Eosinophilic Gastroduodenitis with Pyloric Obstruction'WILLIAM S. MCCUNE, M.D., MILTON GUSACK, M.D., AND WILLIAM NEWMAN, M.D.

Washington, D. C.

From the Departments of Surgery, iMedicine and Pathology, The George Washington University Schoolof Medicine.

IN RECENT YEARS reports of eosinophilicinfiltrations of many organs have appearedin the literature. The etiology of many ofthese lesions remains a subject of contro-versy. The symptoms which they producevary in kind with the organ involved, and indegree of involvement, for reasons unknown.Since tissue eosinophils probably are de-rived from similar cells of the peripheralblood, which in turn originate in the bonemarrow, it is not surprising that varyingdegrees of peripheral eosinophilia often ac-company the parenchymatous lesions. Thelung shadows with eosinophilia and a re-markable lack of symptoms which Loefflerdescribed in 1932 fall within this category.Considered transient and benign by him,some later cases have been severe, and endedfatally.

Reports of similar lesions in the intesti-nal tract have not been numerous. In 1937Kaijser8 described three cases, one of whichinvolved the pyloric antrum. On resection ofthis latter lesion, pathological study dis-closed an eosinophilic granuloma of thestomach. Postoperatively the eosinophilcount rose to 26 per cent. In 1948 Barrie andAnderson' reported the first case of general-ized eosinophilic gastritis. In these patients,as in almost all other instances of such infil-tration of the stomach, either localized orgeneralized, pyloric obstruction has been animportant presenting symptom, and surgicalexploration has been necessary to relieve theobstruction or to disprove the possibility ofmalignancy. Because of the unusual charac-

* Presented before the American Surgical Asso-ciation, Philadelphia, Pa., April 28, 1955.

ter of these lesions and their importance inthe differential diagnosis of the causes ofpyloric obstruction, three additional casesare presented.

GENERALIZED EOSINOPHILIC GASTRODUODENITIS

Barrie and Anderson described the case ofa 27-year-old woman who was hospitalizedbecause of recurring attacks of periumbili-cal pain and vomiting, and who came to op-eration because of roentgenologic finding ofa prepyloric filling defect. The stomach andduodenum were edematous and the pyloricmuscle greatly hypertrophied. Gastrectomywas performed. Microscopic examination re-vealed extensive infiltration of the stomachwall by eosinophils, almost to the exclusionof other cell types. The preoperative eosino-phil count was 31 per cent. In 1950 Spencer,Comfort and Dahlin12 reported a similar casein a 40-year-old male who had complainedof recurring attacks of epigastric distresswith diarrhea for 11 years. Operation dis-closed obstruction due to thickening of thepyloric ring, and edema of the muscle wall.Massive infiltration of the resected stomachby eosinophils was seen microscopically. Thepatient whose only allergic manifestationhad been rhinitis and two attacks of urti-caria, had eosinophilia of 63 per cent. Sternalpuncture showed 50 per cent of the marrowcells to be of the same series. Cases of similarmassive invasion of the stomach, with ob-structive symptoms in the absence of ulcer,and with eosinophilia, have been reported byMoloney9 in 1949, and by Doniach andMcKeown4 in 1951. Ruzic et al.10 describeda patient with comparable pathological find-

510

Volume 142Number 3 EOSINOPHILIC GASTRODUODENITIS

TABLE I. Generalized Eosinophilic Gastroduodenitis.

VascularAuthor Age Pain Vomiting Allergy Site Obstruction Eosinophilia Changes

BarrieAnderson 27F Yes Yes No Stomach Yes 31% Giant cell

1948 Duodenum folliclesMoloney 57F Yes Yes No Stomach Yes 12% Inflammatory

1949 Duodenum infiltrationSpenceret al 28M Yes Yes Urticaria Stomach Yes 63% No1950 Duodenum

DoniachMcKeown 39M Yes Hematemesis No Entire Slight 5-10%o Fibrinoid

1951 Stomach necrosisRuzicet al 53M Yes No Asthma Entire No 53% Collagen1952 Loeffler's Stomach necrosis

McCuneet al 28F Yes Yes Urticaria Stomach Yes 59%l Endarteritis

Total.... 3 under 6 5 3 Sromach 5 6 530 6

TABLE II. Eosinophilic Granuloma.

