2025 Volume 32 Issue 6 Pages 135-138
Eosinophilic gastroenteritis is primarily an allergic disease. This report describes a case of eosinophilic gastroenteritis successfully treated with Hangekobokuto. Patient: 30-year-old male, height 173 cm, weight 65 kg. The patient presented with severe diarrhea. He was diagnosed with eosinophilic gastroenteritis and started taking 30 mg of prednisolone (PSL), which was gradually tapered off. In 16 months after onset, we prescribed Hangekobokuto at our pain clinic, and the diarrhea improved within a week, and the PSL dose was gradually reduced. The patient's symptoms did not flare up. Hangekobokuto was effective for eosinophilic gastroenteritis. Soyo, which is included in Hangekobokuto, suppresses the production of IgE antibodies. The constituent crude drugs Hange and Bukuryo have been shown to inhibit histamine release and leukotriene release. These were effective in the treatment of eosinophilic gastroenteritis.
Eosinophilic gastrointestinal disease is an inflammatory condition characterized by clinical symptoms and pathological findings associated with gastrointestinal tissue dysfunction caused by severe infiltration of eosinophils. Most of these primary diseases are allergic, including eosinophilic gastroenteritis, wherein eosinophilic infiltration is observed in the stomach, small intestine, and large intestine1). Most cases show temporary relief of symptoms, but 60％ of the cases undergo relapse. Moreover, many steroid-dependent patients undergo relapse when steroid is tapered down, complicating the treatment plan. Here, we report a case of eosinophilic gastroenteritis in a steroid-dependent patient who was successfully treated with Hangekobokuto (Tsumura, Tokyo, Japan).
Kampo medicine is an important integral part of the pain clinic field. This patient had previously been treated with Kampo medicine in our pain clinic for migraine headaches and we report on this patient, who was also treated with Kampo medicine.
Blanket consent for the research was obtained from all patients. Furthermore, consent was obtained from the patient to publish this case report in writing.
Patient: 30-year-old male, height 173 cm, weight 65 kg.
Chief complaint: Diarrhea.
Present illness: The patient had experienced diarrhea more than 10 times a day and weight loss. His previous physician performed an upper gastrointestinal endoscopy, and a mucosal biopsy showed an inflammatory cell infiltrate consisting mainly of eosinophils. His IgE-RIST (radioimmunosorbent test) was as high as 325 U/ml (normal value: ＜170 U/ml). The patient was diagnosed with eosinophilic gastroenteritis because he fulfilled the essential diagnostic criteria for the condition and for the reference items, which included coexisting allergic rhinitis, increased eosinophil count in the peripheral blood, thickening of the intestinal wall on computed tomography (CT), and multiple erosions from the gastric antecubital area to the duodenum. On 1 month after onset, he was initiated with 30 mg of prednisolone (PSL) and 10 mg of vonoprazan orally, followed by tapering doses of PSL after a week. However, in 4 months after onset, when his PSL dosage reached 2 mg, he developed diarrhea, abdominal pain, and an elevated eosinophil count on a blood test, with CT scan revealing edema of the pelvis and terminal ileum. He was followed up with 5 mg d-chlorpheniramine and 20 mg esomeprazole, but his symptoms did not improve; therefore, the dose was increased to 30 mg in 5 months after onset and then tapered to 20 mg. Thereafter the patient was referred to our department of internal medicine, where treatment was initiated with 15 mg PSL, 5 mg d-chlorpheniramine, and 20 mg vonoprazan. Although only small doses were administered, hepatic dysfunction was thought to be caused by d-chlorpheniramine, and the patient was continuously monitored. In 12 months after onset, when the dosage of PSL was reduced to 5 mg, diarrhea flared, and blood tests showed elevated eosinophils; therefore, he continued on PSL 5 mg. In 14 months after onset, he visited our pain clinic.
Inspection: Physique is muscular. But the back is bent.
Listening and smelling examination: No bounce in the voice detected.
Inquiry: The patient used to experience a heavy workload and was constantly stressed.
Palpation: Pulse examination; No abnormalities detected.
Abdominal examination: Fluid retention in the stomach; Present.
Tongue inspection: No abnormality in color tone, or any coating detected, and tooth mark present.
