Clinical Case Summary

Eosinophilic Colitis (EoC) is a rare diagnosis in adults. The exact pathogenesis is not yet understood. EoC is a diagnosis of exclusion. Here, we describe the case of a 48-years old gentleman previously healthy, status post cholecystectomy who presented to the gastroenterology clinic with 3 months history of loose stool after eating. Patient opened his bowel 2-3 times a day, it was normal in color, without blood or mucus associated with cramping abdominal pain partially relieved with defecation and postprandial abdominal bloating. Patient denied taking any medication.
Examination was unremarkable except for gaseous abdominal distension. Investigations showed elevated fecal calprotectin148ug/ml and IgE 183IU/mL. TSH, TTG IgA&IgG, CBC, ESR, CRP were unremarkable. Ultrasound abdomen showed fatty liver. Gastroscopy showed gastric antral erythema and few duodenal bulb erosions. Biopsies were taken and histopathology revealed reactive gastropathy with negative H pylori and chronic duodenitis with increased lamina propria eosinophils. Ileocolonoscopy showed normal colonic mucosa, diverticulosis in the sigmoid colon, a small tubular adenoma in the cecum that was removed with cold snare. Random colon biopsies revealed increased eosinophils in the lamina propria without evidence of characteristic changes of IBD confirming diagnosis of EoC. He was started on PPI, montelukast and budesonide 6 mg daily with primary clinical response. Budesonide was reduced to 3mg oral daily after a month and then discontinued with a telephone follow up in 1 month confirming clinical remission. Our case highlights the challenge of diagnosing and treating EoC since this entity is rare and there are no clear guidelines available.

References

Díaz Del Arco C, Taxonera C, Olivares D, Fernández Aceñero MJ. Eosinophilic colitis: Case series and literature review. Pathol Res Pract. 2018 Jan;214(1):100-104. doi: 10.1016/j.prp.2017.09.029. Epub 2017 Oct 18. PMID: 29103770.
Egan M, Furuta GT. Eosinophilic gastrointestinal diseases beyond eosinophilic esophagitis. Ann Allergy Asthma Immunol. 2018 Aug;121(2):162-167. doi: 10.1016/j.anai.2018.06.013. Epub 2018 Jun 22. PMID: 29940308.
Impellizzeri, Giovanna, et al. "Eosinophilic colitis: A clinical review." Digestive and Liver Disease 51.6 (2019): 769-773.‏

Introduction

Celiac disease (CD) is an autoimmune enteropathy induced by the ingestion of gluten in genetically predisposed individuals. Although its clinical expression is most often digestive, extra-digestive manifestations can occur, among which thromboembolic complications, although rare, deserve particular attention.
The aim of this study is to describe the profiles of coeliac patients with thromboembolic complications, analyze their clinical, paraclinical and etiological characteristics, and discuss the underlying pathophysiological mechanisms.

Aims & Methods

This is a retrospective, descriptive, monocentric study conducted in the hepato-gastroenterology department of Ibn Sina Hospital in Rabat over a 30-year period, from 1995 to 2025. The records of 344 patients followed for celiac disease were reviewed. Patients with one or more documented thromboembolic complications during follow-up were included in the study. Clinical, biological, endoscopic and histological data were collected and analyzed.

Results

Of a total of 344 patients followed for celiac disease in the department, 5.5% (n=19) developed a thromboembolic complication during follow-up. The population concerned was predominantly female, with 89.5% women (n=17) versus only 10.5% men (n=2). The mean age at the time of complication was 39.6 years, with a median of 35.5 years, and extremes ranging from 18 to 62 years.
Endoscopic exploration (oesogastro duodenal fibroscopy) in these patients showed lesions suggestive of celiac disease in 68.4% (n=12), while it was non-specific in 31.6% (n=6), and normal in 5.3% (n=1). Histologically, villous atrophy was found in all patients, with 78.9% (n=15) showing total atrophy (Marsh IIIc) and 21.1% (n=4) subtotal atrophy (Marsh IIIb).
As regards thromboembolic manifestations, portal vein thrombosis was the most frequent complication, observed in 57.9% of cases (n=11). It was followed by deep vein thrombosis of the lower limbs, reported in 15.8% of cases (n=3), and ischemic stroke in 10.5% (n=2). Isolated cases of thrombosis of the inferior vena cava, axillary vein and femoral vein were recorded, each accounting for 5.3% of cases (n=1).
The etiological study revealed hyperhomocysteinemia in 36.8% of patients (n=7) and protein C and/or S deficiency in 21.1% (n=4). In the remaining 42.1% of patients (n=8), the thrombophilia work-up was normal, suggesting that celiac disease itself was the cause of the thrombotic event.
Therapeutically, all patients were treated with oral anticoagulation. One patient required a vena cava filter because of the risk of bleeding on anticoagulation, and another underwent surgical treatment for axillary thrombosis. The outcome was favorable in all cases, with no recurrence or major complication during follow-up.

