characterized by recurrent episodes of infiltration of
the gastrointestinal wall with eosinophils and peripheral
eosinophilia. Eosinophilic colitis with ascites is
extremely rare, in reviewing the literature (Pubmed
and Medline), we learned that there is only one case
reported about eosinophilic colitis with ascites.
osinophilic gastroenteritis with ascites is an
uncommon disorder of unknown etiology;
admitted with 3-weeks history of abdominal pain,
and distention. He described the abdominal pain as
being generalized colicky in nature, associated with
nausea, vomiting, and diarrhea 4-6 times per day
resolved 2 days after admission. No obvious aggravating
or relieving factors. The past medical history was
unremarkable and he denied any history of smoking
or alcohol consumption. Physical examination was
unremarkable apart from ascites, no stigmata of
chronic liver disease. Initial investigations showed
hemoglobin level of 15 g/dl, total leucocyte count
15700/mm3 (neutrophils 15.6%, lymphocytes 17.6%,
monocyte 2.8%, eosinophils 63.8%, and basophil
0.1%), and adequate number of platelets; erythrocyte
A 32-year-old man was
From the Department of Medicine (Yassin, Khan, Al-Ani, Fawzy), and the Department of Laboratory Medicine and Pathology (Al-Bozom), Hamad
General Hospital, Doha, Qatar.
Received 27th March 2005. Accepted for publication in final form 28th August 2005.
Address correspondence and reprint request to: Dr. Mohammed A. Yassin, Department of Medicine, Hamad General Hospital, PO Box 3050, Doha,
Qatar. Fax. +974 4392273. E-mail: firstname.lastname@example.org
ABS T RACT
sedimentation rate (ESR) was 2 mm/hour; blood chemistry
showed normal liver function test and serum electrolytes;
prothrombin time (PT) and partial thromboplastin
time (PTT) were normal. Immunoglobulin E level
was 2271 ku/l. We carried out abdominal
paracentesis under ultrasound guidance; cytological
preparations from the ascitic fluid using both
Papanicolaou and wright-Giemsa stains revealed a
heavy population of mature eosinophils mixed with
occasional lymphocytes, macrophages, and rare
reactive mesothelial cells (Figure 1), while acid-fast
bacilli, gram stain, and culture were negative. Bone
marrow aspiration showed marked eosinophilia
(Figure 2). Ultrasound showed moderate ascites,
otherwise, the ultrasound was normal, CT scan of the
chest abdomen, and pelvis with contrast for abdomen
showed changes in the small bowel as well as the
left cecal region and ascending colon and few small
mesenteric lymph nodes and moderate ascites.
Upper gastrointestinal endoscopy was normal, while
the lower gastrointestinal endoscopy showed multiple
lesions. Histological examination of colonic biopsies
revealed heavy expansion of the mucosa by sheaths of
eosinophils with occasional lymphocytes and plasma cells.
Mohammed A. Yassin, MD, Fahmi Y. Khan, MD, Ahmed Al-Ani, MRCP, Zeinab Fawzy, MD, Issam A. Al-Bozom, MD.
A 32-year-old man presented with 3-weeks history of abdominal pain and distention. Physical examination showed
ascites, with no stigmata of chronic liver disease. Cytological preparations from the ascitic fluid showed a heavy
population of mature eosinophils. Histological examination of colonic biopsies revealed a heavy expansion of the
mucosa by sheaths of eosinophils. On the following days, the peripheral eosinophilia, ascites and abdominal pain
Saudi Med J 2005; Vol. 26 (12): 1983-1985
C a s e R e p o r t
1984 Saudi Med J 2005; Vol. 26 (12)www.smj.org.sa
Ascites and eosinophilic colitis ... Yassin et al
Figure 1 - Cytological preparation of ascitic fluid showing numerous
eosinophils with rare mesothelial cells. (Wright and
Giemsa stain x 400)
nonspecific symptoms, which depend upon the
organ(s) involved. The entire gastrointestinal tract from
the esophagus to the colon, including bile ducts, can be
affected.15,17 Serosal eosinophilic infiltration, the rare
form of presentation, may result in development of
eosinophilic ascites. Our patient had predominantly
subserosal type of eosinophilic colitis. This layer
involvement usually occurs as a part of a transmural
infiltration of the gastrointestinal tract layer as in the
case being described here. Erythrocyte sedimentation
rate is normal or high in eosinophilic gastro enteritis
with peripheral eosinophilia; in our patient ESR was
2 mm/l hour, and the peripheral eosinophilia was
obviously elevated (10,000/uL). The evidence of
elevations in IgE suggested that atopy might be involved
in the pathogenesis of the disease. Immunoglobulin
E level was high in our patient. The endoscopic
appearance in eosinophilic gastroenteritis is non-
specific, including erythematous, friable, nodular,
and occasional ulcerative changes. Definitive diagnosis
requires histological evidence of eosinophilic infiltration.
Eosinophilic infiltrates are usually patchy in distribution
and may be present in otherwise, normal, non-
inflamed bowel wall.
In our patient, we carried out different examinations,
such as gastroduodenoscopy and colonoscopy; the
biopsies taken from upper gastrointestinal were
normal, while the lower gastrointestinal biopsies
showed eosinophilic colitis. Eosinophilic gastroenteritis
either will remit spontaneously2 as our patient
remitted spontaneously and did not require any
treatment, or it probably progress to malabsorption3-
11 in a form of iron deficiency anemia, which we can
treated easily with iron supplements, or diarrhea that
can managed with antidiarrheal agents. In severe
cases of eosinophilic gastroenteritis, we can used
steroids in a dose of 20-40 mg/day. Flare-up after
tapering the steroids could happen, which requires
another dose of steroids. Eosinophilic ascites have a
wide differential diagnosis including hyper-
eosinophilic syndrome, lymphoma, strongyloids
stercoralis infection, ruptured hydatid cyst, and EGE.
