eosinophilic enteritis is an uncommon disease of unknown etiology , which can affect any area of the gastrointestinal tract , from the esophagus to the rectum , although the stomach and small bowel are most commonly involved1 ) .
it usually presents as colicky abdominal pain , and rarely as an acute intestinal obstruction2 , 3 ) or perforation4 - 6 ) , making the initial diagnosis very difficult .
eosinophilic enteritis should be considered in the differential diagnosis of unexplained gastrointestinal symptoms , since most patients with eosinophilic enteritis can be treated successfully with corticosteroid therapy , if the correct diagnosis is made7 ) .
development of a new capsule video endoscope , which is small enough to be swallowed and has no external wires , fiber - optic bundles , or cables , has made it possible to acquire images of the whole of the small bowel .
it has been proven to be very useful in the diagnosis of small bowel disease in the case of negative gastroscopy and colonoscopy8 ) , suggesting it can contribute to the localization of lesions for laparoscopic biopsy , and thus lead to conclusive diagnoses of eosinophilic enteritis .
we present the case of a patient who underwent an emergency laparotomy for acute intestinal obstruction due to ileal eosinophilic enteritis , followed by hematochezia due to mid - to - distal jejunal bleeding , which was visualized by capsule endoscopy .
the hematochezia was rapidly controlled by high - dosage steroid injection therapy , which suggests that it was a manifestation of eosinophilic enteritis .
a 62-year - old man visited the emergency room complaining of epigastric and periumbilical pain , which had developed 3 hours prior to his admission .
the nature of his complaint was colicky pain , but he had experienced neither nausea nor vomiting .
the patient 's leukocyte count was 10,420/mm ( 2.9% eosinophils , normal range [ nr ] , 0~5% ) .
abdominal computed tomography ( ct ) examination showed segmental wall thickening of the small bowel and proximal dilatation , mesenteric edema , and focal fluid collection in the adjacent peritoneal cavity ( figure 1 ) .
however , there was no abrupt transition in the luminal diameter at either end of the pathologic bowel loop , suggesting a radiological abnormality , other than the strangulation normally observed in a case of intestinal obstruction .
the radiological differential diagnosis included segmental enteritis of unclear cause , and focal mesenteric ischemia by a certain kind of systemic vasculitis , or post- strangulation state following the relief of obstruction .
twelve hours after his admission to the emergency room , the abdominal pain progressed , rebound tenderness developed , and finally , an exploratory laparotomy was performed .
exploration revealed edema , congestion , and bluish discoloration of the distal ileum , 50 cm from the ileocecal valve .
only a 15 cm segment was involved , and the remaining bowel was seen to be normal .
the involved ileal segment was resected , and end - to - end anastomosis was performed . gross examination showed an ill - defined mass - like wall thickening with multifocal erosion of the overlying mucosa , 7 centimeters in length , and the surrounding small intestinal mucosa was moderately edematous .
histologically , extensive eosinophilic infiltration was found in the mass - like lesion , which was found from submucosa to subserosa ( figure 2 ) . in the surrounding mucosa ,
there was found to be no evidence of parasites , granulomas , malignancy , vasculitis , or embolism in the surgical specimen , either in the bowel wall or in the mesenteric vessels .
two days after the operation , the patient 's leukocyte count decreased to 8,070/mm ( 8.7% eosinophils ) .
12 days after the operation , the patient 's total ige was 1,310 u / ml above the normal range ( 0~100 u / ml ) , but skin prick test was normal , suggesting no specific allergic etiology .
seventeen days after the operation , similar characteristic abdominal pain developed again in the patient 's periumbilical area , but to a milder degree than before the operation .
the patient was advised to undergo gastroenterological testing in order to evaluate the abdominal pain , but he refused .
instead he ( 60 kg - weight ) received 40 mg intramuscular injections of methylprednisolone acetate for two days , and simultaneously took 10 mg prednisolone three times per day , resulting in improvement of abdominal pain .
two weeks after this abdominal pain attack , hematochezia occurred for 4 days , in spite of continuous 30 mg prednisolone per day .
the patient experienced dizziness , and his hemoglobin decreased from 13.6 g / dl ( nr , 13 - 17 g / dl ) to 9.5 g / dl .
emergency colonoscopy showed no evidence of bleeding after bowel preparation with colyte , nor did it reveal any definite mucosal abnormality up to the ileocecal valve .
although there was no definite intrinsic mucosal lesion , six pieces of blind biopsy were taken from the hepatic flexure and 40 cm above the anal verge , but the pathologic results indicated only nonspecific change .
in addition , gastroduodenoscopy up to the 3 portion of duodenum revealed no abnormalities , and there was no evidence of bleeding .
on the next day , the initial negative tc - tagged red blood cell scan showed a small amount of bleeding from the right iliac artery 2 hours and 30 minutes after injection of tc - tagged red blood cells , and migration of blood into the right ileal lumen after 4 hours and 30 minutes .
however , ct angiography and arteriography , which were taken successively , showed no focus of bleeding , indicating that the bleeding had already stopped , or that the bleeding speed was slower than 0.5 ml / min . on the next day , m2a capsule endoscopy was performed .
it showed that multiple hemorrhagic spots were scattered throughout the proximal jejunum ( figure 3a ) .
after the normal jejunal segment , abrupt spurting of fresh arterial bleeding was detected in the mid - to - distal jejunum , but no ulcer , mass or vascular abnormalities were detected ( figure 3b ) .
the ileum was normal , and the anastomotic site at the ileum was not noticed , suggesting no definite lesion around the previous operation site .
