Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist.

New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.

Evaluation of chronic diarrhea in patients newly diagnosed with HIV infection through the FilmArray® gastrointestinal panel.

INTRODUCTION: The treatment and diagnosis of chronic diarrhea in the immunocompromised patient depends on the ability to rapidly detect the etiologic agents. AIMS: Our aim was to evaluate the results of the FilmArray® gastrointestinal panel in patients newly diagnosed with HIV infection that presented with chronic diarrhea. MATERIAL AND METHODS: Utilizing nonprobability consecutive convenience sampling, 24 patients were included that underwent molecular testing for the simultaneous detection of 22 pathogens. RESULTS: In 24 HIV-infected patients with chronic diarrhea, enteropathogen bacteria were detected in 69% of the cases, parasites in 18%, and viruses in 13%. Enteropathogenic Escherichia coli and enteroaggregative Escherichia coli were the main bacteria identified, Giardia lamblia was found in 25%, and norovirus was the most frequent viral agent. The median number of infectious agents per patient was three (range of 0 to 7). The biologic agents not identified through the FilmArray® method were tuberculosis and fungi. CONCLUSIONS: Several infectious agents were simultaneously detected through the FilmArray® gastrointestinal panel in patients with HIV infection and chronic diarrhea.

Diarrea crónica en paciente inmunocompetente / Chronic diarrhea in an immunocompetent patient

Presentamos un caso de diarrea crónica en un paciente varón de 58 años que no tenía antecedentes personales de interés ni alteraciones conocidas en su estado inmunitario. (AU)

We present a case of chronic diarrhea in a 58-year-old male patient with no relevant personal history and no known alterations in his immune status. (AU)

Síndrome de Good, una causa infrecuente de diarrea crónica / Good Syndrome, a rare cause of chronic diarrhea

Chronic diarrhea is a frequent cause of consultation in daily clinical practice. There are multiple diagnostic algorithms that allow a staggered approach to the most frequent pathologies, leaving out some lesser-known ones. This article reports the case of a 66-year-old female patient with a history of arterial hypertension, dyslipidemia and resected AB thymoma and a history of chronic diarrhea of 8 weeks of evolution. The etiological study ruled out infectious causes, celiac disease and negative viral serology. Due to a history of thymoma, immunoglobulin count was performed, showing severe pan-hypogammaglobulinemia. Good's Syndrome is the combination of thymoma and hypogammaglobulinemia, where patients may present with diarrhea secondary to immunodeficiency. Hypogammaglobulinemia associated with the presence of a thymoma is a rare cause but widely described in the literature as Good's Syndrome. Therefore, it seems relevant to describe a case, its approach and subsequent management.

La diarrea crónica constituye una causa frecuente de consulta en la práctica clínica diaria. Existen múltiples algoritmos diagnósticos que permiten realizar un abordaje escalonado de las patologías más frecuentes y permiten descartar algunas menos conocidas. En el presente artículo se reporta el caso de una paciente de género femenino de 66 años, antecedentes de hipertensión arterial, dislipidemia y timoma AB resecado con historia de diarrea crónica de 8 semanas de evolución. Dentro del estudio etiológico se descartan las causas infecciosas, enfermedad celíaca y serologías virales negativas. Por antecedente de timoma, se realizó recuento de inmunoglobulinas, evidenciando una severa pan-hipogammaglobulinemia. El Síndrome de Good es la combinación de timoma e hipogammaglobulinemia, donde los pacientes podrían presentar diarreas secundarias a inmunodeficiencia. La hipogammaglobulinemia asociada a la presencia de un timoma es una causa poco frecuente pero ampliamente descrita en la literatura como Síndrome de Good. Por lo antes señalado, nos parece relevante describir un caso, su abordaje y manejo posterior.

