ACG Case Reports Journal

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id="ga_2dcfa0bc-e955-4f29-bec6-96c8894801be" class="ad-slot-container ad-slot-container-ga_2dcfa0bc-e955-4f29-bec6-96c8894801be" data-sizemap="[[[730, 500], [[728, 90]]], [[0, 0], [[300, 50]]]]" data-adpath="/15726702761/Desktop/acgcr/Article/Top" data-autoload="yes" data-outofpage="no" data-sticky="no" data-slottargeting='' data-displayslug="yes" data-sticky-duration="5" data-name="Top"></div> </div> </div> </div> </div> </div> <div class="main-wrapper"> <div id="main-container">  <header class="header"> <div class="header__holder"> <div class="header__layout-top wk-grid-page-container"> <script type="text/javascript" src="https://lww.com/_layouts/15/1033/Scripts/wk/UserToolbarDropdown.js?v=05.24.00.023" defer="true"> </script> <section class="user-action-toolbar"> <ul class="user-menu user-info" role="tablist"> <li id="ctl00_ctl51_Header_UserActionTools_liLogin" class="user-menu__item user-menu__item--popup-container user-menu__item--login-popup-container dib"> <button class="user-menu__link user-menu__link--login js-ejp-login-btn" type="button" data-config="{"eventName":"login","eventDetail":{"source":"Masthead Dropdown"},"isNull":false}"> <i class="fa fa-sign-in"></i> <span>Log in</span> </button> </li> <li id="ctl00_ctl51_Header_UserActionTools_liOr" class="dib or-spacing"><span>or</span></li> <li id="ctl00_ctl51_Header_UserActionTools_liRegister2" class="user-menu__item dib"> <a id="ctl00_ctl51_Header_UserActionTools_RegisterUserPopupLnk" class="user-menu__link js-register-link" data-config="{"eventName":"Register","eventDetail":{"source":"Masthead Dropdown"},"isNull":false}" href="https://journals.lww.com/acgcr/pages/register.aspx?ContextUrl=%2facgcr%2ffulltext%2f2023%2f11000%2fa_case_of_refractory_eosinophilic_gastrointestinal.14.aspx">Register</a> </li> <li id="ctl00_ctl51_Header_UserActionTools_liIssueAlerts" class="user-menu__item dib"> <i class="fa fa-envelope"></i> <a rel="nofollow" title href="javascript:javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');;" onclick="javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');" class="user-menu__link"><span id="ctl00_ctl51_Header_UserActionTools_SubscribeToAlertsActionToolLink_defaultText" class="hideOnFixed">Get new issue alerts</span><span id="ctl00_ctl51_Header_UserActionTools_SubscribeToAlertsActionToolLink_stickyText" class="showOnFixed">Get alerts</span></a> </li> </ul> </section> <span id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_dummyTargetControl"></span> <div id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pnlunSubscribeToAlerts" style="display: none;"> <div tabindex="-1" role="dialog" class="wk-modal horizontally-centered small wk-modal-with-overlay wk-modal-small ejp-modal"> <div id="ej-box-modal-style-1"> <div id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pnlMain"> <div id="tocUnsubscribeModal" > <section class="wk-modal-content"> <header class="wk-modal-header ejp-modal-header"> <div class="wk-modal-title ejp-modal-title"></div> <button aria-label="close dialog" class="js-close primary-button wk-button-icon wk-modal-close ejp-modal-close "><i class="fa fa-times"></i></button> </header> <div class="wk-modal-body"> <div class="wk-field-item"> <p> <span id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage"></span> </p> <div class="wk-button-bar"> <div class="wk-button-group-left"> <p id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons" Style="display: none;"> <input type="submit" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$btnContinue" value="Yes" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$btnContinue", "", true, "", "", false, false))" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_btnContinue" class="primary-button" /> <input type="button" value="No" id="btnCancel" aria-label="close dialog" class="js-close secondary-button" /> </p> </div> </div> </div> </div> </section> </div> </div> </div> </div> </div> <div id="ej-clear-float"> </div> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenUnSubscribeAlertType" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenUnsubscribeJournalId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenUnsubscribeMessage" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenTopicalCollectionId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenTopicalCollectionId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenOvidId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenOvidId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$ucUnsubscribeToAlertsUserControl$hiddenJournalId" id="ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId" /> <script