Author Age Pain Vomiting Allergy Site Obstruction Eosinophilia Vascular

Kaijser Food 26% Changes1937 53M Yes Yes Allergy Antrum No (post-op.) No

HerreraGuardia 55M Yes Yes No Pylorus Yes 20% Fibrinoid1948 (post-op.) degeneration

SchneiderDailey 64M Yes Hematemesis No Antrum Yes 1% Inflammatory11948 infiltration

\BarnettKazrann 58 Yes No No Prepyloric Yes 10% No1952 (post-op.)Frank 38M Yes No Rhinitis Antrum Yes 6% No1953

McCune 54M Yes No No Antrum Yes 34% Endarteritiset al (post-op.)

McCune 30M Yes Yes No Antrum Yes 2% Noet al

Total.... 5 over 7 4 2 Antrum or 6 5 353 Pylorus

7

ings, who was also said to have asthma andLoeffler's infiltration of the lungs, but didnot have pyloric obstruction as a presentingsymptom.

Case 1. A 28-year-old Negro housewife wasadmitted to George Washington University Hos-pital on October 30, 1954, with a chief complaintof nausea, vomiting and diarrhea of 10 days' dura-tion. The patient had been well until September1953. At that time she had an attack of persistentnausea and vomited thin, green emesis 2 or 3 timesdaily. She also passed 9 or 10 loose green stools aday, and complained of recurring, midabdominal

cramping pain. She lost 25 pounds in weight butregained this rapidly and was in good health there-after until April 1954. At that time she had a similarattack of nausea, vomiting, diarrhea and weight lossfor which she was hospitalized for a period of 7weeks. She returned home feeling somewhat underpar, but again rapidly regained her strength andweight. On October 20, 1954, a third episode of asimilar nature began, which persisted until heradmission. For the first time she noticed some streak-ing of blood in her bowel movements. Her systemreview and past history were not remarkable.

Physical Examination. Temperature on admis-sion was 38.5°C., pulse 110, blood pressure 95/60.

511

McCUNE, GUSACK AND NEWMAN

FIG. 1. Upper gastro-intestinal roentgenogramshowing pyloric obstruction, with 95 per cent re-tention due to eosinophilic gastritis (Case 1).

Examination of the heart, lungs, neck and extremi-ties was within normal limits. There was some ten-derness in the epigastrium and left lower quadrant,on deep palpation. Rectal and pelvic examinationswere noncontributory.

Laboratory studies. Hemoglobin, 14.4 Gm., 96per cent; volume of packed cells, 48; leucocytes,13,500; segmented forms, 21 per cent; lymphocytes,20 per cent; eosinophils, 59 per cent. Urinalysis,serology and admission blood chemistry studieswere within normal limits. Agglutinations for ty-phoid and paratyphoid were negative, and stoolexaminations disclosed no ova or parasites. OnNovember 3, 1954, the total eosinophil count was

8,130; total protein, 7.28 mg. per cent; albumin-globulin ratio, 0.93.

Roentgenologic studies. November 1 and 2,1954, a flat abdominal film and barium enema were

normal. An oral cholecystogram showed a non-

functioning gallbladder. November 5, 1954, upper

G.I. series (Fig. 1).The esophagus was normal and there was mod-

erate atony and dilatation of the stomach. The duo-denal bulb was never well filled. There was mod-

erate dilatation of several loops of jejunum in theleft upper quadrant, the cause of which was notapparent on the films. There was about 95 per centsix hour gastric retention. The impression was:(1) pyloric stenosis, probably due to a pyloric ringulcer, or to hypertrophy of the pyloric muscle,with about 95 per cent gastric retention, and (2)moderate dilatation of several loops of upperjejunum.

