S3466 Eosinophilic Esophagitis With Rare Ascitic Presentation: A Case Report

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Introduction: Eosinophilic gastrointestinal disease (EGID) is an uncommon condition characterized by eosinophils infiltration of gastrointestinal wall and should be considered in patients with nonspecific GI symptoms and peripheral eosinophilia. In this report, we present a case of eosinophilic esophagitis (EoE) who presented with eosinophilic ascites as a rare complication. Case Description/Methods: A 43-year-old woman presented with persistent nausea, intermittent dysphagia, and abdominal distention for duration of 4 weeks. She was recently discharged after being treated supportively for presumed infectious gastroenteritis. She denied fevers, weight loss, or changes in bowel habits. A physical exam revealed diffusely tender, moderately distended abdomen with positive shifting dullness. Labs showed elevated WBC (15.7 x10^9/L) with 57% eosinophils. Other tests, including a complete metabolic panel and stool analysis, were normal. Abdominal CT revealed circumferential thickening and enhancement in the small bowel walls, circumferential hypodensity around the distal esophagus, and moderate ascites. Paracentesis drained 2.5 liters of ascitic fluid revealed low serum-albumin ascites gradient (< 1.1), with an eosinophil count exceeding 10,000/µL and 96% polymorphonuclear leukocytes (PMNs). She was treated with antibiotics for suspected spontaneous bacterial peritonitis. An esophagogastroduodenoscopy revealed a tight spasm above the gastroesophageal junction at 35 cm. Biopsies showed esophageal squamous epithelium with up to 20 eosinophils/HPF. No Barrett's esophagus, dysplasia, or malignancy was found. Bone marrow biopsy indicated normocellular marrow with increased eosinophils and precursors, ruling out any eosinophilic clonal disorder. She was subsequently diagnosed with EoE and suspected enterocolitis. Treatment with methylprednisone led to significant symptom improvement and normalization of peripheral eosinophilia. Discussion: This case emphasizes the necessity of considering EGID in patients with nonspecific GI symptoms and peripheral eosinophilia. EGID, though rare, can present diversely, including with eosinophilic ascites, as seen here. It highlights the crucial role of thorough diagnostic evaluation—including imaging, endoscopy, and biopsy to distinguish EGID from conditions such as infectious gastroenteritis or malignancy. The patient's significant response to methylprednisone underscores corticosteroids' efficacy in EGID management, highlighting the importance of timely recognition and treatment (see Figure 1).Figure 1.: Figure A: Abdominal CT demonstrating circumferential thickening and enhancement in the small bowel walls, circumferential hypodensity around the distal esophagus, and moderate ascites. Figure B and C: Esophageal biopsy slides at low and high power showing esophageal squamous epithelium with up to 20 eosinophils per high-power field (HPF) and reactive changes. Figure D and E: Bone marrow biopsy slides at low and high power indicating normocellular marrow with increased eosinophils and precursors.

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