type="text/javascript"> function alerts_ShowUnSubscribeeTOCPopup(title, alertType, journalId) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = alertType; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == null || document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == '') { document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value = journalId; } if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCPopup_Root(title, journalId, alertType) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = alertType; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId').value = journalId; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCPopup_Citation(title, journalId, ovidId) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = 'Citation'; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId').value = journalId; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenOvidId').value = ovidId; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCPopup_Topical(title, journalId, topicalCollectionId) { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); var lblUnsubscribeMessage = document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_lblUnsubscribeMessage'); lblUnsubscribeMessage.innerHTML = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeMessage').value = title; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnSubscribeAlertType').value = 'Topical'; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenUnsubscribeJournalId').value = journalId; document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenTopicalCollectionId').value = topicalCollectionId; $('#' + 'ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_pUnsubscribeButtons').show(); if (document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == null || document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value == '') { document.getElementById('ctl00_ctl51_Header_UserActionTools_ucUnsubscribeToAlertsUserControl_hiddenJournalId').value = journalId; } if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } function alerts_ShowUnSubscribeeTOCSuccessPopup() { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.show(); } } $('.js-close').on('click', function() { var unSubscribeeTocPopup = $find('unSubscribeToAlerts'); if (unSubscribeeTocPopup != null) { unSubscribeeTocPopup.hide(); } return false; }); </script> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_dummyTargetControl"></span> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenSubscribeToEtocPopupState" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscribeToEtocPopupState" value="showemail" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenConfirmSubscriptionPageUrl" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenConfirmSubscriptionPageUrl" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenJournalId" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenJournalId" /> <input type="hidden" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$hiddenSubscriptionType" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscriptionType" /> <div id="divPopupOverLay" class="Popup-Overlay" style="display: none; position: fixed; left: 0; top: 0; z-index: 3800; width: 1920px; height: 4517px;"></div> <div id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlSubscribeToEtoc" class="etoc-popup ej-box-modal-drop-shadow" style="display: none;"> <div tabindex="-1" role="dialog" class="wk-modal horizontally-centered small wk-modal-with-overlay wk-modal-small ejp-modal"> <div id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlMain" onkeypress="javascript:return WebForm_FireDefaultButton(event, 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_btnContinue')"> <section class="wk-modal-content"> <header class="wk-modal-header ejp-modal-header"> <div class="wk-modal-title ejp-modal-title"> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblTitle"></span> </div> <button aria-label="close dialog" class="js-close primary-button wk-button-icon wk-modal-close ejp-modal-close "> <i class="fa fa-times"></i> </button> </header> <div class="wk-modal-body"> <div class="wk-field-item"> <div class="wk-field-body"> <strong> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblThankYouMessage"></span></strong> </div> <div class="wk-field-body"> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_cvEmailError" style="color:Black;display:none;"> <div class="ej-error-message"> <p class="ej-error-message-icon error-red"> </p> </div> </span> <label for="Email input">Enter your Email