term follow-up. METHODS: This was a retrospective cohort study of 55 patients diagnosed with EGE admitted to one medical center between 2013 and 2022. Clinical records were collected and analyzed. Kaplan-Meier curves and log-rank tests were conducted to reveal the risk factors for long-term relapse-free survival (RFS). RESULTS: EGE showed a median onset age of 38 years and a slight female predominance (56.4%). The main clinical symptoms were abdominal pain (89.1%), diarrhea (61.8%), nausea (52.7%), distension (49.1%) and vomiting (47.3%). Forty-three (78.2%) patients received glucocorticoid treatment, and compared with patients without glucocorticoid treatments, they were more likely to have elevated serum immunoglobin E (IgE) (86.8% vs 50.0%, P = 0.022) and descending duodenal involvement (62.8% vs 27.3%, P = 0.046) at diagnosis. With a median follow-up of 67 mo, all patients survived, and 56.4% had at least one relapse. Six variables at baseline might have been associated with the overall RFS rate, including age at diagnosis < 40 years [hazard ratio (HR) 2.0408, 95% confidence interval (CI): 1.0082-4.1312, P = 0.044], body mass index (BMI) > 24 kg/m2 (HR 0.3922, 95%CI: 0.1916-0.8027, P = 0.014), disease duration from symptom onset to diagnosis > 3.5 mo (HR 2.4725, 95%CI: 1.220-5.0110, P = 0.011), vomiting (HR 3.1259, 95%CI: 1.5246-6.4093, P = 0.001), total serum IgE > 300 KU/L at diagnosis (HR 0.2773, 95%CI: 0.1204-0.6384, P = 0.022) and glucocorticoid treatment (HR 6.1434, 95%CI: 2.8446-13.2676, P = 0.003). CONCLUSION: In patients with EGE, younger onset age, longer disease course, vomiting and glucocorticoid treatment were risk factors for disease relapse, whereas higher BMI and total IgE level at baseline were protective.

Etiologic and Anti-microbial Susceptibility Profiles of Bacterial Urinary Tract Infection and Bacterial Enteritis among Children at a Private Multi-Specialty Healthcare Facility in Abuja, Nigeria: A 5-Year Separate and Comparative Review.

BACKGROUND: Urinary tract infection (UTI) and enteritis are major causes of morbidity and mortality in children. A combined profiling of UTI and enteritis could be helpful since stool plays a major role in the etiopathogenesis of UTI. AIM: This study aimed to examine and compare bacterial UTI and bacterial enteritis in respect of their etiology and anti-microbial susceptibility (AMS) in children aged 0 to 17 years at Alliance Hospital, Abuja. MATERIALS AND METHODS: This is a retrospective descriptive study of urine cultures in children who were investigated for UTI and of stool cultures in those investigated for enteritis. Data of 543 urine cultures and 614 stool cultures from January 1, 2017 to May 31, 2022 were retrieved. Bacterial yields, percentage susceptibility (PS), log-normalized susceptibility value (SVn), percentage of multi-drug-resistant (MDR) pathogens, and multiple anti-microbial resistance index (MARI) were computed and compared. RESULTS: The bacterial yields of urine and stool cultures were 29% and 34%, respectively. Escherichia coli was the most common bacterial cause of UTI and enteritis. Overall susceptibility was sub-optimal and similar between uropathogens and enteropathogens [PS, 64% vs. 62%; mean SVn, 5.75 vs. 5.62 (P = 0.564)]. Levofloxacin was the most effective anti-microbial agent against both uro- and entero-pathogens, while amoxicillin clavulanate and cotrimoxazole were among the least effective. The burdens of MDR uro- and entero-pathogens were 39% and 46%, and their MARIs were 0.36 and 0.38, respectively. CONCLUSIONS: Like in many healthcare institutions, Escherichia coli is the most common bacterial cause of UTI and enteritis in children at our facility. Second-generation fluoroquinolones remain effective against bacterial UTI and bacterial enteritis in children. Stool AMS surveillance could potentially be a surrogate strategy for urine AMS surveillance in children. Training and re-training on anti-microbial stewardship remain crucial in Nigeria.

Eosinophilic enteritis in a case of cystic fibrosis: an elusive diagnosis with an elementary cure.

