Unusual cause of acute abdominal pain: Eosinophilic colitis case report and review of the literature

Eosinophilic colitis is an exceptionally rare condition, the clinical symptoms is polymorphic and non-specifi c. The diagnosis is based on the grouping of endoscopic and essentially histological, clinical arguments. We describe the case of a male patient with eosinophilic colitis revealed by bloody mucous diarrhea and acute abdominal pain. The diagnosis has been made after eliminating the parasitic, infl ammatory and drug causes. This posed a diagnostic problem for us because of the non-specifi c symptoms associated with the lack of standardized histological criteria and the lack of clear, codifi ed consensus regarding treatment. Case Report Unusual cause of acute abdominal pain: Eosinophilic colitis case report and review of the literature S Bouchrit*, A Ait Errami, Z Samlani, S Oubaha and K Krati Department of Gastroenterology, CHU Mohamed VI, Marrakech, Morocco Received: 17 February, 2021 Accepted: 05 March, 2021 Published: 06 March, 2021 *Corresponding author: S Bouchrit, Department of Gastroenterology, CHU Mohamed VI, Marrakech, Morocco, E-mail:


Introduction
Eosinophilic colitis is a rare disease of the digestive tract characterized by abnormal infi ltration of the colonic mucosa by eosinophilic polynuclear cells. Since 1979, only a few cases of eosinophilic colitis have been reported [1]. Its exact prevalence remains unknown, with a peak prevalence in newborns and young adults and without any gender preference [1].
The digestive symptomatology of eosinophilic colitis is highly variable and nonspecifi c; the clinical symptoms are dominated by diarrhea and abdominal pain. There is no histological consensus to make the diagnosis of eosinophilic colitis a polynucleareosinophils rate greater than 40 per high magnifi cation fi eld in at least two different colonic segments could be the criterion used for the diagnosis [2].
We present in this work the case of eosinophilic colitis in a 69-year-old man and we discuss in the light of data from the literature the diagnostic and therapeutic modalities of this rare and ambiguous entity.

Case report
We report the case of a 69-year-old man, operated 6 years ago for localized prostatic adenocarcinoma, without any other particular pathological history, in particular no history of atopic diseases, no known food or drug allergy and no recent trip. Admitted in a table of mucous-bloody diarrhea at a rate of 3-4 stools/day evolving for 5 days aggravated by the installation of acute abdominal pain evolving for less than 24 hours in a context of apyrexia and conservation of the general state. On clinical examination, the patient was hemodynamically and respiratory stable, temperature at 37.5°C, maximum diffuse abdominal tenderness in the left iliac fossa, on rectal examination the fi nger cot came back soiled with stool and blood.
An abdominal CT scan was performed urgently objectifying a regular and circumferential parietal thickening of the descending colon, extended to the sigmoid loop, measuring 15mm thick extended over 20cm and obstructing the lumen in places, enhanced after injection of contrast product with hyperemia and infi ltration of neighboring mesenteric fat. The free prostatectomy compartment without nodular lesions.
The biological blood test showed a predominantly eosinophilic hyperleukocytosis and the serum immunoglobulin E level assay was normal at 40KU/l (N <150 KU/l). The results of the biological test represented in the following Table 1. A left colonoscopy performed with progression to the left colonic angle showing a fragile erythematous mucosa bleeding on contact with an interval of healthy mucosa, located in the descending colon of a large digging ulceration, staged biopsies were performed ( Figure 1).
Anatomopathological study objective a subacute and chronic exulcerative and infl ammatory reshuffl es with a richness in eosinophils (more than 100 eosinophils/mm 2 ), architectural disorganization, without signs of specifi city or malignancy ( Figure 2).
The three coproparasitological examinations of stools returned negative.
In front of blood eosinophilia, the richness in eosinophils in the histological study of colonic biopsies, the negativity of the copro-parasitological examinations of the stool, and the absence of secondary causes of colonic eosinophilia, the diagnosis of eosinophilic colitis was retained and the management was to put the patient on corticosteroid therapy (prednisone) orally full dose at 1mg/kg/day for 1 month then decrease over 8 weeks associated with a diet with avoidance of six foods (soy, wheat, eggs, milk, peanuts, shellfi sh) for 6 weeks then gradual re-introduction of each product. infl ammation by releasing toxic cationic proteins [7]. It can probably be both an IgE and non-IgE mediated disease [8].
The diagnosis of eosinophilic colitis is a diagnosis of exclusion, it is based on the association of non-specifi c gastrointestinal symptoms, the demonstration of an eosinophilic infi ltration on the biopsies, and the exclusion of the causes secondary effects of eosinophilic infi ltration such as parasitosis, drugs, chronic infl ammatory digestive disease, malignant causes, autoimmune damage and hypereosinophilic syndrome [8,9]. There are no standardized histological criteria to make the diagnosis [1]. Imaging results are nonspecifi c and may show thickening of the colonic wall as well as ascites in some cases [10].
The treatment of eosinophilic enterocolitis remains a challenge in the absence of specifi c recommendations as there are no controlled trials to date on a specifi c treatment [11]. So far, the treatment of eosinophilic enterocolitis has been empirical and based on the severity of clinical manifestations, as well as the experience of clinicians. Patients with mild disease can be treated symptomatically, while more symptomatic patients and those with signs of malabsorption need more aggressive treatment [12].
A high proportion of cases of eosinophilic gastroenteritis are associated with food allergy. Therefore, diet therapy can improve symptoms [10]. It involves a "six-food elimination   diet", avoiding milk, soy, eggs, wheat, peanuts, tree nuts and shellfi sh.
Corticosteroids are the optimal therapy for the induction of remission. Oral prednisone is the most common therapy, with an initial dose of 0.5-1mg/kg and decreased over a period of 6-8 weeks. Relapses can occur and require low maintenance doses (1 to 10mg / day) of prednisolone [13] or the substitution of prednisolone by budesonide which has a better safety profi le [14,15].
Other therapies targeting immune modulation have been described in reports and small case series are likely to be helpful in treating recurrent or refractory symptoms. They include mast cell inhibitors such as cromolyn, ketotifen, leukotriene receptor antagonists, anti-IL-5 antibodies, omalizumab and anti-IgE monoclonal antibodies [12].

Conclusion
Our clinical case highlights a rare condition of the digestive tract which is often underdiagnosed. Eosinophilic colitis is rarely described and remains a diagnosis by exclusion, hence the need for further studies in order to better defi ne the diagnostic criteria and the therapeutic attitude towards this rare and unknown entity.