address:</label> <div class="wk-field-body"> <input name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$txtEmailAddress" type="text" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_txtEmailAddress" class="ej-box-modal-style-1-input" /> </div> </div> <div class="wk-button-bar"> <div class="wk-button-group-left"> <input type="submit" name="ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$btnContinue" value="Continue" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ctl51$Header$UserActionTools$SubscribeToEtocPopupControl$btnContinue", "", true, "", "", false, false))" id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_btnContinue" class="primary-button" /> <input type="button" value="Cancel" id="btnCancel" class="js-close secondary-button" /> </div> </div> </div> <div class="wk-field-item"> <div class="wk-field-body"> <a id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hypPrivacy" href="https://journals.lww.com/acgcr/_layouts/oaks.journals/privacy.aspx" target="_blank">Privacy Policy</a> </div> </div> </div> </section> </div> <div id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlAuthenticatedUser" style="display: none;"> <section class="wk-modal-content"> <header class="wk-modal-header ejp-modal-header"> <div class="wk-modal-title ejp-modal-title"></div> <button aria-label="close dialog" class="js-close primary-button wk-button-icon wk-modal-close ejp-modal-close "><i class="fa fa-times"></i></button> </header> <div class="wk-modal-body"> <div class="wk-field-item"> <p> <strong> <span id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblAuthenticatedUserTitle"></span> </strong> </p> </div> <p id="ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pAuthenticatedUserMessage"> </p> </div> </section> </div> </div> </div> <div id="ej-clear-float"> </div> <script type="text/javascript"> function alerts_SaveSubscriptionTypeInHiddenField(url, subscriptionType, journalId, yearId, issueId, articleId) { if (journalId && yearId && issueId && articleId) { logCounterDataAlertWhenCitedSynchronously(journalId, yearId, issueId, articleId); } $('#' + 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscriptionType').val(subscriptionType); $('#' + 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenJournalId').val(journalId); if (url) window.location = url; else __doPostBack('hypSubscribeToAlerts'); return false; } function alerts_ShowSubscribeeTOCPopup(journalTitle, journalId, subscriptionType, displaySubscriptionType) { $('#' + 'ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscriptionType').val(subscriptionType); var subscribeToEtocPopup = $find('subscribeToEtoc'); subscribeToEtocPopup.show(); document.getElementsByTagName( 'html' )[0].classList.add('no-scroll'); var modelPopupState = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenSubscribeToEtocPopupState'); var emailTextBox = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_txtEmailAddress'); var thanksPanel = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlAuthenticatedUser'); var mainPanel = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_pnlMain'); var thankYouMessageUnAuthenticated = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblThankYouMessage'); var thankYouMessageAuthenticated = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_lblAuthenticatedUserTitle'); if (!displaySubscriptionType) { displaySubscriptionType = subscriptionType; } if (modelPopupState.value == 'showthanksmessage') { thanksPanel.style.display = "block"; mainPanel.style.display = "none"; thankYouMessageAuthenticated.innerHTML = "Thank you for subscribing to the " + displaySubscriptionType + " for " + journalTitle + "."; } if (modelPopupState.value == 'showemail') { thanksPanel.style.display = "none"; mainPanel.style.display = "block"; thankYouMessageUnAuthenticated.innerHTML = "Thank you for choosing to subscribe to the " + displaySubscriptionType + " for " + journalTitle + "."; } if ($('.etoc-popup') != null) { document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenJournalId').value = journalId; if (modelPopupState.value == 'showemail') emailTextBox.focus(); } } $('.js-close').on('click', function () { document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_txtEmailAddress').value = ""; document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_cvEmailError').style.display = "none"; var pageUrl = document.getElementById('ctl00_ctl51_Header_UserActionTools_SubscribeToEtocPopupControl_hiddenConfirmSubscriptionPageUrl'); var subscribeeTocPopup = $find('subscribeToEtoc'); if (subscribeeTocPopup != null) { subscribeeTocPopup.hide(); document.getElementsByTagName( 'html' )[0].classList.remove('no-scroll'); if (pageUrl.value !