A late adolescent man diagnosed with cystic fibrosis and presenting with predominantly gastrointestinal symptoms, including chronic constipation, exocrine pancreatic insufficiency and gastro-oesophageal reflux disease, experienced recurrent episodes of nausea, vomiting and abdominal pain. CT of the abdomen unveiled the presence of chronic appendicitis, alongside constipation without evidence of distal intestinal obstruction syndrome. Endoscopic biopsies revealed small bowel eosinophilic infiltrates. Subsequently, the patient underwent an appendectomy, and a tailored regimen was established to address constipation, resulting in an initial alleviation of his symptoms. Three months later, a resurgence of symptoms occurred, coinciding with persistent intestinal eosinophilic infiltrates. A diagnosis of eosinophilic enteritis was rendered, and treatment commenced with an oral dosage of 40 mg of prednisone. Two weeks later, the patient experienced symptom resolution, corroborated by the findings of an endoscopic biopsy conducted 8 weeks later. During a follow-up examination 6 months later, the patient remained asymptomatic.

Eosinophilic enteritis presenting as intestinal obstruction: case report and review of the literature.

Eosinophilic enteritis (EE) is characterized by intense eosinophilic infiltrate of the gastrointestinal tract. Clinical manifestations depend on the affected segment and intestinal layer. First-line treatment is systemic corticosteroids; surgery is reserved for complications. 84-year-old male patient with a history of right hemicolectomy and two episodes of intestinal obstruction presented to the ED with abdominal pain, distension, nausea, and vomiting. CBC showed leukocytosis and no eosinophilia. Contrast-enhanced CT revealed stenosis with thickening of the distal intestinal wall and partial intestinal obstruction. Colonoscopy found aphthous ulcers. Histopathology reported EE. The patient received budesonide and metronidazole, with resolution within 24 h.

La enteritis eosinofílica (EE) se caracteriza por infiltrado eosinofilico del tracto GI. Las manifestaciones clínicas dependen de la capa intestinal afectada. Se recomiendan esteroides sistémicos como primera línea de tratamiento, reservando la cirugía para complicaciones. Masculino de 84 años con antecedente de hemicolectomía derecha y dos episodios de oclusión intestinal acude al servicio de urgencias con dolor abdominal, distensión, náusea y vómito. Laboratorio reportó leucocitosis, sin eosinofilia. Tomografía con contraste evidenció estenosis, con engrosamiento de la pared del intestino delgado e imagen compatible con oclusión intestinal. La colonoscopía demostró ulceras en íleon terminal la cual reporto EE. Se inició tratamiento con budesonide y metronidazol, con adecuada respuesta y resolución a las 24 h.

Review of Non-Eosinophilic Esophagitis-Eosinophilic Gastrointestinal Disease (Non-EoE-EGID) and a Case Series of Twenty-Eight Affected Patients.

Eosinophilic gastrointestinal disease (EGID) is divided into eosinophilic esophagitis (EoE) and non-eosinophilic esophagitis eosinophilic gastrointestinal disease (non-EoE-EGID) based on the involved gastrointestinal segments. Reports regarding non-EoE-EGID are limited, in part because of its rarity. The present study was performed to review non-EoE-EGID, including its pathogenesis, diagnosis, treatment, and prognosis. Additionally, details regarding 28 cases of non-EoE-EGID recently diagnosed at our Japanese tertial medical center are presented and compared with 20 EoE cases diagnosed during the same period at the same medical center. Comparisons of the two groups clarified differences regarding age- and gender-dependent prevalence between the two conditions, and also showed that systemic involvement and disease severity were greater in the non-EoE-EGID patients. Notably, diagnosis of non-EoE-EGID is difficult because of its lack of specific or characteristic symptoms and endoscopic findings. The clinical characteristics of EoE and non-EoE-EGID differ in many ways, while they also share several genetic, clinical, laboratory, and histopathological features.