Coursc in the hospital. A gastric tube was passedand the patient placed on constant suction. Intra-venous fluids and electrolytes were administeredto compensate for the gastric drainage and con-tinuing diarrhea. Because of the failure of the pa-tient to improve, exploratory laparotomy was per-formed on November 17, 1954, with a preoperativediagnosis of plyloric obstruction, cause undeter-mined.

Operation. A right rectus incision was made andextended into the abdominal cavity. Explorationdisclosed several medium sized stones in the gall-bladder, but no other abnormalities except in thestomach. The wall of this organ was thickened andedematous, and at the pylorus there was a firm,thickened ring which completely encircled thestomach. No other mass was palpable. The pyloricmuscle was so thick that it resembled a leiomyoma.Through a gastrotomy incision the stomach wall wasfound to be edematous, but no ulcer or tumor wasdetected. The pylorus was greatly narrowed, appar-ently due to thickening of the muscle layer. A sub-total gastrectomy utilizing the IHoffmeister type ofanastomosis was carried out.

Pathologic examination. The specimen consistedof the distal two-thirds of the stomach, and meas-

uLred 8.5 cm. along the lesser curvature and 20 cm.

along the greater curvature. The walls of the organwere thickened, and 2.2 cm. from the distal line ofresection there was an unusual prominence of thepyloric ring. On digital examination through thedistal end of the specimen there was marked steno-sis at this area of external prominence so that a tight"cuff" was created about the examining finger. Onopening the stomach there was no evidence of an

ulcer, and aside from slight mucosal congestion inthe region of the pyloric antrum, no abnormalitiesof the mucosal surface were seen. The walls of theorgan were thickened, measuring 5 to 7 mm. atthe proximal margin of excision, 8 to 9 mm. alongthe body, and up to 1.4 cm. along the pyloric canal.The bulk of the thickening seemed to be due tohypertrophy of the muscularis propria. No leiomyo-mas were found.

Microscopic examination revealed a strikingpicture. The mucosa showed no ulcerations, and theglands revealed no abnormalities. There appearedto be some increase in the eosinophils and plasma

512

Annals of SurgerySeptember, 1 9 5 5

Volume 142 EOSINOPHILIC GASTRODUODENITIS\umber 3

ture eosinophils extending along interfascicular _;1 l 1 - 69>a9_ >|i>2e~~~~~~~~~~~~~~~.... ..g

..

of.2reil (ase 1).bti (A,O0Upe let. Marke

felusid (edem) Glamndrpi,uhswasndt msculrikn.smucosaeupperoahgleft (x50) us(B, SUpper rgt.)k Shectiof sma-tur eosinophilsc exoteningaludongaiint oerfascicular

septae (x50.2A). (C, Lower sright.) Arterioingseand_ ...

smalvidntin tesubmucosa, soingmendoatheliadaetol hy-petrohyrn segmentprral firnodintecroscuaisofsmediaofarteriolemandr phebpitis(xlOO). geo blbae _

cells indthraelamn propra,bte thisgwasBnoThstriking E

soThe musculari mucosaews. notrathickned Sectionsherapproachingoatthepyorus sho°wedincreasingtamountohs(Fg2A.Themostrstrikingfetrofhindleiong weretheY

thamscularico propethriaand in thenmseraise itelf nn hnddtevnoseeet.Teewrexgitesnd oingto altherseros.intese arteails,shenuetsand ra areilswtnateiltsadedte

cnellsandatrae lybmphcyte (Fig. 2B). Thes ceallsla yetoh oehr wt oa emna ra

aThere othe srteriking fhoeatr mofesthisinleionvlewas theyirnidncoi,btthr a oei

513

McCUNE, GUSACK AND NEWMAN

FIG. 3. Upper gastro-intestinal roentgenogramshowing cone-like narrowing of prepyloric area dueto eosinophilic granuloma (Case 2).

dence of thrombosis. Veins and venules did notshow any segmental necrosis of their walls butshowed the greatest degree of involvement wherethey were contiguous with severely affected arter-ies and arterioles. There were no sites of extravascu-lar collagen necrosis, and no extravascular granulo-mas were found.