== '' && pageUrl.value !== window.location.pathname) window.location = pageUrl.value; } return false; }); </script> <div id="ctl00_ctl51_Header_UserActionTools_eTocTopContainer"> <div id="eTocTop" style="display: none;"> <a rel="nofollow" title href="javascript:javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');;" onclick="javascript: alerts_ShowSubscribeeTOCPopup('ACG Case Reports Journal','acgcr','eTOC', 'eTOC');"><span id="ctl00_ctl51_Header_UserActionTools_alertLinkControlTop_defaultText" class="hideOnFixed">Subscribe to eTOC</span></a> </div> </div> <script> $(function () { //find recent searches link and move container var recentSearchesControl = $("a[id$='RecentSearches']"); if (recentSearchesControl.length) { recentSearchesControl.click(function (e) { e.stopPropagation(); if ($("#ResentSearchContainer").is(":hidden")) { $("#ResentSearchContainer").slideDown("slow"); recentSearchesControl.addClass('open'); } else { $("#ResentSearchContainer").hide(); recentSearchesControl.removeClass('open'); } }); } var eTocAccountLink = $("ul.js-user-action-toolbar__dropdown>li>a[id='SubscribeToEToc']"); if (eTocAccountLink.length) { eTocAccountLink.parent().html($("#eTocTop>a")); } }); </script> <a class="logo-secondary black" href="http://wolterskluwer.com/" target="_blank"> <h3 class="logo-secondary-text">Secondary Logo</h3> </a> <a href="#" class="sticky-search"><i class="fa fa-search"></i></a> </div> <div class="header__layout-bottom wk-grid-page-container"> <a id="hypJournals" class="logo-main" href="https://journals.lww.com/acgcr/pages/default.aspx"> <h3 class="logo-main-text">Journal Logo </h3> </a> <div class="search-v2"> <div class="search-wrapper"> <select name="ctl00$ctl51$Header$SearchTopBoxControl$ddlContentScope" id="ctl00_ctl51_Header_SearchTopBoxControl_ddlContentScope"> <option value="All">All</option> <option selected="selected" value="Articles">Articles</option> <option value="Images">Images</option> <option value="Videos">Videos</option> <option value="Podcasts">Podcasts</option> <option value="Blogs">Blogs</option> </select> <div class="input-group" id="globalSearch"> <input name="ctl00$ctl51$Header$SearchTopBoxControl$txtKeywords" type="text" value="Search" id="ctl00_ctl51_Header_SearchTopBoxControl_txtKeywords" class="form-control searchText" /> <span class="input-group-btn"> <button id="ctl00_ctl51_Header_SearchTopBoxControl_btnGlobalSearchMagnifier" type="submit" class="btn btn-default"><i class="fa fa-search"></i></button> </span> <input type="hidden" name="ctl00$ctl51$Header$SearchTopBoxControl$IsAutoCompleteEnabled" id="ctl00_ctl51_Header_SearchTopBoxControl_IsAutoCompleteEnabled" value="false" /> <input type="hidden" name="ctl00$ctl51$Header$SearchTopBoxControl$AutocompleteApiUrl" id="ctl00_ctl51_Header_SearchTopBoxControl_AutocompleteApiUrl" value="https://platformservices.wolterskluwerhealth.com/autocomplete/ACGCRJ/shingle/" /> </div> </div> <div class="advance-search" style=""> <a id="ctl00_ctl51_Header_SearchTopBoxControl_lnkAdvanceSearch" href="https://journals.lww.com/acgcr/pages/advancedsearch.aspx">Advanced 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Refractory Eosinophilic Gastrointestinal Disease Successfully Treated With Dupilumab', '11062023', 'Casey Arnold, Jeptha Johnson, Nieka Harris, et al', '10', '11', 'Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.', '02075970-202311000-00014', '', true, ''); } </script> <div id="ArticleContainer"> <article id="ej-article-view" class="js-article-view ej-article-view" xmlns:ssr="http://ssr-eus-go-csi.cloudapp.net/v1/assets" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xhtml="http://www.w3.org/1999/xhtml"><section class="ejp-r-article-subsection"><div class="ejp-r-article-subsection__text">CASE REPORT: STOMACH</div></section><header class="ejp-article-header"><h1 class="ejp-article-title">A Case of Refractory Eosinophilic Gastrointestinal Disease Successfully Treated With Dupilumab</h1></header><section id="ejp-article-authors"><p id="P7">Arnold, Casey MD, LT, MC, USN<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>; Johnson, Jeptha MD, LCDR, MC, USN<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>; Harris, Nieka MD, CDR, MC USN<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>; Sadowski, Brett MD, LCDR, MC, USN<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">2</sup>; Banks, Taylor MD, CDR, MC, USN<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>; Bush, Allison MD, LCDR, MC, USN<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup></p><section><a