Olmesartán y enteropatía una década después: una asociación quizá no tan excepcional / Olmesartan and enteropathy a decade later: a perhaps not so exceptional association

Olmesartán es un potente antagonista de los receptores de la angiotensina II utilizado habitualmente en el tratamiento de la hipertensión arterial. Durante la última década se han descrito varios casos de enteropatía tipo esprúe asociados al uso de este fármaco, con afectación clínica severa que precisan hospitalización, pero afortunadamente con remisión completa tras la retirada del mismo. Se presenta el caso de una mujer de 82 años pluripatológica, con un síndrome diarreico crónico que derivó en una pérdida de 20kg de peso en los últimos tres meses. Para su hipertensión seguía doble terapia: olmesartán 40mg y lercanidipino 10mg/día. Basado en los hallazgos de la paciente presentada, se realiza una búsqueda bibliográfica de todos los casos publicados en revistas indexadas españolas (PubMed) y se comparan, intentando establecer un perfil de sospecha que promueva la suspensión de olmesartán y acelere las pruebas complementarias necesarias para descartar otros diagnósticos.(AU)

Olmesartan is a potent angiotensin II receptor antagonist commonly used in the treatment of high blood pressure. During the last decade, several cases of sprue-like enteropathy have been described associated with the use of this drug - with severe clinical involvement that requires hospitalization - but fortunately with complete remission after its discontinuation. We present the case of a multi-pathological 82-year-old woman with a chronic diarrhoeal syndrome that resulted in a weight loss of 20kg over the last three months. She was prescribed dual therapy for her hypertension: olmesartan 40mg, torasemide 10mg, and lercanidipine 10mg/day. Based on the findings of the patient presented, we conducted a literature search of all the cases published in Spanish indexed journals (PubMed) and compared them, attempting to establish a suspicion profile that would result in the suspension of olmesartan and accelerate the complementary tests necessary to rule out other diagnoses.(AU)

Diarrea grave en una lactante previamente sana: un reto diagnóstico / Severe diarrhoea in a previously healthy infant: a diagnostic challenge

Aunque la causa más frecuente de los procesos diarreicos infantiles son las infecciones, ante cuadros graves y prolongados en el tiempo en los lactantes hay que descartar causas congénitas como trastornos genéticos o inmunodeficiencias. La colitis por citomegalovirus (CMV) es una causa poco frecuente de diarrea crónica en niños inmunocompetentes. Por lo general, su curso es leve y autolimitado, por lo que debemos pensar la posibilidad de que exista una inmunodeficiencia en los casos con una evolución más grave. Se recomienda realizar un estudio endoscópico en estos pacientes, precisando tratamiento antiviral aquellos con un curso de la enfermedad más grave o en caso de confirmarse situación de inmunodepresión (AU)

Although the most frequent cause of childhood diarrheal processes is infection, in the case of severe and prolonged symptoms in infants, congenital causes such as genetic disorders or immunodeficiencies must be ruled out. Cytomegalovirus (CMV) colitis is a rare cause of chronic diarrhoea in immunocompetent children. In general, it is a mild and self-limiting disease, so the possibility of immunodeficiency should be considered in cases with a more severe course. Performance of an endoscopic examination is recommended in these patients, and antiviral treatment is required in those with more severe forms of disease or with confirmed immunosuppression. (AU)

Colitis ulcerosa en adolescente / An Adolescent with Ulcerative Colitis

Introducción: La colitis ulcerosa es una enfermedad inflamatoria intestinal de etiología multifactorial, que afecta principalmente al colon y al recto. Sus síntomas cardinales son diarrea crónica, rectorragia y dolor abdominal en cuadros severos. Su curso se caracteriza por periodos de remisión y de actividad llamados brotes, aunque en una menor proporción puede mostrar una actividad continua. Cuando afecta el recto, el colon izquierdo o más zonas se denomina pancolitis. La colonoscopia con biopsias múltiples es imprescindible para confirmar el diagnóstico y valorar la extensión de la enfermedad. Objetivo: Remarcar y promover el cuadro clínico que permita la sospecha diagnóstica de la colitis ulcerosa en el primer nivel de atención. Caso clínico: Paciente de 19 años de edad con antecedentes de diarrea crónica sanguinolenta, refractaria a varios tratamientos, que remitió por sí misma y que posteriormente recidiva con mayor severidad, lo que hace sospechar de una etiología atípica: colitis ulcerosa(AU)

