Overview
Definition:
Eosinophilic colitis (EC) in infants is a non-IgE mediated food hypersensitivity disorder characterized by eosinophilic infiltration of the colonic mucosa
It typically presents with gastrointestinal symptoms such as vomiting, diarrhea, abdominal pain, and failure to thrive.
Epidemiology:
The exact incidence is not well-established but it is considered a rare cause of infant GI distress
It is more common in infants with a family history of atopy or allergies
Peak incidence is often within the first few months of life.
Clinical Significance:
Accurate diagnosis and prompt management of eosinophilic colitis are crucial to prevent malnutrition, dehydration, and long-term growth impairment
Understanding the role of dietary therapy is fundamental for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Vomiting, often projectile
Diarrhea, which may be watery or bloody
Abdominal distension and pain
Poor feeding and reduced oral intake
Failure to thrive or weight loss
Irritability and fussiness
Constipation can also occur in some cases.
Signs:
Signs of dehydration
Abdominal tenderness on palpation
Poor weight gain or anthropometric measurements below expected percentiles
Pallor may be present due to occult blood loss.
Diagnostic Criteria:
No universally agreed-upon diagnostic criteria exist
Diagnosis is typically based on clinical presentation, exclusion of other causes, and response to dietary elimination
Endoscopic biopsy showing eosinophilic infiltration (typically >15-20 eosinophils per high-power field in the lamina propria) is considered diagnostic but may not always be necessary for initial management decisions.
Diagnostic Approach
History Taking:
Detailed feeding history is paramount
Identify specific trigger foods, timing of symptom onset relative to feeding, and response to changes in diet
Assess for atopic manifestations (eczema, asthma, rhinitis) in the infant or family history
Rule out infectious causes and surgical emergencies.
Physical Examination:
Assess hydration status and vital signs
Perform a thorough abdominal examination, noting any distension, tenderness, or masses
Evaluate growth parameters (weight, length, head circumference) and plot on growth charts.
Investigations:
Complete blood count (CBC) may show eosinophilia, but this is not specific
Stool examination for blood, parasites, and white blood cells
Imaging modalities like abdominal ultrasound are generally not helpful for diagnosis but can rule out other conditions
Endoscopy with biopsies of the colon is the gold standard for confirming eosinophilic infiltration, but often dietary elimination is attempted first based on clinical suspicion.
Differential Diagnosis:
Gastroesophageal reflux disease (GERD)
Cow's milk protein allergy (IgE and non-IgE mediated)
Infective gastroenteritis
Surgical causes like intestinal obstruction or intussusception
Lactose intolerance
Other food protein-induced enterocolitis syndromes (FPIES)
Necrotizing enterocolitis (NEC) in preterm infants.
Management
Initial Management:
Fluid and electrolyte resuscitation if dehydrated
Nutritional support is crucial to ensure adequate growth
Symptomatic relief for vomiting or diarrhea.
Dietary Therapy:
The cornerstone of management
For breastfed infants, the mother may need to eliminate trigger foods (commonly cow's milk protein, soy, eggs, wheat)
For formula-fed infants, a trial of a hypoallergenic extensively hydrolyzed formula (eHF) or an amino acid-based formula (AAF) is usually the first step
If symptoms persist, further elimination of multiple common allergens may be required
Hydrolyzed rice protein formulas can be considered if other options fail.
Duration Of Elimination:
Dietary elimination is typically continued for 2-6 months, or until symptoms resolve and growth improves
Subsequent reintroduction of suspected allergens should be done systematically under medical supervision to identify specific triggers.
Supportive Care:
Close monitoring of growth parameters
Education of parents regarding dietary management and potential long-term implications
Regular follow-up with the pediatrician or pediatric gastroenterologist.
Complications
Early Complications:
Severe dehydration and electrolyte imbalance
Malnutrition and failure to thrive
Anemia due to occult gastrointestinal blood loss.
Late Complications:
Chronic growth retardation
Development of other atopic diseases
Recurrent episodes if dietary triggers are not identified or are reintroduced prematurely.
Prevention Strategies:
Early identification and appropriate dietary management
Educating parents on strict adherence to elimination diets
Systematic challenge testing to confirm trigger foods.
Prognosis
Factors Affecting Prognosis:
Severity of initial presentation
Timeliness and effectiveness of dietary intervention
Presence of other atopic conditions
Compliance with dietary recommendations.
Outcomes:
With appropriate dietary therapy, most infants show significant improvement in symptoms and catch up on growth
The condition often resolves spontaneously as the infant matures or with successful identification and avoidance of trigger foods.
Follow Up:
Long-term follow-up is important to monitor growth, assess for recurrence, and manage any developing atopic conditions
Periodic re-evaluation of dietary tolerance may be warranted in older children.
Key Points
Exam Focus:
Dietary elimination is the primary management strategy
Hypoallergenic formulas (eHF, AAF) are the first-line treatment for formula-fed infants
Maternal elimination diets are indicated for breastfed infants
Biopsy confirmation of eosinophilic infiltration is the gold standard but often preceded by dietary trials.
Clinical Pearls:
Always consider eosinophilic colitis in infants with persistent GI symptoms refractory to simpler treatments, especially if there is a history of atopy
Detailed dietary history is crucial
Reintroduction of allergens must be done carefully and systematically.
Common Mistakes:
Delaying dietary intervention due to reliance on biopsy confirmation
Inadequate dietary elimination (e.g., not addressing hidden sources of allergens)
Premature reintroduction of suspected trigger foods without proper testing
Misinterpreting non-specific eosinophilia as diagnostic of EC.