A 54-year-old male presented to the emergency department with complaints of acute onset of abdominal pain and vomiting. He also had history of intermittent dull aching pain in the abdomen since fifteen days prior to this acute episode. The patient denied history of taking any drugs. He had no history of drug allergy, asthma or allergic rhinitis. There was no history of allergy or atopy in family members. There was no past history of fever, diabetes, tuberculosis, asthma, hepatitis or ischemic heart disease.
Physical examination revealed a slightly distended abdomen with rigidity and tenderness. There was no organomegaly. Laboratory investigations showed Hb-11.4 gm/L and total leukocyte count 9.8x109/L. Differential count revealed polymorphs -47%, lymphocytes -24% and eosinophils -29%. Absolute eosinophil count was 2842/mm3 (2.8x109/L). Other laboratory studies with serum IgE were within normal limits.
Chest X-ray was within normal limits. Abdominal X-ray displayed multiple air-filled levels in the small intestine. Emergency laparotomy was performed with a midline incision in view of increasing distension and tenderness of abdomen. Exploration revealed multiple ileal strictures with proximal dilatation. Segmental resection of the ileum and end-to-end anastomosis was performed and a resected specimen sent for histopathology.
Gross examination revealed a segment of small intestine about 24 cm in length with three strictures in the ileum and proximal dilatation of intestine with congestion of serosa (Figure 1). On cutting open, a narrowed lumen due to stricture with congestion of mucosa was noted (Figure 2). Peripheral surgical margins were unremarkable.
Multiple sections of the resected specimen showing layers of small intestine (Figure 3) were studied. All the layers of intestine showed diffuse and dense infiltration of eosinophils of >40-60 eosinophils/hpf (Figure 4). All the coats showed congestion and serosa were covered by inflammatory exudates. The section through stricture showed fibrosed wall with dense eosinophilic infiltration (Figure 5). Final histological diagnosis of eosinophilic enteritis with stricture was made presenting as acute intestinal obstruction with peritonitis. The patient recovered well and was free of gastrointestinal symptoms during the follow up period of one year. During this period, upper GI endoscopy and biopsy were performed. These showed no eosinophilic infiltration in the stomach. Postoperative stool examination was negative for ova, cyst or worm infestation on two separate occasions. Occult blood in stool was negative. The patient was given oral prednisolone 10 mg daily for six weeks and tapering thereafter, resulting in a normal hematologic examination.