Introduction: Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) of multifactorial etiology that affects the colon and rectum. Its cardinal symptoms are diarrhea, rectal bleeding and abdominal pain(in severe cases). In its course alternate periods of remission and activity (flares), although in a minority it has continuous activity. The extension may affect the rectum, the left colon or even more zones (pancolitis). Colonoscopy with multiples biopsies is essential to confirm diagnosis and evaluate the extension of the disease. Objective: To publicize the clinical picture that allows the diagnostic suspicion of ulcerative colitis at the first level of care. Clinical case: We report a clinical case of a patient of 19 years old with a history of chronic bloody diarrhea refractory to various treatments, which remitted itself and later relapsed more severely, making suspicious of an atypical etiology: ulcerative colitis(AU)

Enterocolopatía sprue-like asociada a la toma de olmesartán / Olmesartan-induced sprue-like enteropathy

Resumen La diarrea crónica es una patología frecuente con un amplio diagnóstico diferencial. Presentamos el caso de un paciente con diarrea crónica secundaria a enterocolopatía por la toma prolongada de olmesartán. Se trata de una patología infradiagnosticada por desconocimiento de la entidad, pero que debe considerarse en base a la frecuencia de uso del grupo farmacológico. En nuestro caso, la buena evolución clínica tras la retirada del fármaco nos muestra la necesidad de considerarlo como causa directa del cuadro clínico. Un adecuado enfoque terapéutico en estos pacientes nos permitirá evitar pruebas complementarias, costos innecesarios y se traducirá en una mejora diagnóstica y del pronóstico de estos pacientes. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2203).

Abstract Chronic diarrhea is a common pathology with a broad differential diagnosis. We present the case of a patient with chronic diarrhea secondary to enteropathy due to prolonged consumption of olmesartan. This is an underdiagnosed pathology due to lack of knowledge regarding this entity, but it should be considered, given the frequency with which this pharmacological group is used. In our case, the favorable clinical progression after withdrawing the medication indicates the need to consider it as the direct cause of the clinical picture. An appropriate therapeutic approach to these patients will allow us to avoid complementary tests and unnecessary costs, and will translate into a better diagnosis and prognosis in these patients. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2203).

[Olmesartan and enteropathy a decade later: a perhaps not so exceptional association]. / Olmesartán y enteropatía una década después: una asociación quizá no tan excepcional.

Olmesartan is a potent angiotensin II receptor antagonist commonly used in the treatment of high blood pressure. During the last decade, several cases of sprue-like enteropathy have been described associated with the use of this drug - with severe clinical involvement that requires hospitalization - but fortunately with complete remission after its discontinuation. We present the case of a multi-pathological 82-year-old woman with a chronic diarrhoeal syndrome that resulted in a weight loss of 20kg over the last three months. She was prescribed dual therapy for her hypertension: olmesartan 40mg, torasemide 10mg, and lercanidipine 10mg/day. Based on the findings of the patient presented, we conducted a literature search of all the cases published in Spanish indexed journals (PubMed) and compared them, attempting to establish a suspicion profile that would result in the suspension of olmesartan and accelerate the complementary tests necessary to rule out other diagnoses.

Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome.