Ethical Implications of Continuing Oral Immunotherapy After the Development of Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease requiring maintenance therapy. Traditionally, EoE has been a contraindication to oral immunotherapy (OIT) and a rationale for discontinuing treatment because OIT may induce EoE. Most, but not all patients with OIT-induced EoE experience symptom resolution and histologic remission after discontinuing OIT. Recent studies report OIT continuation even after EoE onset, despite the previously accepted standard of care. This creates clinical as well as ethical challenges for allergists treating these patients. Considering the published literature on EoE and OIT and the primary medical ethics principles of beneficence, nonmaleficence, autonomy, and justice, we discuss the ethical implications of pursuing desensitization despite the potential complications associated with EoE. When ethical principles are in opposition, shared decision-making should be employed to determine whether OIT should be continued after an EoE diagnosis. This article highlights the ethical dilemmas allergists face when determining whether patients with a diagnosis of EoE should continue OIT.

18 F-FDG PET/CT Reveals Localized Inflammation in Lupus Enteritis.

ABSTRACT: Lupus enteritis is classified into the colon poly-ulcerative type and the small intestine ischemic serositis type. Colon poly-ulcerative lupus enteritis is a disease that is mainly due to mesenteric arteritis. In recent years, 18 F-FDG PET/CT has been frequently used to assess the extent of the disease in patients with systemic vasculitis. We present the case report of 18 F-FDG PET/CT results in a 57-year-old woman with colon poly-ulcerative lupus enteritis.

Early life exposures as risk factors for non-esophageal eosinophilic gastrointestinal diseases.

OBJECTIVES: Early life exposures increase risk of eosinophilic esophagitis (EoE), but it is unknown whether they contribute to increased risk for non-EoE eosinophilic gastrointestinal diseases (EGIDs). We aimed to assess the association between prenatal, antenatal, and early life factors and non-EoE EGIDs. METHODS: We conducted a case-control study based in EGID Partners, an online patient-centered research network. Adults (≥18 years) with non-EoE EGIDs, caregivers of children <18 years of age with an EGID, and non-EGID adult controls were eligible. Subjects completed our Early Life Exposure Questionnaire, detailing maternal and early childhood exposures. We assessed for associations between non-EoE EGIDs and early life exposures, focusing on exposures previously evaluated in association with EoE. RESULTS: We analyzed 61 non-EoE EGID cases and 20 controls. Of the EGID cases, 14 had eosinophilic gastritis, 19 had eosinophilic enteritis, 6 had eosinophilic colitis, and 22 had multiple areas affected; additionally, 30 had esophageal involvement. Relative to controls, EGID cases were more likely to have had antenatal/perinatal pregnancy-related complications (43% vs 13%; p = 0.02), NICU admission (20% vs 0%; p = 0.03), and antibiotics in infancy (43% vs 10%; p = 0.01). With adjustment for age at diagnosis, we observed increased odds of an EGID for pregnancy complications (aOR 3.83; 95% CI: 0.99-14.9) and antibiotic use in infancy (aOR 7.65; 95% CI: 1.28-45.7). CONCLUSIONS: Early life factors, including pregnancy complications, NICU admission, and antibiotics in infancy, were associated with development of non-EoE EGIDs. The impact of early life exposures on non-EoE EGID pathogenic mechanisms should be investigated.

Eosinophilic enteritis requiring differentiation from chronic enteropathy associated with SLCO2A1 gene: A case report.

BACKGROUND: Eosinophilic gastrointestinal disease (EGID) is a disorder characterized by infiltration of eosinophils causing mucosal damage and dysfunction of the gastrointestinal tract. The endoscopic findings of eosinophilic enteritis (EoN), an EGID variant, are nonspecific and occasionally difficult to diagnose. In contrast, chronic enteropathy associated with SLCO2A1 (CEAS) is a chronic persistent small intestinal disorder characterized by endoscopic findings such as multiple oblique and circular ulcers. CASE SUMMARY: We report the case of a 10-year-old boy who had suffered abdominal pain and fatigue for the preceding 6 mo. He was referred to our institute for investigation of suspected gastrointestinal bleeding because of severe anemia with hypoproteinemia and positive fecal human hemoglobin. The upper and lower gastrointestinal endoscopic findings were normal; however, double-balloon small bowel endoscopy showed multiple oblique and circular ulcers with discrete margins and mild constriction of the intestinal lumen in the ileum. The findings were highly consistent with CEAS, but urine prostaglandin metabolites were within normal limits, and no previously reported mutations in the SLCO2A1 gene were identified. Histological evaluation demonstrated moderate to severe eosinophilic infiltration localized to the small intestine suggesting a diagnosis of EoN. Clinical remission was maintained with montelukast and a partial elemental diet, but emergent surgery for bowel obstruction due to small intestinal stenosis was performed two years after the initial treatment. CONCLUSION: EoN should be considered in the differential diagnosis of CEAS-like small intestinal ulcerative lesions and normal urinary prostaglandin metabolite levels.

