[Chronic upper abdominal pain without improvement after using proton pump inhibitors]

A 57-year-old woman was admitted to our hospital because of relapsing, therapy-resistant pain, predominantly in the upper abdomen. The symptoms began 6 years previously, after a resection of parts of the small intestine for an ileus of unclear cause. Subsequently 11 (!) gastroscopies showed repeatedly gastritis and Helicobacter pylori- negative gastric and/or small intestinal ulcers which were treated with proton pump inhibitors. This led to no significant improvement of the complaints and produced no healing.

Gastroscopy showed, at the transition of the gastric fundus to the corpus, an area with multiple, fibrin coated ulcers. Histologically an active, chronic gastric ulcer was seen, with perifocally dense inflammatory infiltration by predominantly eosinophils. In the colon these histological findings, although clearly less pronouncedly, were also seen i.e. an eosinophilic gastroenteropathy. This was initially treated with 60 mg/day prednisone. Under this treatment she became completely symptom-free. After a dose reduction to 5 mg prednisone daily the symptoms occurred again. Thereupon long-term immunosuppressive therapy with 100 mg azathioprine daily was introduced. Regular clinical and endoscopic monitoring showed a complete remission of the ulcers and no complaints after 1.5 years.

Our case report shows that in patients with uncharacteristic abdominal pain and gastric ulcers, which improve inadequately under the usual medication such as proton pump inhibitors, less common illnesses must be considered. Despite the rarity of eosinophilic gastroenteropathy the exact (histological) diagnosis plays an important role, because a specific therapy with corticosteroids and/or azathioprine can induce improvement of the symptoms.