Review Article
Eosinophilic colitis: A clinical review

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Abstract

Eosinophilic colitis is a rare entity characterized by the presence of a high eosinophilic infiltrate into the colonic wall in symptomatic patients, more often presenting with abdominal pain or diarrhea. These characteristics distinguish eosinophilic colitis from primary colonic eosinophilia, in which patients are asymptomatic. Primary colonic eosinophilia does not need any therapy, while eosinophilic colitis requires a strict treatment, similar to that of the more codified chronic intestinal inflammatory diseases. To date the lack of codified guidelines regarding the diagnostic criteria and the eosinophil threshold values for each colonic segment are the main diagnostic challenge for eosinophilic colitis. In addition, eosinophilic colitis is a diagnosis of exclusion, once all other causes of colonic eosinophilia (food allergens, infections, drugs, etc.) have been excluded. Several treatment options are available for eosinophilic colitis, although the evidence for most of them is limited to case reports and small case series.

We examine the epidemiology, etiology, pathophysiology, diagnostic criteria and therapeutic options of eosinophilic colitis reporting recent evidence from the current literature.

Section snippets

Background

Eosinophilic colitis (EC) is a rare condition included in the group of eosinophilic gastrointestinal disorders (EGIDs), that are characterized by a high eosinophilic infiltrate in the gut wall, without evidence of other causes [1,2]. In the EC there is a segmental or diffuse intense eosinophilic infiltration in the colon [3,4].

The definition of EC is still object of debate. For most authors the term “eosinophilic colitis” should be reserved to symptomatic patients, while in the case of

Epidemiology

The epidemiology of EC is difficult to study, partly due to the lack of well-defined diagnostic criteria [7]. Eosinophilic colitis seems to have a bimodal age distribution, with a first peak in neonates and a second peak in young adulthood [8,9]. A recent review of a population-based database in the USA, including more than 35 million of children and adults, reported an overall prevalence of EC of 2.1 per 100,000 subjects, with a prevalence of 2.3 per 100,000 in adults and 1.6 per 100,000 in

Etiology

The specific etiology of primary EC is unclear. There is undoubtedly an interaction between genetic and environmental factors considering that 16% of patients with EGIDs have a family member with a similar disorder. Several authors associated EC with allergic diseases [8] such as rhinitis, asthma, sinusitis, dermatitis, food allergies, eczema, or urticarial [10] or atopic conditions [12,13]. An allergic component is likely to be present in all EGIDs considering that 80% of patients have a

Pathophysiology

Although the physiologic functions of eosinophils remain largely unknown, they are known to be involved in host immune response to infections, tissue remodeling, tumor surveillance, and maintenance of other immune cells [27].

Eosinophils are primarily tissues-swelling cells and they are several hundred-fold more abundant in tissues than in the blood [28]. In healthy individuals, eosinophils can be found in the spleen, lymph nodes, thymus, and are normally found in the mucosa of all the

Clinical presentation

Eosinophilic colitis is a heterogeneous entity, ranging from an acute self-limited bloody diarrhea in otherwise healthy infants to a chronic colitis with abdominal pain and/or chronic diarrhea in young adults [1]. Other symptoms include nausea, vomiting, GI bleeding, bowel obstruction, malabsorption, weight loss or ascites [17]. Clinical features are related to the layers of bowel with eosinophilic infiltration [35]. Mucosa predominant EC, which is the most common form, is associated with

Diagnosis

The diagnosis of EC is challenging [1]. A reasonable approach should require both a clinical and histological diagnosis of EC, associating symptoms referable to colonic dysfunction with colon biopsies showing excess eosinophils [5], in patients without other causes of colonic eosinophilia, such as infectious colitis or IBD [37].

Allergic skin testing (AST) and radioallergosorbent tests (RASTs) are useful in detecting IgE-mediated responses to inhaled or ingested allergens, although ASTs lack

Treatment

Eosinophilic colitis in infants is a rather benign entity and is food-associated; therefore, dietary elimination of the triggering allergen often resolves the disorder within days. Adolescents and older patients require more aggressive medical management [1]. If no secondary cause of eosinophilia is found, and a diagnosis of primary EC is made, several treatment options are available, although the evidence for most of them are limited to case reports and small uncontrolled case series [34].

Conclusion

Eosinophilic colitis remains a rare entity, whose natural history and pathophysiology is still unclear, currently lacking codified guidelines for the diagnosis and treatment. In particular, there is still a lack of well-defined threshold values for the diagnosis of EC. Therefore, future studies including a large sample of patients should aim to define and validate specific diagnostic criteria and establish the most appropriate treatment for the disease.

Conflict of interest

None declared.

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