Stress Ulcer Prophylaxis in Cardiac Surgery: A Retrospective Cohort Study to Analyze the Effects of SUP Cessation.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is an important complication among critically ill adults, especially those having cardiac surgery as management is complicated by the requirement for antiplatelet/anticoagulant therapy. As a result, stress ulcer prophylaxis (SUP) has become routine practice in many centers, utilizing either proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs). Recent evidence from the PEPTIC trial indicated an increase in mortality risk among cardiac surgery patients receiving PPIs compared to H2RBs. Considering these findings, alongside practical difficulties surrounding the transition to H2RBs as a prophylactic agent in New Zealand, Wellington Hospital intensive care unit elected to discontinue routine PPI use for SUP in cardiac surgery patients. A retrospective study was conducted to assess patient outcomes following the discontinuation of routine SUP. METHOD: A retrospective cohort study was conducted of all adult patients who underwent cardiac surgery at Wellington Hospital between February/2018 and January/2022, and divided patients into cohorts before and after the discontinuation of routine use of SUP on the 31st of January 2020. The primary outcomes were the rate of UGIB, oesophagogastroduodenoscopy (OGD) and 180-day postoperative mortality. Secondary outcomes included rates of postoperative Clostridium difficile enteritis, pneumonia, deep sternal wound infection, and length of stay of the index admission. RESULTS: The rate of UGIB statistically significantly increased since the cessation of routine SUP in January 2020 (2.4% vs 5.4%, P-value = .004). This finding was mirrored with the increased rates of OGD (1.9% vs 4.0%, P-value = .005). There were no significant changes in 180-day mortality, hospital length of stay, or any of the postoperative infective complications analyzed, pneumonia, deep sternal wound infection, or C difficile enteritis. CONCLUSION: This study suggests an association between routine use of SUP and reduced rates of clinically significant UGIB and OGD requirements in cardiac surgery patients without increasing risk of infective complications or postoperative mortality.

Eosinophilic Esophagitis beyond Eosinophils - an Emerging Phenomenon Overlapping with Eosinophilic Esophagitis: Collegium Internationale Allergologicum (CIA) Update 2023.

Having long been considered the mainstay in eosinophilic esophagitis (EoE) diagnosis and pathogenesis, the role of eosinophils has been questioned and might be less important than previously thought. It is well known now that EoE is a Th2-mediated disease with many more disease features than eosinophilic infiltration. With more knowledge on EoE, less pronounced phenotypes or nuances of the disease have become apparent. In fact, EoE might be only the tip of the iceberg (and the most extreme phenotype) with several variant forms, at least three, lying on a disease spectrum. Although a common (food induced) pathogenesis has yet to be confirmed, gastroenterologists and allergologists should be aware of these new phenomena in order to further characterize these patients. In the following review, we discuss the pathogenesis of EoE, particularly those mechanisms beyond eosinophilic infiltration of the esophageal mucosa, non-eosinophilic inflammatory cell populations, the new disease entity EoE-like disease, variant forms of EoE, and the recently coined term mast cell esophagitis.

Discrepancy between Abdominal Symptoms and Endoscopic Findings in Patients with Gastro-duodenal Eosinophilia: A Case Series.

Some patients present gastro-duodenal eosinophilia without abdominal symptoms. Nine cases with gastro-duodenal eosinophilia were seen at the Tohoku University Hospital between January 2011 and June 2022. Seven (78%) patients had a background of allergic or hyper-eosinophilic disease. Esophagogastroduodenoscopy showed erosions (n=6), discoloration (n=4), ulcers (n=3), erythema (n=3), muskmelon-like appearance (n=2), and cracks (n=1). Two cases were asymptomatic with eosinophilic gastroenteritis (EGE)-like endoscopic findings, and two were symptomatic with normal endoscopic findings. The discrepancy between the abdominal symptoms and esophagogastroduodenoscopy findings suggests that clinicians should assess patients for background allergic disease, regardless of abdominal symptoms.