Postoperative course. The postoperative course

was uneventful except for fever which varied from380 to 390 C. for the first 8 days. A minor woundinfection developed, which was drained success-

fully, after which her temperature fell to normal.Four months after discharge her eosinophils hadfallen to 2 per cent.

A comparison of this case with the five reportedinstances of generalized eosinophilic gastroduodeni-tis found in the literature revealed many similarities(Table I). All complained of abdominal pain, usu-

ally recurrent, and usually accompanied by vomit-ing. In two cases beside our own (Spencer et al.,12Ruzic et al.10) diarrhea was a prominent symptom.Roentgenologic evidence of obstruction was presentin all cases, preoperatively, and microscopic exam-

ination of the resected stomach (biopsy only inthe patients of Moloney and Ruzic et al.) disclosedmassive infiltration of all layers of the organ, exceptthe mucosa, by eosinophils. Angiitis, segmentalfibrinoid necrosis, giant cell follicles or giant cellswith collagen necrosis were present in 4 of the 6specimens.

EOSINOPHILIC GRANULOMA

In addition to the case reported by Kaijserin 1937, localized areas of eosinophilic infil-tration in the stomach have been reportedby several authors. Herrera and Guardia"described a case in a 52-year-old man inwhom a barium roentgenogram showed anobstructing pyloric lesion. At operation asoft, friable pseudotumor was encounteredat the pylorus, with "bands of thickening"extending along the small intestine. Micro-scopic examination of the resected stomachshowed extensive eosinophilic infiltration ofthe musculkris mucosae and submucosa.Other instances of similar lesions have beenreported by Schneider and Dailey," Bar-nett and Kazmann,2 Frank,5 Judd et al.,7 andothers. Surgical exploration was necessarybecause of pyloric obstruction, or to provethe etiology of a prepyloric lesion. Eosino-philia was present in the case reported byKaijser, preoperatively, and in those of Her-rera and Guardia,6 and Barnett and Kaz-mann2 during the postoperative period. Allresected lesions disclosed extensive eosino-philic infiltration, although there was a

somewhat greater admixture of plasma cellsand lymphocytes than in the patients in-cluded in the generalized eosinophilic gas-tritis group described above, and less ten-dency toward massive invasion of all layersof the stomach wall. Fibrinoid necrosis ofblood vessel walls was described only in thepatient of Herrera and Guardia (Table II).Two additional instances of localized eo-

sinophilic granulomas with pyloric obstruc-tion are presented.

Case 2. A 54-year-old white man was hospi-talized in September 1946 with complaints of epi-gastric fullness and discomfort, which has recurredintermittently over a period of 7 years. More severe

514

Annals of SurgerySeptember, 1 9 5 a

EOSINOPHILIC GASTRODUODENITIS

8 2_

FIG. 4. Resected portion of stomach with pre-pyloric narrowing (Case 3).

during periods of stress, they were aggravated bylarge meals but relieved to some degree by lyingdown. He had also been troubled by occasionalnausea and diarrhea. His weight had varied ratherwidely, but there had been a gain to match everyloss. His past history was not remarkable. He hadnever vomited blood, and gave no history of melena.

Physical Examination revealed a fairly welldeveloped man in no acute distress. General exami-nation of the heart, lungs, abdomen and rectumdisclosed no abnormalities.