INTRODUCTION: Primary eosinophilic colitis (PEC) is an inflammatory disease caused by the infiltration of eosinophils into the mucosa of the colon, determined after having ruled out other possible causes. It is characterized by abdominal pain and diarrhea and its prevalence is unknown. AIMS: To know the prevalence of PEC in patients with chronic diarrhea and in those with clinical criteria for diarrhea-predominant irritable bowel syndrome (IBS-D). PATIENTS AND METHODS: All patients with chronic noninflammatory diarrhea that were consecutively seen over a decade were studied through colonoscopy, with systematic biopsy. Patients with a known or decompensated organic disease, alarm features, abnormal minimal laboratory test results, and factors associated with eosinophilia were excluded. Patients with the clinical criteria for IBS-D (Rome III) were selected from the general group. Eosinophilic colitis was defined as the presence of > 35 eosinophils/100 epithelial cells per field in any of the segments. RESULTS: From the 683 patients seen, a total of 545 patients (361 women) were included in the study. Twenty-two cases of PEC were detected, resulting in a prevalence of 4.0%. A total of 343 patients had IBS-D criteria (223 women), with 16 cases of PEC detected, for a prevalence of 4.7%. Colonoscopy was normal, or almost normal, in all the PEC cases detected. CONCLUSIONS: The prevalence of PEC was 4.0% in the patients with chronic diarrhea and 4.7% in the patients with IBS-D. Peripheral eosinophilia appeared to be the main distinctive clinical characteristic, but systematic biopsy was essential for making the diagnosis.

Tumor neuroendócrino gástrico: relato de caso e revisão de literatura / Gastric neuroendocrine tumor: case report and literature review / Tumor neuroendocrino gástrico: reporte de caso y revisión de la literatura

Este artigo consiste em um estudo de caso de paciente do sexo masculino, 40 anos, com diarreia e perda ponderal significativa iniciada sete meses depois da sua admissão no Hospital Geral Roberto Santos. O paciente não apresentava alterações significativas no exame físico e as investigações clínicas e laboratoriais foram inexpressivas. Foram realizados estudos endoscópicos e anatomopatológicos, confirmando o diagnóstico de neoplasia neuroendócrina gástrica. Os achados histopatológicos evidenciaram um tumor bem diferenciado do tipo dois, sendo uma neoplasia rara de bom prognóstico. O paciente foi submetido a gastrectomia segmentar de corpo gástrico e evoluiu com melhora clínica da diarreia. Ele recebeu alta hospitalar e segue em acompanhamento com os serviços de gastroenterologia e endocrinologia.

This study reports the case of a 40-year-old male patient presenting with diarrhea and significant weight loss initiated seven months before admission at the Hospital Geral Roberto Santos. The patient showed no significant changes in the physical examination, and clinical and laboratory investigations were inexpressive. Gastric neuroendocrine neoplasia was diagnosed by endoscopic and anatomopathological studies. Histopathological findings showed a well-differentiated type 2 tumor ­ a rare neoplasm with a good prognosis. The patient underwent segmental gastrectomy of the gastric body, evolving with clinical improvement of diarrhea. He was discharged from the hospital and is being followed by gastroenterology and endocrinology services.

Paciente del sexo masculino, 40 años, con diarrea y pérdida significativa de peso, que inició siete meses después de su ingreso en el Hospital Geral Roberto Santos. El paciente no presentó cambios significativos en la exploración física y las investigaciones clínicas y de laboratorio fueron inexpresivas. Se realizaron estudios endoscópicos y anatomopatológicos que confirmaron el diagnóstico de neoplasia neuroendocrina gástrica. Los hallazgos histopatológicos mostraron un tumor tipo 2 bien diferenciado, que es una neoplasia poco frecuente y de buen pronóstico. El paciente fue sometido a gastrectomía segmentaria del cuerpo gástrico y evolucionó con mejoría clínica de la diarrea. Fue dado de alta del hospital y aún está en seguimiento con los servicios de gastroenterología y endocrinología.

Variation of enterohepatic circulation observed with 75SeHCAT images in the first three hours. Scintigraphic patterns and analysis of their association with the diagnosis of bile acid malabsorption.