Two cases of eosinophilic gastrointestinal disorder due to newly appearing food allergies after cord blood transplantation.

Eosinophilic gastrointestinal disorders (EGIDs) are infrequent complications after allogeneic hematopoietic cell transplantation (allo-HCT). Furthermore, it is well-known that allergic diseases are transferable after allo-HCT from allergic donors to non-allergic recipients. However, the type of graft-versus host disease (GVHD) prophylaxis that leads to allergic disease transfer is unclear. Furthermore, no study has reported a case of acquired food allergy resulting in EGID that was detected based on the clinical course and the detection of antigen-specific immunoglobulin E after allo-HCT. We encountered two patients with acute leukemia accompanied by eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE) due to newly appearing food allergy after cord blood transplantation (CBT) with T-cell non-depletion GVHD prophylaxis. Despite having no history of allergic disease, the patients experienced allergic symptoms due to dairy products (Case 1) and eggs (Case 2) after CBT. They subsequently experienced severe nausea, heartburn, and anorexia (Case 1) and diarrhea (Case 2). Cases 1 and 2 were diagnosed with EoE and EGE, respectively, based on endoscopic and histological examinations. Dietary treatment without steroids improved the symptoms in both cases. These cases highlight that the unexpected transfer of food allergy after CBT can lead to EGIDs, especially in patients receiving T-cell non-depletion GVHD prophylaxis.

A rare case of Pseudomonas aeruginosa enteritis induced by pembrolizumab.

A 72-year-old male had pseudomonal enteritis related to pembrolizumab. Chemotherapy for hypopharyngeal carcinoma with lung metastasis comprised cisplatin, 5-FU, and pembrolizumab. On day 14 of chemotherapy treatment he had a sudden prominent abdominal bulge, decreased consciousness, and drop in blood pressure in septic shock. CT scan showed marked intestinal gas through to intrahepatic bile ducts. Pseudomonas aeruginosa was simultaneously detected in both blood and stool cultures. Intestinal endoscopy revealed ulcerative lesions from the transverse colon to the rectum. Pathological investigations indicated apoptosis of the villus. The patient was diagnosed with pseudomonal enteritis induced by immune-related adverse events from the use of pembrolizumab. Treatment by corticosteroid and meropenem were subsequently switched to cefepime and metronidazole, and this successfully improved his colitis. In this new era of biological-targeted drugs and as clinical experience grows, we recommend a high level of alertness for potential diagnosis of infectious complications.

Small Intestinal Perforation Secondary to Necrotizing Enteritis-An Under-Recognized Complication of Crohn's Disease.

Small bowel perforation is an uncommon but severe event in the natural history of Crohn's disease with fewer than 100 cases reported. We review Crohn's disease cases with necrotizing enteritis and share a case of a 26-year-old female who presented with a recurrent episode of small intestinal perforation. A PubMed literature review of case reports and series was conducted using keywords and combinations of "Crohn's disease," "small intestine perforation," "small bowel perforation," "free perforation," "regional enteritis," and "necrotizing enteritis." Data extracted included demographic data, pre- or postoperative steroid administration, medical or surgical management, and case fatality. Nineteen reports from 1935 to 2021 qualified for inclusion. There were 43 patients: 20 males and 23 females with a mean age of 36 ± 15 years old. 75 total perforations were described: 56 ileal (74.6%), 15 jejunal (20.0%), 2 cecal (2.7%), and 1 small intestine non-specified (2.7%). 38 of 43 patients were managed surgically by primary repair (11), ostomy creation (21), or an anastomosis (11). Of 11 case fatalities, medical management alone was associated with higher mortality (5/5; 100% mortality) compared to those treated surgically (6/38; 15.8% mortality; P < .001). Patient sex, disease history, acute abdomen, and pre- or postoperative steroid use did not significantly correlate with mortality. Jejunal perforation was significantly (P = .028) associated with event mortality while ileal was not (P = .45). Although uncommon, necrotizing enteritis should be considered in Crohn's patients who present with small intestinal perforation. These cases often require urgent surgical intervention and may progress to fulminant sepsis and fatality if not adequately treated.