Roentgenologic Studies. Shortly after admission,roentgenologic study of the upper gastro-intestinaltract disclosed a cone-like deformity at the pylorus,with moderate gastric retention (Fig. 3). Severalgastroscopic examinations were performed. Thepylorus was seen to remain in a contracted state forrather long periods of time, but otherwise seemedto function normally. The mucosa was of normalcolor without ulceration or other abnormal appear-ance.

Operation. Since it was impossible to excludethe presence of a malignant prepyloric lesion ex-ploratory laparotomy was performed. This re-vealed some thickening of the pyloric and pre-pyloric areas of the stomach without evidence ofulceration. Remainder of the abdominal examinationshowed no other abnormalities. A subtotal gastrec-toimiy was performed with a Polya type of gastro-

jejunostoimiy. His postoperative course was satis-factory.

Pathological examination. On gross examinationthe distal portion of the stomach and prepyloricarea were thickened, especially along the lessercurvature. No ulceration was present and the re-mainder of the stomach appeared to be normal.Microscopically there was evidence of acute in-flammation of the submucosa, with some invasionof the muscularis mucosae by polymorphonuclearleucocytes, lymphocytes and plasma cells. Muchof the thickening was due to submucosal edema.There was hypertrophy of the musculature in theprepyloric area, and a diffuse infiltration by matureeosinophils. Arteriolar walls were thickened andshowed some perivascular inflammatory reaction.The mucosa was normal.

Laboratory Studies. Preoperatively blood andurine studies had been within physiological limits.Postoperatively repeated blood counts showed a

gradual rise in the percentage of eosixiophils to 1per cent, 15 per cent, 18 per cent, 34 per cent and33 per cent over a two month period .

Case 3. A 30-year-old white male was hospi-talized on April 9, 1953, with a chief complaint ofnausea and vomiting of 2 months' duration. He hadhad no symptoms referrable to his stomach priorto February 1, 1953, except for occasional epigastricfullness and heartburn, which he attributed to over-eating. Shortly after recovering from an upperrespiratory infection in the early part of January1953 he began to be troubled by nausea, followedby vomiting and midepigastric pain. An uppergastro-intestinal roentgenologic series revealed py-loric stenosis with gastric retention.

Physical examination. Blood pressure, 118/82;pulse, 80; respirations, 16. The patient was a welldeveloped but rather undernourished white male.Examination of the heart, lungs, neck and extremi-ties was noncontributory. The abdomen wasscaphoid, muscular and slightly tender in the epi-gastric area, with midepigastric guarding.

Laboratory studies. RBC, 4,600,000; WBC,10,150; 6 per cent segmented forms, 4 per centbands, 2 per cent eosinophils, 32 per cent lympho-cytes, 1 per cent monocytes. Total protein, 6.4 mg.per cent; globulin, 1.8 mg. per cent; albumin, 4.6mg. per cent; hemoglobin, 14.5 Gm. Urinalysis wasnormal except for a finding of 2 plus acetone.

Roentgenologic studies. Roentgenologic exami-nation of the upper gastro-intestinal tract revealedan ulcer-like crater in the prepyloric region, withconsiderable narrowing of the lumen in this area.The duodenal cap was symmetrical. A diagnosis ofa large prepyloric ulcer was made, which could notbe distinguished from a malignant neoplasm.

515

Volume 142Number 3

McCUNE, GUSACK AND NEWMAN

Operation. The abdomen was entered througha right subcostal incision, which was extended tothe left costal margin. A thickened pylorus andprepyloric area were found, without evidence ofacute inflammation. A subtotal gastric resection wasperformed, using the Hoffmeister technic, with aposterior gastroenterostomy. There were no post-operative complications.

Pathological report. The specimen consisted ofa resected portion of stomach measuring 9 cm. alongthe lesser curvature, and 16 cm. along the greatercurvature. The prepyloric region was narrowed to0.5 to 1 cm. in diameter (Fig. 4). The area ofnarrowing was visualized by opening the stomachlongitudinally, when the narrowest point was seen

to be approximately 2 cm. proximal to the pylorus.The mucosa over this area was granular, but no

ulceration was seen.

