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Eosinophilic GI Disorders (EGID) following Immunosuppression for Liver Transplantation

Saranya Ravindran, Alberto Quaglia and Alastair Baker

Background: Eosinophilic gastrointestinal disorders (EGID) are a group of inflammatory gastrointestinal disorders, characterised by inappropriate eosinophil infiltration and symptoms that affect one or more parts of the GI tract, in the absence of extra-intestinal causes. They include eosinophilic oesophagitis (EO), eosinophilic gastroenteritis (EG) and eosinophilic colitis (EC), all of which can occur following immunosuppression for liver transplantation.

Aim: To present a review of the recent literature on EGID following immunosuppression for liver transplantation in order to clarify their diagnosis and treatment.

Methods: We performed a PubMed search for EGID, eosinophilic oesophagitis (EO), eosinophilic gastroenteritis (EG) and eosinophilic colitis (EC), associated with liver transplantation, their clinical presentation, diagnosis and treatments.

Results: In the liver transplant population, prevalence of EGID is up to one hundred times greater than the non-transplant population, making it a significant contributor to post-transplant morbidity. EGID affects individuals of all ages, favouring those in the third and fourth decades, and males over females. There is a strong association between these conditions and calcineurin inhibitors, tacrolimus and CsA, with tacrolimus appearing to confer a higher risk for the development of eosinophilic disorders.

Diagnosis of EGID depends on endoscopic and histological features, due to similar non-specific symptomatology of EGID but distinct endoscopic and histological features.

The mainstay of treatment for EO, EG and EC is systemic steroid therapy, however some specific therapies have been suggested including biologics such as mepolizumab (anti-IL-5 monoclonal antibody) for EO, octreotide (somatostatin analogue) for EG and montelukast (LTD4 receptor antagonist) for all three conditions. Empirical dietary elimination may also provide symptomatic relief.

Conclusion: EGID is an important but under-recognised complication of immune suppression, particularly of the drugs that predominate current anti-rejection therapy for liver transplantation. They are quite common and likely to impact on the patient’s quality of life. In patients presenting with non-specific GI symptoms, there must be a high index of suspicion for EGID, prompting further investigation through upper and lower endoscopy and histological analysis.

Modification of the immunosuppressive regime can contribute to reducing risk of relapse and treating active or refractory episodes. Therefore, in patients suffering from EGID, management of the their immune suppression becomes important in control of the condition, rendering EGID a key factor in the design of their tailored immunosuppression.