href="#" id="ejp-article-authors-link"> Author Information <i class="wk-icon-arrow-down-r"></i></a></section></section><section id="ejp-article-authors-info" class="ejp-article-authors-info ejp-article-authors-info--hidden"><div class="ejp-article-authors-info-holder"> <p id=""><sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">1</sup>Naval Medical Center Portsmouth, Portsmouth, VA</p> <p id=""><sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0">2</sup>Naval Medical Center San Diego, San Diego, CA</p> <p id="cor1"><strong xmlns:mrws="http://webservices.ovid.com/mrws/1.0">Correspondence:</strong> Casey Arnold, MD, LT, MC, USN (<span><a href="/cdn-cgi/l/email-protection#4d202c24213922772e2c3e2834632a632c3f23222129632024210d25282c21392563202421" onclick="javascript:window.open('mailto:mailto:casey.g.arnold.mil@health.mil');return false"><span class="__cf_email__" data-cfemail="f99a988a9c80d79ed7988b9796959dd7949095b9919c98958d91d7949095">[email protected]</span></a></span>).</p> </div></section><section id="article-journal-info"><div class="ej-journal-info"><span class="ej-journal-name">ACG Case Reports Journal </span><span id="ej-journal-date-volume-issue-pg"><a href="/acgcr/toc/2023/11000">10(11):p e01187, November 2023.</a></span><span> | </span><span class="ej-journal-doi">DOI: </span>10.14309/crj.0000000000001187</div></section><section id="ejp-article-indicators" class="ejp-article-indicators"><ul class="ejp-article-indicators__list"> <li id="ej-article-indicators-open" class="ejp-article-indicators__list-item" onmouseover="javascript:Tooltip_Open()" onmouseout="javascript:Tooltip_MouseOut()"><span class="ejp-indicator">Open</span></li> </ul><button id="openArticleMetricsPopupButton" type="button" class="wk-button wk-button-ghost wk-button-icon-left ejp-article-metrics-btn" data-articleMetricsEndpoint="//services.journals.lww.com/IntegrationServices/ArticleMetricsService.svc" data-articleMetricsDetailsUrl="https://wolterskluwer.altmetric.com/details/" data-doi="10.14309/crj.0000000000001187" data-suiteId="vrs_woltere_journalsglobalvrs" data-articlePublicationDate="2023-11-06" data-articlePublicationDateString="November 6, 2023" data-receivedDate="2023-07-30" data-revisionReceivedDate="" data-acceptedDate="2023-09-25" data-crossrefRefLinkRoot="https://doi.org/" data-medlineRefLinkRoot="http://www.ncbi.nlm.nih.gov/pubmed/" data-pubMedId="37941581"><i class="wk-icon-filled-chart-r"></i><i class="wk-icon-filled-chart-white-r"></i> Metrics </button></section><section class="ejp-article-tabs" id="abstractWrap"><h2 class="ejp-article-tabs-heading">Abstract</h2> <div class="ejp-article-tabs__tabpanel" id="panel1" role="tabpanel" aria-labelledby="tab1"> <div id="article-abstract-content1"> <div class="ejp-article-text-abstract"> <p>Eosinophilic infiltration of the gastrointestinal (GI) tract beyond the esophagus is a rare condition in adults with limited data on treatment. Current treatments with steroids and diet modifications have shown benefit, but when these treatments fall short, there is little research-driven guidance for further recommendations. We present a case of eosinophilic GI disease with extensive involvement of the GI tract successfully treated with dupilumab after failure of traditional treatment occurred.</p> </div> </div> </div></section><div class="ejp-fulltext-content js-ejp-fulltext-content"><section id="ArticleBody"><h2 class="ejp-article-outline-heading" data-level="1" id="s1">INTRODUCTION</h2> <p id="JCL-P-1">Eosinophilic gastrointestinal diseases (EGID) are disorders of chronic eosinophilic infiltration of gastrointestinal (GI) tissue.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R1">1</a></sup></sup> Eosinophilic disease of the GI system beyond the esophagus is an uncommon diagnosis involving infiltration of the mucosal, serosa, or muscular layer of the GI tract.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R2">2</a></sup></sup> Prevalence of EGID is currently 6.3/100,000 persons for eosinophilic gastritis, 8.4/100,000 persons for eosinophilic enteritis, and 3.3/100,000 persons for eosinophilic colitis.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R3">3</a></sup></sup> The incidence of these cases is increasing, yet the treatments remain limited.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R4">4</a></sup></sup> This can cause malabsorption, strictures, obstruction, and pain. Although rare, cases of ulcers in EGID have been reported.