Because eosinophilic gastroenteritis is an allergic disease, he was prescribed Hangekobokuto, which contains Soyo, an antiallergic agent, in 14 months after onset. He had chronic sinusitis and had been prescribed Shohangekabukuryoto, so we opted for Hangekobokuto, which is Shohangekabukuryoto plus Koboku and Soyo. Within a week, the diarrhea symptoms caused by eosinophilic gastroenteritis improved, and the stools became soft. The PSL dose was gradually tapered down during which there was no relapse of symptoms. PSL was terminated in 20 months after onset, and d-chlorpheniramine was discontinued the following month. An upper gastrointestinal endoscopy performed in 21 months after onset revealed no abnormalities, and Hangekobokuto was completed in 26 months after onset with no further worsening of symptoms. The eosinophilic gastroenteritis did not recur thereafter. The treatment course is shown in Figure 1. There was no abdominal pain associated with diarrhoea symptoms. There were no recurrent headaches during diarrhoea treatment.
Course of treatment
This diagram shows the course of treatment. The horizontal axis is after onset (month). The vertical axis shows the amount of PSL taken (mg). The red arrows indicate the period of diarrhea and eosinophilia. The period during which d-chlorpheniramine and Hangekobokuto were taken concomitantly is shown above. One month after the onset, the patient was diagnosed with eosinophilic gastroenteritis and PSL were started. The PSL were gradually tapered, but the symptoms recurred 4 months after the onset, and the dose of steroids was increased. Subsequently, the patient's PSL dosage was gradually tapered and symptoms recurred repeatedly, and 14 months after the onset, he visited a pain clinic and started taking Hangekobokuto, and was able to gradually taper off the PSL dosage without any recurrence of symptoms.
We encountered a case in which Hangekobokuto was effective in treating steroid-resistant eosinophilic gastroenteritis. The first-line treatment for eosinophilic gastroenteritis is oral systemic steroids such as PSL. Other treatments include topical steroid therapy, dietary therapy, antiallergic drugs, immunosuppressive drugs, biological agents, acid secretion inhibitors, and Japanese Kampo medicine2). In most cases, symptoms improve temporarily, with recurrence being reported in approximately 60％ of cases. The present case involved a steroid-dependent patient who developed recurrent relapse while receiving a reduced dose of steroids3). The cause of eosinophilic gastroenteritis is unknown; however, 46％ of affected patients in Japan have a history of allergic disease, of which approximately 60％ have bronchial asthma and approximately 10％ have atopic dermatitis and food allergy4). In the present case, the patient developed allergic rhinitis and other allergies. Some reports 118 have indicated that antiallergic drugs are more effective treatments than steroids5,6). In this case, Hangekobokuto was significantly successful in the remission of eosinophilic gastroenteritis. Hangekobokuto comprises of five crude drugs: Hange, Bukuryo, Koboku, Soyo, and Shokyo7). Among these, Soyo has been shown to inhibit the production of IgE antibodies and other antiallergic effects8,9). Hange and Bukuryo have also been shown to have antiallergic effects by inhibiting histamine release, and anti-inflammatory effects by inhibiting leukotriene release10). We 124 believe that these factors play important roles in the development of eosinophilic gastroenteritis. Fluid retention in the stomach on palpation suggested that the patient had fluid retention in the stomach on palpation suggested that the patient had gastrointestinal disorder. Gastrointestinal disorders and chi disorders are linked11). Hangekobokuto is a Kampo medicine and a good choice for qi stagnation. The Inquiry also considered that he was in a qi stagnation and that the mood stabilizers of Hange and Koboku may have reduced his stress and led to an improvement in his eosinophilic gastroenteritis. He did not complain of a lump in his throat or a depressed mood. However, he stated that his work was stressful. He had a history of tension type headache diagnosed at another hospital and was taking daily non-steroid anti-inflammatory, muscle relaxants and anti-anxiety medication. He had visited our department at that time and experienced a reduced headache with Kakkonto. He requested Kampo medication again this time. Kakkonto has the effect of warming the body and relieving stiffness in the neck and back and is thought to be effective against his tension headaches. Kampo medicine treatment is very important in the treatment of pain and the progress of Kampo medicine treatment was reported in this case.
Hangekobokuto may be effective for eosinophilic gastroenteritis, particularly in cases in which patients show recurrent relapse when steroid dosages are tapered down.
We would like to thank Editage (www.editage.jp) for English language editing.