Microscopically, a section through the area ofconstriction showed hyperplasia of the muscularismucosae, with a rather marked degree of hyaliniza-tion and fibrosis. The submucosa was thickened,and contained large numbers of lymphocytes andeosinophils.

DISCUSSION

The degree of eosinophilic infiltration inthese three cases varied from massive inva-sion of the entire stomach wall to localizedareas of involvement, in which lymphocytesand plasma cells were found in addition tothe eosinophils. Whether or not all were

manifestations of the same disease process

cannot be stated with certainty.One is tempted to compare these cases

with others involving different organs inwhich allergy or hypersensitivity has beenimplicated. In many instances the allergenicor hypersensitivity factors have not beenidentified. Case 1 had urticaria, as did thatof Spencer et al.'2 Kaijser's patient has a life-long allergy to onions. Ruzic and his co-

workers described their case as a "gastriclesion of Loeffler's syndrome," although onlya small biopsy of the stomach was availablefor study.The vascular lesions in Case 1, and in cases

described by Barrie and Anderson,' Herreraand Guardia,6 Ruzic et al.'0 and Doniachand McKeown4 suggest a possible relation-ship to those reported by Churg and

Strauss,3 and Zeek et al.'3 as allergic or hy-persensitivity angiitis. Indeed, the pathologi-cal description of "giant cell follicles" inBarrie and Anderson's case is suggestive ofthe extravascular allergic granulomas de-scribed by Churg and Strauss. Similar le-sions have been observed in the lungs ofpatients with Loeffler's pulmonary infiltra-tion with eosinophilia. They also reportedallergic granulomas occurring in combina-tion with angiitis, but indicated that eosino-philia and granulomatous inflammationmight exist independently of vascular in-volvement.The surgical importance of these lesions

lies in their location. Pyloric obstruction isalmost invariably present, and if they aresituated in the antrum they may be indis-tinguishable from malignant neoplasms. Innone of our three cases, or in any which weencountered in the literature, was the cor-riect diagnosis made preoperatively. It isprobable that in many future cases the samediagnostic problem will obtain. However,the presence of eosinophilia in a patient whohas had recurring attacks of pyloric obstruc-tion, with or without weight loss and diar-rhea, should at least suggest the possibilityof eosinophilic gastritis. Surgical explora-tion may still be necessary to confirm thediagnosis.

In each of these three cases pyloric ob-struction due to hypertrophy of the pyloricmuscle or to a granuloma of the pyloricantrum necessitated surgical interference.Conservative subtotal gastrectomy was per-formed in all of our cases, and in most ofthose reported in the literature. If the diseasecan be recognized at operation, the ex-

tensive resection indicated in malignancyshould not be required.

SUMMARY

A case of generalized eosinophilic gastro-duodenitis has been described, with a reviewof the literature. Symptoms of recurring epi-gastric pain and vomiting were present with

516

Annals of SurgerySeptember, 1 9 5 5

V'olumne 142 EOSINOPHILIC GASTRODUODENITIS2Vlni-

pyloric obstruction and eosinophilia of 59per cent. Subtotal gastrectomy was per-formed; the stomach revealed massive infil-tration by eosinophils with angiitis and focalfibrinoid necrosis.Two cases of eosinophilic granuloma of

the stomach were also reported and the lit-erature reviewed. Pyloric obstruction due toeosinophilic lesions of the pyloric antrumnecessitated surgical intervention. Eosino-philia of 34 per cent was present in one casepostoperatively.

ACKNOWLEDGMENT

The authors wish to express their thanks toDr. Eddy Palmer for permitting us to include Case 2and Figure 3, and to Dr. Louis J. Goffredi andDr. Kenneth McCoy for Case 3 and Figure 4.