OBJETIVE: To evaluate the enterohepatic circulation of 75-Selenium turoselecolic acid (75Se-SeHCAT) during the first 3 h and its correlation with the abdominal retention at the 7th day (AR7), as contribution to the clinical study of biliar acid malabsorption (BAM). MATERIALS AND METHODS: 38 patients with chronic diarrhea were retrospectively studied. Acquisition protocol included static abdominal images at 1st, 2nd and 3rd hour and the 7th day after oral administration of the radiopharmaceutical. Images of 1-3 h determined 5 patterns of enterohepatic circulation that, due to their location, were characterized as: 1) gallbladder 2-3 h, 2) gallbladder 3 h, 3) gallbladder-abdomen 2-3 h, 4) abdomen, 5) upper left abdomen. The association of these patterns with the AR7 (Fisher, STATA) were investigated. Patients were classified as Non BAM (AR7 > 15%), mild-BAM (AR7 15-10%), moderate-BAM (AR7 10-5%) or severe-BAM (AR7 < 5%). RESULTS: 19 patients had an AR7 diagnostic of BAM (7 mild-BAM, 5 moderate-BAM, 7 severe-BAM). The pattern "gallbladder at 2-3 h" was statistically associated with Non BAM (p 0,008), while "gallbladder-abdomen at 2-3 h" was correlated with having BAM (p 0,029). CONCLUSION: Variations detected at the abdominal level in images during the first 3 h were associated with changes in intestinal absorption and the incorporation of the radiopharmaceutical into the pool of bile acids, so visual interpretation of the images at 2nd and 3rd hour could be useful in the final assessment of the study.

Mujer de 70 años con diarrea crónica / 70-year-old woman with chronic diarrhea

Presentamos el caso de una paciente mujer de 70 años hipertensa en tratamiento con olmesartán desde hace un año, sin otros antecedentes personales de interés. Ingreso a cargo del servicio de Medicina Interna por cuadro constitucional a estudio consistente en la pérdida confirmada de peso de 13 kg, diarrea crónica, pérdida de apetito, astenia y dolor abdominal tipo cólico intermitente. Tras un primer despistaje en busca de proceso neoplásico, se pensó en otras posibles opciones (AU)

We present the clinical case of a seventy-year-old female patient with hypertension in treatment with olmesartan since one year ago and no other past medical history of interest. She was hospitalized in the internal medicine department in order to study constitutional symptoms which consisted of confirmed weight loss of 13 kg, chronic diarrhea, loss of appetite, asthenia, and intermittent colic-like abdominal pain. After an initial screening for neoplastic disease, other possible options were considered (AU)

Approach to the adult patient with chronic diarrhea: A literature review.

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

70-year-old woman with chronic diarrhea.

We present the clinical case of a seventy-year-old female patient with hypertension in treatment with olmesartan since one year ago and no other past medical history of interest. She was hospitalized in the internal medicine department in order to study constitutional symptoms which consisted of confirmed weight loss of 13 kg, chronic diarrhea, loss of appetite, asthenia, and intermittent colic-like abdominal pain. After an initial screening for neoplastic disease, other possible options were considered.

Approach to the adult patient with chronic diarrhea: a literature review. / Abordaje de la diarrea crónica en el adulto: Revisión de la literatura.

Chronic diarrhea is defined by symptoms lasting longer than 4 weeks. It is a common problem that affects up to 5% of the adult population. Different pathophysiologic mechanisms involve numerous causes, including drug side effects, postoperative anatomic and physiologic alterations, intestinal and colonic wall abnormalities, inflammatory or malabsorption causes, pancreatobiliary diseases, and functional or gut-brain axis disorders associated with dysbiosis or gastrointestinal motility alterations. Due to such a broad differential diagnosis, it is important to categorize chronic diarrhea into five main groups: drug side effect, postoperative, postinfectious, malabsorptive, inflammatory, and functional. The present review is a narrative analysis of the diagnostic approach, emphasizing key aspects of the clinical history, the utility of biomarkers (in breath, stool, urine, and serology) and malabsorption and motility tests, the role of radiologic and endoscopic studies, and the most common histologic findings. A diagnostic algorithm aimed at determining etiology and personalizing therapy is also proposed.