Thus, we should always considered EGE in the
differential diagnosis of eosinophilic ascites.
mucosal infiltration produces
A good number of those eosinophils are observed
traversing the mucularis mucosa. There is no
evidence of parasitic eggs, granulomas, inflammatory
bowel disease, ischemia, viral inclusions, amyloid
deposits or malignancy (Figure 3). On the following
days, the peripheral eosinophilia, ascites and abdominal
pain resolved spontaneously. Accordingly, the patient
(EGE) is a rare condition of unknown cause
characterized by peripheral eosinophilia, eosinophilic
infiltration of the gastrointestinal tract, and
colitis with ascites is extremely rare, in reviewing
the literature (Pubmed and Medline), 49 cases of
eosinophilic colitis were reported in adults, from
March 1953 until December 2004, of these only one
case of eosinophilic colitis with ascites was
reported.2 Nine cases of eosinophilic colitis with
malabsorption were reported mostly related to
intestinal warms.3-11 Klein et al,12 suggested a
classification, based on the histology of the lesion:
mucosal, muscularis, and subserosal disease. The
signs and symptoms of eosinophilic gastroenteritis
are related to the layer(s), and extent of bowel
involved with eosinophilic infiltration: mucosa;
muscle; and subserosa.12 The prevalence of each
subtype is unknown as reporting and referral biases.
Surgical series report a predominance of muscular
disease with obstruction,12 while medical series primarily
describe patients with mucosal involvement.13-15
Figure 2 - Bone marrow biopsy showing marked eosinophilia.
(Hematoxylin and Eosin x 1000)
Figure 3 - Colonic biopsy showing expansion of the mucosa by
numerous clusters of eosinophils. (Hematoxylin and Eosin
www.smj.org.sa Saudi Med J 2005; Vol. 26 (12) 1985 Download full-text
Ascites and eosinophilic colitis ... Yassin et al
9. Liu LX, Chi J, Upton MP, Ash LR. Eosinophilic colitis
associated with larvae of the pinworm Enterobius
vermicularis. Lancet 1995; 346: 410-412.
10. Macedo T, MacCarty RL. Eosinophilic ileocolitis
secondary to Enterobius vermicularis: case report. Abdom
Imaging 2000; 25: 530-532.
11. Moore D, Lichtman S, Lentz J, Stringer D, Sherman P.
Eosinophilic gastroenteritis presenting in an adolescent with
isolated colonic involvement. Gut 1986; 27: 1219-1222.
12. Klein NC, Hargrove RL, Sleisenger MH, Jeffries GH.
Eosinophilic gastroenteritis. Medicine 1970; 49: 299-319.
13. Ureles AL, Alschibaja T, Lodico D. Idiopathic eosinophilic
infiltration of the gastrointestinal tract, diffuse and
circumscribed. Am J Med 1961; 30: 899.
14. Talley NJ, Shorter RG, Phillips S, Lichtman S, Lentz J,
Stringer D, et al. Eosinophilic gastroenteritis: A
clinicopathological study of patients with disease of the
mucosa, muscle layer, and subserosal tissues. Gut 1990; 31:
15. Cello JP. Eosinophilic gastroenteritis a complex disease
entity. Am J Med 1979; 67: 1097-1104.
16. Schoonbroodt D, Horsmans Y, Laka A, Geubel AP, Hoang
P. Eosinophilic gastroenteritis presenting with colitis and
cholangitis. Dig Dis Sci 1995; 40: 308-314.
17. Matsushita M, Hajiro K, Morita Y, Takakuwa H, Suzaki T.
Eosinophilic gastroenteritis involving the entire digestive
tract. Am J Gastroenterol 1995; 90: 1868-1870.
1. Kuri K, Lee M. Eosinophilic gastroenteritis manifesting
with ascites. South Med J 1994; 87: 956-957.
2. Ong GY, Hsu CC, Changchein CS, Lu SN, Huang SC.
Eosinophilic gastroenteritis involving the distal small
intestine and proximal colon. Chang Gung Med J 2002;
3. de Jong MD, Baan J, Lommmerse E, Van Gool T. Severe
diarrhea and eosinophilic colitis attributed to pinworms
(Enterobius vermicularis). Ned Tijdschr Geneeskd 2003;
4. Corsetti M, Basilisco G, Pometta R, Allocca M, Conte D.
Mistaken diagnosis of eosinophilic colitis. Ital J
Gastroenterol Hepatol 1999; 31: 607-609.
5. Al-Samman M, Haque S, Long JD. Strongyloidiasis colitis:
a case report and review of the literature. J Clin
Gastroenterol 1999; 28: 77-80.
6. Takeyama Y, Kamimura S, Suzumiya J, Oh K, Okumura
M, Akahane H, et al. Case report: eosinophilic colitis with
high antibody titre against Ascaris suum. J Gastroenterol
Hepatol 1997; 12: 204-206.
7. Cacopardo B, Onorante A, Nigro L, Patamia I, Tosto S,
Romano F, et al. Eosinophilic ileocolitis by Enterobius
vermicularis: a description of two rare cases. Ital J
Gastroenterol Hepatol 1997; 29: 51-53.
8. Gutierrez Y, Bhatia P, Garbadawala ST, Dobson JR,
Wallace TM, Carey TE. Strongyloides stercoralis
eosinophilic granulomatous enterocolitis. Am J Surg
Pathol 1996; 20: 603-612.