just 8 hours after the capsule endoscopy examination , a large amount of hematochezia , dizziness , and diaphoresis occurred , along with a decrease in hemoglobin level , from 9.7 g / dl to 6.9 g / dl .
the patient did not take oral prednisolone during the 2 days of examination due to the unavailability of an oral intake state .
immediately after the detection of massive hematochezia , intravascular injections of 125 mg methylprednisolone sodium succinate per every 8 hours were started , and an emergency operation was prepared .
surprisingly , the hemoglobin increased to 10.7 g / dl with 3 packs of rbc transfusion , suggesting termination of the bleeding .
five days later , the methylprednisolone sodium succinate injections were replaced with oral prednisolone treatment , 60 mg per day for 2 days , which was to taper down over a two - week period .
the etiology of eosinophilic gastroenteritis is unknown , and a definitive pathologic mechanism has not been elucidated . instead , it is likely that eosinophilic gastroenteritis is not a single entity , but rather a heterogenous collection of disorders -- with varied causes , but with similar clinicopathologic features9 ) .
allergic phenomena , particularly food sensitivity , have been proposed , but the evidence for this is limited .
although food hypersensitivity ( usually to milk ) may be found in children with eosinophilic gastroenteritis , the response to dietary elimination is usually disappointing .
however , eosinophilic ileitis with perforation can be caused by angiostrongylus ( parastrongylus ) costaricensis5 ) , and eosinophilic ileocolitis by enterobius vermicularis10 ) , suggesting an allergic pathogenesis .
eosinophilic gastroenteritis is generally considered to be a chronic benign disease , but there have been several reports of fatal outcomes11 , 12 ) .
eosinophilic gastroenteritis is categorized according to three distinct forms ( mucosal , mural , and serosal ) based on its dominant location in the gut wall13 ) . in the mucosal type
, the condition behaves like other forms of inflammatory bowel disease , with diarrhea , cramping , postprandial nausea , vomiting , and periumbilical pain .
the mural type is characterized by the localization of tissue injury and inflammatory reaction with abundant eosinophils in the submucosa and muscularis propria . in this case , the clinical presentation consists of intestinal obstruction , with nausea , vomiting , abdominal pain , and distension .
the serosal type , which is the rarest form , is characterized by diffuse eosinophilic infilatrates of the gut serosa , and may be associated with eosinophilic ascites . if the eosinophilic infiltration is extensive , there may also be malabsorption , weight loss , enteropathy with protein loss , blood loss , and anemia14 ) . in our case ,
the initial relevant site was the submucosa and muscle layer in the distal ileum , which is consistent with mural type , and explaining both the obstruction symptoms , and the ct finding of segmental small bowel wall thickening .
however , the abdominal pain , reoccurring 17 days after the operation , subsided following moderate doses of steroids , suggests another eosinophilic enteritis - related small bowel involvement .
furthermore , the capsule endoscopy showed multiple hemorrhagic spots throughout the proximal jejunum , and spurting of fresh arterial bleeding in the mid - to distal jejunum , far from the anastomotic site .
there was no definite ulcer , mass , or vascular abnormality , and this bleeding was rapidly controlled by high - dose injections of steroid , indicating that it was a manifestation of jejunal eosinophilic enteritis , the first bleeding case visualized by capsule endoscopy so far .
this spurting of fresh arterial bleeding suggests that eosinophilic enteritis can be fatal if it is not rapidly controlled , as it was in our case .
the diagnosis of eosinophilic enteritis is a rather difficult one , especially when it presents as abrupt obstruction , perforation , or bleeding , especially in the small bowel .
most diagnoses are made retrospectively and histopathologically , as in our case . if there is a high degree of suspicion of eosinophilic enteritis for a patient with ill - defined abdominal pain , coupled with nonspecific laboratory results and inconclusive radiologic findings , laparoscopy , instead of laparotomy ,
can be tried for a full - thickness biopsy of the intestine15 - 17 ) .
recently , wireless capsule endoscopy has been shown to be useful in the diagnosis of small bowel disease , which is beyond the reach of standard upper endoscopy and colonoscopy .
maybe the combined approach of capsule endoscopy for localization of lesion , and laparoscopy for the biopsy can facilitate the early diagnosis of eosinophilic enteritis , hence early steroidal treatment .
we report a case of eosinophilic enteritis , presenting as a small bowel obstruction , followed by severe jejunal bleeding , which was visualized by capsule endoscopy .
this case suggests that if there are symptoms of eosinophilic enteritis , such as abdominal pain , a period of high - dosage steroid therapy is mandatory , in order to prevent further occurrences of complications such as fatal bleeding .
 eosinophilic enteritis is a rare disease characterized by tissue eosinophilia , which can affect different layers of bowel wall . 
 normally , the disease presents as colicky abdominal pain , and rarely as an acute intestinal obstruction or perforation . in this paper 
 , we report a case of eosinophilic enteritis , hitherto unreported , presenting as an ileal obstruction , and followed by jejunal bleeding , which was visualized by capsule endoscopy . 
 a 62-year - old man received a 15 cm single segmental ileal resection at a point 50 cm from the ic valve due to symptoms of obstruction , which were diagnosed as eosinophilic enteritis . 
 seventeen days after operation , intermittent abdominal pain occurred again , and subsided upon 30 mg per day treatment with prednisolone . 
 fourteen days after this pain attack , the patient exhibited hematochezia , in spite of continuous prednisolone treatment . 
 capsule endoscopy showed fresh blood spurting from the mid - to - distal jejunum , in the absence of any mass or ulcer . 
 this hematochezia rapidly disappeared following a high - dose steroid injection , suggesting it was a manifestation of jejunal eosinophilic enteritis . 
INTRODUCTION
CASE REPORT
DISCUSSION