Variation of enterohepatic circulation through the image with 75SeHCAT in the first 3 hours. Scintigraphic patterns and análisis of its association with the diagnosis of bile acid malabsorption. / Variación de la circulación enterohepática a través de la imagen con 75SeHCAT en las 3 primeras horas. Patrones gammagráficos y análisis de su asociación con el diagnóstico de malabsorción de ácidos biliares.

OBJETIVE: To evaluate the enterohepatic circulation of 75-Selenium turoselecolic acid (75Se-SeHCAT) during the first 3 hours and its correlation with the abdominal retention at the 7th day (AR7), as contribution to the clinical study of biliar acid malabsorption (BAM). MATERIALS AND METHODS: 38 patients with chronic diarrhea were retrospectively studied. Acquisition protocol included static abdominal images at 1st, 2nd and 3rd hour and the 7th day after oral administration of the radiopharmaceutical. Images of 1 to 3 hours determined 5 patterns of enterohepatic circulation that, due to their location, were characterized as: 1) gallbladder 2-3 hours, 2) gallbladder 3 hours, 3) gallbladder-abdomen 2-3 hours, 4) abdomen, 5) upper left abdomen. The association of these patterns with the AR7 (Fisher, STATA) were investigated. Patients were classified as Non BAM (AR7>15%), mild-BAM (AR7: 15-10%), moderate-BAM (AR7: 10-5%) or severe-BAM (AR7<5%). RESULTS: 19 patients had an AR7 diagnostic of BAM (7 mild-BAM, 5 moderate-BAM, 7 severe-BAM). The pattern "gallbladder at 2-3 hours" was statistically associated with Non BAM (p 0,008), while "gallbladder-abdomen at 2-3 hours" was correlated with having BAM (p 0,029). CONCLUSION: Variations detected at the abdominal level in images during the first 3 hours were associated with changes in intestinal absorption and the incorporation of the radiopharmaceutical into the pool of bile acids, so visual interpretation of the images at 2nd and 3rd hour could be useful in the final assessment of the study.

Prevalence of primary eosinophilic colitis in patients with chronic diarrhea and diarrhea-predominant irritable bowel syndrome. / Prevalencia de colitis eosinofílica primaria en pacientes con diarrea crónica y síndrome de intestino irritable con predominio de diarrea.

INTRODUCTION: Primary eosinophilic colitis (PEC) is an inflammatory disease caused by the infiltration of eosinophils into the mucosa of the colon, determined after having ruled out other possible causes. It is characterized by abdominal pain and diarrhea and its prevalence is unknown. AIMS: To know the prevalence of PEC in patients with chronic diarrhea and in those with clinical criteria for diarrhea-predominant irritable bowel syndrome (IBS-D). PATIENTS AND METHODS: All patients with chronic noninflammatory diarrhea that were consecutively seen over a decade were studied through colonoscopy, with systematic biopsy. Patients with a known or decompensated organic disease, alarm features, abnormal minimal laboratory test results, and factors associated with eosinophilia were excluded. Patients with the clinical criteria for IBS-D (Rome III) were selected from the general group. Eosinophilic colitis was defined as the presence of>35eosinophils/100 epithelial cells per field in any of the segments. RESULTS: From the 683 patients seen, a total of 545 patients (361 women) were included in the study. Twenty-two cases of PEC were detected, resulting in a prevalence of 4.0%. A total of 343 patients had IBS-D criteria (223 women), with 16 cases of PEC detected, for a prevalence of 4.7%. Colonoscopy was normal, or almost normal, in all the PEC cases detected. CONCLUSIONS: The prevalence of PEC was 4.0% in the patients with chronic diarrhea and 4.7% in the patients with IBS-D. Peripheral eosinophilia appeared to be the main distinctive clinical characteristic, but systematic biopsy was essential for making the diagnosis.