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R5">5</a></sup></sup> Avoidance of common food triggers and corticosteroids are the mainstay of treatment for EGID. When these therapies fail, there only limited reports of successful options for treatment. In addition, elimination diets can be challenging to maintain, and prolonged or recurrent corticosteroids have many potential side effects. Beyond these therapies, there is little evidence for other treatments for persistent or refractory disease. Case reports of the use of other therapies for EGID have been published, but large-scale data are not yet available. Dupilumab is a therapy that has been used for refractory cases of eosinophilic esophagitis, but there are limited data on other EGIDs.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R6">6</a></sup></sup> We present a rare case of diffuse EGID involving the esophagus, stomach, small intestine, and colon with severely symptomatic duodenal ulcers and pyloric stenosis, which was successfully treated with dupilumab, obtaining both histologic and symptomatic improvement.</p> <h2 class="ejp-article-outline-heading" data-level="1" id="s2">CASE REPORT</h2> <p id="JCL-P-2">A 22-year-old woman presented to her primary care provider while working in the Mediterranean and Italy with 6 months of nausea, vomiting, abdominal pain, and weight loss. On physical examination, she had tachycardia and epigastric abdominal tenderness. Laboratory evaluation demonstrated an absolute eosinophil count of 659 cells/μL, and a computed tomography scan noted thickening of the gastric and duodenal mucosa. Reflux esophagitis and a clean-based duodenal ulcer were identified on esophagogastroduodenoscopy (EGD), although no biopsies were obtained. Her initial management was treatment with a proton-pump inhibitor and antibiotics for a suspected <em xmlns:mrws="http://webservices.ovid.com/mrws/1.0">Helicobacter pylori</em> infection. She returned from overseas, and her symptoms persisted. A repeat EGD and colonoscopy showed traversable pyloric stenosis but otherwise normal-appearing mucosa (<a href="javascript:void(0)" onclick="javascript:showSlideShowByImageID('F1', '02075970-202311000-00014');">Figure 1</a>). Biopsies demonstrated mild chronic inflammation and increased eosinophils found in the esophagus, stomach, duodenum, terminal ileum, and large intestine. The number of eosinophils was not reported by pathology.</p><section class="ejp-r-article-images"><figure class="ejp-r-article-images__figure"><a href="javascript:void(0)" class="ejp-r-article-images__image-link" onclick="showSlideShowByImageID('F1', '02075970-202311000-00014')"><img class="ejp-r-article-images__img js-lazy-load lazy-load" src="javascript:void(0);" data-src="https://images.journals.lww.com/acgcr/ArticleViewerPreview.02075970-202311000-00014.F1.jpeg" data-srcset="https://images.journals.lww.com/acgcr/ArticleViewerPreview@2.02075970-202311000-00014.F1.jpeg 2x" srcset="" alt="F1"></a><figcaption class="ejp-r-article-images__figcaption"><a href="javascript:void(0)" class="ejp-r-article-images__figcaption-link" onclick="showSlideShowByImageID('F1', '02075970-202311000-00014')">Figure 1.: </a><div class="ejp-r-article-images__figcaption-text">(A) Stomach before treatment demonstrating diffuse collections of eosinophils and intraepithelial eosinophils, magnification 400×, stained with hematoxylin and eosin (H&E). (B) Pretreatment esophagus with diffuse eosinophils and eosinophilic microabscesses (arrows), stained with hematoxylin and eosin (H&E), magnification 400×. (C) Esophagus post-treatment with rare intraepithelial eosinophils, stained with H&E, magnification 200×. (D) Pylorus before dupilumab treatment, visualized with endoscopy. (E) Pylorus post-treatment with dupilumab, visualized with endoscopy.</div></figcaption></figure></section><p id="JCL-P-3">Evaluation for infections, vasculitis, and malignancy to include stool ova and parasites, viral hepatitis A, B, and C, <em xmlns:mrws="http://webservices.ovid.com/mrws/1.0">H. pylori</em>, human immunodeficiency virus, toxocariasis, strongyloidiasis, ANCA, and peripheral flow cytometry was negative. She was treated for EGID with prednisone with initial symptomatic improvement with cessation of pain, nausea, emesis, and weight loss. All these symptoms returned 4 months after cessation of therapy. A repeat EGD showed gastric biopsies with > 40 eosinophils/high-powered field (hpf) and esophagus biopsies with > 50 eosinophils/hpf. She was admitted to the hospital with a perforated duodenal ulcer, weight loss, and inability to tolerate food. She was started on total parenteral nutrition. Because of concern about the use of steroids with a perforated ulcer, there was a multidisciplinary discussion with the allergy, gastroenterology, and general surgery services, and she was initiated on dupilumab. Her symptoms resolved, and she returned to a regular diet. A repeat EGD 8 weeks after initiation of dupilumab showed a small area of erythema in the gastric cardia with focally increased eosinophils of 30 cells/hpf, but the remaining gastric mucosa biopsies were negative for increased eosinophils (<a href="javascript:void(0)" onclick="javascript:showSlideShowByImageID('F1', '02075970-202311000-00014');">Figure 1</a>).