Eosinophilic Cholecystitis and Gastroenteritis: A Rare Case of Abdominal Pain and Diarrhea

Introduction: Eosinophilic gastroenteritis and cholecystitis are uncommon gastrointestinal disorders. Few cases of each have been reported. A high index of clinical judgment is required to diagnose and manage the condition. We present a rare case of combined eosinophilic gastroenteritis and cholecystitis. Case Description/Methods: A 46-year-old woman presented with worsening abdominal pain at the right upper and lower quadrant with nausea, vomiting and non-bloody diarrhea. Blood workup showed peripheral significant leukocytosis with eosinophilia of 58.4%, normal inflammatory markers, liver function tests and stool workup negative. Ultrasound of abdomen showed distended gallbladder with sludge, perihepatic fluid and CT abdomen showed ascites, distended gall bladder and circumferential thickening of descending colon (Figure A) and was proven as sigmoid diverticulitis on colonoscopy. HIDA scan showed nonspecific high grade obstruction of the common bile duct. MRCP also showed a distended gallbladder and hence, the patient had an upper endoscopy and later underwent laparoscopic cholecystectomy which showed thickened duodenum and jejunum with ascites. The ascitic fluid study showed many eosinophils. Upper endoscopy showed edematous, erythematous duodenum, and multiple biopsies were taken. Biopsies showed lamina propria of the duodenum with increased chronic inflammatory cells and patchy distribution of eosinophils (Figure B). Gall bladder biopsy showed numerous eosinophils in lamina propria with cholesterolosis and small mucosal polyps. These findings are consistent with eosinophilic gastroenteritis with cholecystitis. Steroids were started and continued for 4 weeks. On follow-up in a month, the patient's condition improved markedly. Discussion: Eosinophilic gastroenteritis is a rare entity and usually presents as abdominal pain. It can be confused with inflammatory bowel disease or infectious gastroenteritis. Eosinophilic cholecystitis may be associated with parasites, allergies, hypereosinophilic syndromes, cholelithiasis, acalculous cholecystitis or parasites. Diagnostic strategies of both are supported by imaging, endoscopic evaluation and biopsy which shows the presence of eosinophils. Different layers of the mucosa may be involved including muscular and may show scattered arrangements. Multiple biopsies are thus required. Treatment includes medical management in the form of 4-6 weeks of steroids and hypoallergenic formula. Surgical treatment is used when there is evidence of symptoms of obstruction.Figure 1.: A: Imaging finding on CT scan abdomen. B. Biopsy findings- (H&E stain with before and after treatment changes).