BIBLIOGRAPHYBarrie, H. J., and J. C. Anderson. Hypertrophy

of the Pylorus in an Adult With MassiveEosinophil Infiltration and Giant Cell Re-action. Lancet, 2: 1007, 1948.

2 Barnett, L., and Kazmann: Gastric GranulomaWith Eosinophilic Infiltration. Am. J. Surg.,84: 107, 1952.

3 Churg, J., and L. Strauss: Allergic Granuloma-tosis. Allergic Angiitis and Periarteritis No-dosa. Am. J. Path., 27: 277, 1951.

4 Doniach, I., and K. C. McKeown: A Case ofEosinophilic Gastritis. Brit. J. Surg., 39: 247,1951.

5 Frank, Von A.: Uber das eosinophile Granulomdes Magens. Gastroenterologia, 1: 9, 1953.

6 Herrera, J. M., and J. de la Guardia: Un rarocaso de eosinofilia gastrointestinal motiva-doro de un cuadro organico de estenosispilorica. Arch. Hosp. Santo Tomas, 3: 19,1948.

7 Judd, C. S., W. H. Civin and M. L. Mcllhany:Eosinophilic Granuloma of Stomach. Gastro-enteral, 28: 453, 1955.

8 Kaijser, R.: Zur Kenntnis der allergischen Affek-tionen des Verdauungskanals vom Stand-punkt des Chirurgen aus. Arch. klin. Chir.,188: 36, 1937.

9 Moloney, G. E.: Pyloric Hypertrophy With Eo-sinophil Infiltration. Lancet, 1: 412, 1949.

10 Ruzic, J. P., J. M. Dorsey, H. L. Huber and S.H. Armstrong, Jr.: Gastric Lesion of Loeffler'sSyndrome-Report of a Case With Inflamma-tory Lesion Simulating Carcinoma. J. A. M.A., 149: 543, 1952.

Schneider, H., and M. E. Dailey: An UunsualType of Gastritis Gastroenterology, 10: 727,1948.

12 Spencer, J. R., M. W. Comfort and D. C.Dahlin: Eosinophilic Infiltration of the Stom-ach and Bowel Associated With Pyloric Ob-struction and Recurrent Eosinophilia. Gas-troenterology, 15: 505, 1950.

13 Zeek, P. M., C. C. Smith and J. C. Weeter:Studies on Periarteritis Nodosa. III. TheDifferentiation Between the Vascular Lesionof Periarteritis Nodosa and of Hypersensi-tivity. Am. J. Path., 24: 889, 1948.

DIscUSSION.-DR. JOHN M. DORSEY, Evanston,Illinois: I was pleased to hear that Dr. McCune, inhis perusal of the literature, found the case historyof a patient about whom we reported, under thename or authorship of Ruzie et al., in 1952. I wouldlike to give you the follow-up on this patient, con-firming some of the things Dr. McCune has men-tioned.

(Slide) This is a roentgenogram of the stomach,which was reported as showing a stiffening of themucosal pattern in this 53-year-old male who wasreferred to and who was a very severe asthmaticwith allergic symptoms.

(Slide) This is a barium study taken at thesame time. The pyloric obstruction was disturbing,and the roentgenologist made a presumptive diag-nosis of carcinoma, which prompted us to explorethis patient despite the fact that he was a very

severe asthmatic. His eosinophil count at that timewas about 53 per cent.

(Slide) This shows the stomach in a lowermicroscopic power.

(Slide) This slide demonstrates the consider-able similarity of the eosinophil infiltration with thatwhich Dr. McCune has shown you. I believe thisis certainly a patient in this category.

The infiltration of the stomach was so diffusethat we felt it would be to no avail to do a resectionbecause it would require a total resection. We didnot feel the patient would survive this procedure.The biopsy revealed this for us. This man was notat all critically ill.

(Slide) Subsequently he demonstrated the api-cal infiltrate which he had exhibited as early as1947, which was interpreted as a Loeffler's syn-drome.

517