</p> <h2 class="ejp-article-outline-heading" data-level="1" id="s3">DISCUSSION</h2> <p id="JCL-P-4">EGID beyond the esophagus involving infiltration of the mucosal, serosa, or muscular layer of the GI tract with eosinophils is a rare diagnosis. EGID can result in severe symptoms including pain, malnutrition, intestinal fibrosis, or strictures.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R7">7</a></sup></sup> Although EGID localized to the esophagus, eosinophilic esophagitis, have been widely studied with several approved therapies, treatment for more diffuse EGID is often more challenging.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R6">6</a></sup></sup> Corticosteroids are commonly used, but prolonged use risks significant side effects, and their efficacy can be mixed. A food elimination diet, also frequently used as a therapy for EGID, is often difficult to maintain and frequently unsuccessful. There is limited evidence for treatment of persistent or refractory disease. Case reports and small case series have investigated the effects of therapies such as vedolizumab, omalizumab, and benralizumab with varying success.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R4 R7 R8">4,7,8</a></sup></sup> These treatments are hampered by an incomplete understanding of the underlying pathophysiology of EGID. Dupilumab targets the interleukin-4 receptor alpha subunit, antagonizes IL-4 and -13, with impact on IgE production and alternatively activated macrophages.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R9 R10">9,10</a></sup></sup> It was studied, and FDA approved for use in refractory eosinophilic esophagitis with case reports of clinical success in EGID.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R6 R11">6,11</a></sup></sup> In addition, dupilumab has been used as treatment of eosinophilic esophagitis and demonstrated efficacy beyond the distal esophagus in pediatric population.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R6">6</a></sup></sup></p> <p id="JCL-P-5">In this case, mainstays of typical treatment failed, and eosinophilic disease persisted. With the novel use of dupilumab, our patient was able to return to an asymptomatic state off corticosteroids and dietary modification. Although more research is needed to evaluate this treatment modality more fully, we hope our case adds to the literature as an example of successful treatment of EGID with an interleukin-4 and -13 antagonist. The successful use of dupilumab contrasts with the discouraging results of eosinophil-targeted interleukin-5 agents and emphasizes the current, incomplete understanding of the underlying endotypic drivers of EGID.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R12 R13 R14">12-14</a></sup></sup> This case also demonstrates a need for further research into maintenance treatment of EGID to avoid the complications of prolonged steroid use, restrictive diet modification, or long-term complications of eosinophilic infiltration on the GI tract. Successful treatment of EGID as presented in this case will be invaluable to progress treatment and avoid the consequences of long-term steroid use and surgical options in a disease increasing in prevalence.<sup xmlns:mrws="http://webservices.ovid.com/mrws/1.0"><sup><a class="ejp-citation-link js-ejp-citation-link" data-reference-links="R4">4</a></sup></sup></p> <h2 class="ejp-article-outline-heading" data-level="1" id="s4">DISCLOSURES</h2> <p id="JCL-P-6">Author contributions: J. Johnson, N. Harris, B. Sadowski, T. Banks, and A. Bush: contributing authors. C. Arnold is the article guarantor.</p> <p id="JCL-P-7">Financial disclosure: None to report.</p> <p id="JCL-P-8">Informed consent was obtained for this case report.</p></section><section id="article-references" class="article-references js-article-references"><h2 class="ejp-article-outline-heading" data-level="1" id="JCL-L-0">REFERENCES</h2> <div id="R1" class="article-references__item js-article-reference">1. 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