Eosinophilic gastroenteritis mimicking pancreatic cancer

Abstract

Eosinophilic gastroenteritis is a condition characterised by eosinophilic infiltration of the gastrointestinal tract. Biliary obstruction is an unusual presentation. A case where the initial investigations were consistent with carcinoma of the head of pancreas but the resection specimen showed no malignancy is presented. The diagnosis was suspected from a review of the patient's past history and confirmed by re-examination of the histology.A 47 year old man presented with two weeks of fever, vomiting, anorexia, intermittent right upper quadrant and mid-scapular pain exacerbated by eating, followed by jaundice, pale stools, and dark urine. On examination, he was icteric, temperature 38.8°C, with right upper abdominal tenderness, and a palpable gallbladder. Investigations showed a raised white cell count 15.6 × 10 9 /l (4-11.0), neutrophils 13.4 × 10 3 /µl (2-7.5), amylase 256 IU/l (10-90), bilirubin 85 µmol/l (2-20), alanine transferase 204 IU/l (1-65), and alkaline phosphatase 897 IU/l (30-110). Abdominal ultrasound showed a grossly dilated biliary tract, 13 cm gallbladder, 3 cm common bile duct (CBD), and 8 mm pancreatic duct. No gallstones were present. Abdominal computed tomography showed an abrupt occlusion of the CBD and pancreatic duct at the head of pancreas. Endoscopic retrograde cholangiopancreatography was unsuccessful due to duodenal stenosis. Percutaneous transhepatic cholangiography found a tight stricture requiring an external biliary drain for decompression. The diagnosis was thought either to be carcinoma of the ampulla of Vater or the head of pancreas.At laparotomy, a small hard irregular mass in the head of the pancreas was found. Pylorus preserving pancreaticoduodenectomy was performed. The resection specimen was examined by thin sections. The duodenum and ampulla had a chronic inflammatory infiltrate within normal mucosa. There was periductal chronic inflammation, fibrosis and active inflammatory exudate in the CBD, thought consistent with recent cholangitis. Lymph nodes showed follicular hyperplasia and reactive change only. No malignant cells were identified. He was discharged after an uneventful recovery.He then had repeated hospital admissions with abdominal pain and postprandial vomiting. Initially, all investigations were normal apart from a mild neutrophilia. The symptoms resolved with conservative management. At his next admission, he also had diarrhoea. Investigations showed raised white cell count 18.0 × 10 9

Eosinophilic Gastroenteritis due to Cow’s Milk Allergy Presenting with Acute Pancreatitis

“…In the past, only a few cases with a similar course have been reported [6,7,8,9,10,11,12,13]. A food allergen connected to the occurrence of EGE was identified in the case we studied.…”

“…Serosal infiltration with eosinophils causes ascites [2,4]. Any part of the GI tract can be affected, and isolated biliary tract involvement has also been reported [2,12,15,16,17]. The stomach is the organ most commonly affected, followed by the small intestine and the colon [2,3,4,12].…”

“…Any part of the GI tract can be affected, and isolated biliary tract involvement has also been reported [2,12,15,16,17]. The stomach is the organ most commonly affected, followed by the small intestine and the colon [2,3,4,12]. EGE typically presents with a combination of chronic nonspecific GI symptoms that include abdominal pain, nausea, vomiting, diarrhea, weight loss and abdominal distension.…”

[Eosinophilic pancreatitis and autoimmune pancreatitis: comparison, differential diagnosis, and treatment]

“…[39] Nella PE la TC del pancreas può risultare normale (Balthazar score = 0), presentare dilatazione del dotto pancreatico o, più frequentemente, manifestare una forma pseudocistica o pseudotumorale [3][4][5][6][7]9,13,14].…”

“…Le forme di PE descritte in letteratura non presentano un quadro clinico impegnativo, ma spesso hanno comportato l'exeresi chirurgica perché l'aspetto più frequente riguarda forme pseudocistiche simil-tumorali [2][3][4][5][6]8,12,13]: infatti la diagnosi differenziale si pone soprattutto con la neoplasia pancreatica.…”