Conclusion

Thromboembolic complications in celiac disease are rare but potentially serious. This study highlights the predominance of women, the diversity of thrombotic localizations, and the possible involvement of hyperhomocysteinemia and C/S protein deficiencies. In almost half the cases, no thrombophilic cause has been identified, suggesting a role for celiac disease in the genesis of these events. Clinical vigilance is essential, particularly in cases of late diagnosis or poor compliance with the gluten-free diet.

Introduction

Biliary and gastric outlet obstruction (GOO) are common complications in patients with pancreatic cancer, often delaying essential cancer treatments. While endoscopic ultrasound-guided
gastroenterostomy (EUS-GE) has been shown to be superior to duodenal self-expandable metal stents (dSEMS) for managing GOO, the optimal strategy for biliary drainage (BD) in this setting remains unclear. Specifically, there is no consensus on whether to prefer EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided hepaticogastrostomy (EUS-HGS).

Aims & Methods

We conducted a systematic review and meta-analysis to identify the optimal biliary drainage approach in patients undergoing EUS-GE for concomitant GOO and biliary obstruction. We searched Medline, Scopus, and EMBASE up to February 2025. Studies were included if they reported outcomes of EUS-CDS or EUS-HGS in patients with biliary obstruction and concomitant GOO
treated by EUS-GE. Pooled outcomes included technical and clinical success, stent dysfunction, and adverse events, analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs).

Results

Five studies met inclusion criteria, comprising 128 patients (female = 45.5%; mean age range 63.0–73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were conducted in Europe and one in the United States; one study was prospective. Technical success rates were similar between groups (RR 0.96, 95% CI 0.83–1.11; I² = 0%; EUS-CDS 94.5% vs EUS-HGS 96.4%), as were clinical success rates (RR 1.04, 95% CI 0.92–1.19; I² = 0%; EUS-CDS 96.5% vs EUS-HGS 89.1%). However, the risk of stent dysfunction was significantly higher in the EUS-CDS group compared to EUS-HGS (RR 4.42, 95% CI 1.71–11.43; I² = 0%; EUS-CDS 45.1% vs EUS-HGS 10.9%). The incidence of procedure-related adverse events was comparable between the two approaches (RR 1.14, 95% CI 0.24–5.50; I² = 40.8%; EUS-CDS 10.7% vs EUS-HGS 16.0%).

Conclusion

This meta-analysis suggests that both EUS-CDS and EUS-HGS are similarly safe and effective for managing malignant biliary obstruction in the setting of concomitant GOO. However, EUS-CDS is associated with a more than four-fold increase in the risk of stent dysfunction, which may result in delays to critical cancer treatments.

Disclosure

None

Clinical Case Summary

We present a rare case of protein losing gastropathy.A 60-year-old female presented to our clinic with 10 years history of intermittent dyspepsia with no alarm features and peripheral oedema for 6 months.Physical examination was unremarkable except mild bilateral pitting oedema.Pertinent investigations suggested normal albumin,urine analysis,renal&liver profiles and a normal echocardiogram.Subsequent testing with esophagogastroduodenoscopy(EGD) for dyspepsia showed hypertrophied mucosal folds predominantly in gastric corpus while sparing the antrum.Full thickness biopsies were taken and sent for histopathology with differentials of Lymphoma,adenocarcinoma,sarcoidosis and Menetrier’s disease.Stool antigen for Helicobacter Pylori(H.Pylori)thereafter,was positive while Contrast enhanced CT abdomen was consistent with mildly thickened gastric walls.Histological examination demostrated foveolar hyperplasia,elongated gastric pits and cystically dilated gastric glands without any features of malignancy.Hence a diagnosis of Menetrier’s disease(underlying H.Pylori) was made.
Patient then had H.Pylori eradication therapy as well as a diet rich in medium-chain fatty acids and proteins.H.Pylori eradication was confirmed.6 months follow up revealed partial resolution of her symptoms but no change in endoscopic findings.Patient could not undergo further treatment with biologics(cetuximab)due to financial constraints and octreotide for its local unavailability.She is now on a yearly endoscopic surveillance for future high risk of gastric malignancies.

References

​​Fig1A.Haematoxylin & Eosin staining shows foveolar & mucous cell hyperplasia,elongated gastric pits and lymphocytic infiltration.
Fig1B.Haematoxylin & ​Eosin staining shows cystic dilation of gastric glands
1.Pepa P, Uehara T, Wonaga A, Redondo A, Avagnina A, Mazzocchi O, Antelo P, Waldbaum C, Sorda J. Menetrier's disease. A diagnostic and therapeutic challenge. Medicina (B Aires). 2021;81(3):470-473. English. PMID: 34137712.
2.Gore M, Bansal K, Jadhav N. Menetrier Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2023 Jun 25].

Disclosure

No conflicts