Eosinophilic infiltration of gastrointestinal tract causing identifiable clinical disease is rare. This entity was first described by Kaijser1 in 1937 and since then this entity has been reported occasionally as case reports or small case series. Eosinophilic enteritis presenting as sub-acute intestinal obstruction is a rare presentation of eosinophilic enteritis.

A 55year old muslim female presented with sub-acute intestinal obstruction. She had a history of chronic upper abdominal pain for the last 18 months with occasional vomiting and fullness of abdomen after meals. There was no history suggestive of Tuberculosis or any other chronic abdominal disease.

Routine haematological and biochemical investigations were within normal limits.

Plain X-ray of abdomen revealed multiple fluid levels in the central abdomen. Ultrasonography of abdomen suggested dilated fluid filled proximal small bowel loops, no free fluid, no mass lesion or retroperitoneal lymphadenopathy was seen.

Enteroclysis suggested normal proximal jejunal loops with narrowing of the distal jejunal loop, not completely obstructing the lumen. Ileal loops appeared normal in caliber, position and mucosal pattern.

Oesophagogastroduodenoscopy suggested mild gastric reflux causing grade 2 oesophagitis.

Patient was managed conservatively but did not improve. Laparotomy revealed an enterolith with multiple strictures of distal jejunum, few cms apart.

Resection anastomosis of the closely placed three strictures, and stricturoplasty of the two distantly placed strictures were done. Patient recovered well and was discharged on 10th post operative day. Two years postoperatively patient is well.

Histopathology of the strictures suggested diffuse mucosal infiltration of eosinophils and other chronic inflammatory cells with reactive secondary lymphoid follicles in lamina propria and submucosa. Eosinophilic infiltration was seen up to muscularis propria.

Eosinophilic enteritis is a rare clinico-pathological entity. Its clinical presentation depends on the site of involvement of the gastrointestinal tract which varies from mild abdominal discomfort to acute abdominal emergency.4 In milder form disease commonly present as dull abdominal pain, loss of appetite, weight loss, protein losing enteropathy,5 chronic diarrhoea, or recurrent melaena. Acute presentation varies from acute intestinal obstruction6,7 to intestinal perforation.

Four criteria’s are required for the diagnosis of eosinophilic enteritis, namely presence of gastrointestinal symptoms, eosinophilic infiltration of gastrointestinal tract, exclusion of parasitic disease and absence of other system involvement. Peripheral eosinophilia is not universal phenomenon.8 Klein et al reported three pathological presentation of eosinophilic gastroenteritis: mucosal involvement resulting in mal-absorption, diarrhoea and protein losing enteropathy; muscular layer involvement leads to development of stricture and presents with obstruction while serosal involvement presents with ascites.9

Our first patient had mucosal and muscular layer involvement and had multiple strictures causing intestinal obstruction. Enterolith was secondary to stricture. Our second patient had long stricture of proximal jejunum with intense eosinophilic infiltration up to serosal layer. Both the patient did not have peripheral eosinophilia.

Role of steroids and antihelmenthic are not well established, however, in few cases steroids have produced symptomatic improvement in controlling diarrhoea and protein losing enteropathy. Acute obstructive presentation is dealt with laparotomy and segmental resection anastomosis or stricturoplasty, as in our cases. We did not use steroids in our cases as they did not had severe mucosal disease or other impending stricture. Both our cases are well at 6 months and 3 years postoperatively..