Collagenous gastritis

In the present paper, we report a case of rare collagenous gastritis. The patient was a 25‐year‐old man who had experienced nausea, abdominal distention and epigastralgia since 2005. Esophagogastroduodenoscopy (EGD) carried out at initial examination by the patient's local doctor revealed an extensively discolored depression from the upper gastric body to the lower gastric body, mainly including the greater curvature, accompanied by residual mucosa with multiple islands and nodularity with a cobblestone appearance. Initial biopsies sampled from the nodules and accompanying atrophic mucosa were diagnosed as chronic gastritis. In August, 2011, the patient was referred to Tohoku University Hospital for observation and treatment. EGD at our hospital showed the same findings as those by the patient's local doctor. Pathological findings included a membranous collagen band in the superficial layer area of the gastric mucosa, which led to a diagnosis of collagenous gastritis. Collagenous gastritis is an extremely rare disease, but it is important to recognize its characteristic endoscopic findings to make a diagnosis.     

Topographic mapping of collagenous gastritis.

A 74-year-old woman was investigated for abdominal pain and diarrhea. Endoscopic examinations including biopsies of the stomach and colon demonstrated the typical subepithelial deposits characteristic of collagenous gastritis and collagenous colitis. Histochemical and ultrastructural methods confirmed the presence of collagen in the subepithelial deposits. The topographic distribution of these collagen deposits and their relationship to the inflammatory process in the stomach were then defined by endoscopic mapping and multiple site biopsies of the mucosa in the gastric body and antrum. These studies indicate that collagenous gastritis not only is distinctive, but also is a far more extensive and diffuse inflammatory process than has previously been appreciated.     

胶原性胃炎一例并文献复习

目的 胶原性胃炎(coHagenous gastritis,CG)临床少见,现报道一例CG并进行文献复习.方法 患者行胃镜检查,活检组织切片分别行HE染色、Masson染色、刚果红染色及Warthin-Starry染色;分析病例临床资料并进行随访.结果 1例20岁女性患者主因无规律上腹痛4年,伴腹胀、呃逆、体重明显下降2个月就诊.胃镜检查于角切迹及窦部可见白色结节(活检).病理诊断为胶原性胃炎,上皮下胶原带厚度为16.6-120.3μm,平均厚度43.8 μm,Masson染色阳性,刚果红染色阴性.给予泼尼松(20 mg/d)4周,配合促动力和胃黏膜保护药,患者食欲好转,呃逆减轻,体重略有增加.结论 目前国外文献报道CG仅40余例,其发病机制尚不明确.综合本病例临床及组织病理学特点,符合儿童和青少年发病型CG.综合相关文献及本例治疗经验,无谷胶饮食和糖皮质激素可以有效改善患者症状.     

Collagenous gastritis

Subepithelial fibrosis has previously been reported in the small intestine (collagenous sprue) and colon (collagenous colitis). We report a 15-yr-old girl with chronic gastritis and subepithelial fibrosis of the gastric corpus who presented with recurrent abdominal pain and acute upper gastrointestinal bleeding. Nodularity and erythema of the gastric corpus were persistent endoscopic findings. Biopsies revealed patchy chronic active gastritis with a striking focal thick band of collagen immediately beneath the surface epithelial cells that did not extend to deeper portions of the lamina propria. Contrast radiography demonstrated an abnormal mucosa of the gastric corpus with a mosaiclike surface pattern. Numerous studies have failed to elucidate the etiology. Despite treatment with ranitidine, sucralfate, and furazolidone, there has been no clinical or pathologic improvement. The pathogenesis and prognosis of collagenous gastritis, and its relationship to collagenous sprue and collagenous colitis, remain to be defined.     

Collagenous gastritis and collagenous colitis: a report with sequential histological and ultrastructural findings

The case is reported of a young adult man with collagenous gastritis, an extremely rare disorder with only three case reports in the English literature, who subsequently presented with collagenous colitis. Sequential gastric biopsies showed a notable increase in thickness of the subepithelial collagen band. Ultrastructural study of gastric and rectal mucosa showed the characteristic subepithelial band composed of haphazardly arranged collagen fibres, prominent degranulating eosinophils, and activated pericryptal fibroblasts.     

Collagenous gastroduodenitis coexisting repeated Dieulafoy ulcer: A case report and review of collagenous gastritis and gastroduodenitis without colonic involvement

Collagenous gastritis (CG) is a rare disorder characterized by the thick collagenous subepithelial bands associated with mucosal inflammation. There have been approximately fifty reports in the literature since it was first described in 1989. According to previous reports, CG is heterogeneous and classified into two groups—(1) cases limited to the gastric mucosa in children or young adults, and (2) CG associated with collagenous colitis in elderly adults presenting with chronic watery diarrhea. In Japan, only nine previous cases were reported, and all of them were young adults. We report a case of CG with collagenous duodenitis in a 22-year-old female. She had repeated upper gastrointestinal bleeding from a Dieulafoy lesion of the fornix, but had no symptoms of malabsorption or diarrhea. Endoscopic findings revealed striking nodularity with a smooth islet-shaped normal area in the antrum and the body. The pathological findings of nodular mucosa showed the deposition of collagen bands just under the mucoepithelial lesion. In addition, she had collagenous duodenitis in part of the bulbs, and a colonoscopy showed no abnormalities. We provide a literature review of CG and collagenous gastroduodenitis without colonic involvement.     

Diagnosis of Gastric Prepyloric and Antral Lesions

Fibergastroscopy and direct-vision gastric biopsy were performed in 47 patients who had a prepyloric or antral gastric lesion on barium meal (single-contrast) examination. Of 27 cases with a radiological diagnosis of prepyloric or antral ulceration, five cases (18.5%) had evidence of ulceration, 12 cases (44.4%) had acute or chronic gastritis and eight cases (29.6%) had normal gastric mucosa, on fibergastroscopy. Multiple gastric biopsy confirmed the presence of acute-on-chronic gastritis (ACG), chronic gastritis (CG) and chronic atrophic gastritis (CAG), with or without intestinal metaplasia (IM) or epithelial atypia (Aty), in 24 cases (89%). Normal gastric mucosa was found in three cases (11%) and malignancy in none. Of 15 cases with a radiological diagnosis of prepyloric or antral malignancy, only three cases (20%) had evidence of adenocarcinoma on endoscopy and biopsy. One case had rounded nodules seen on endoscopy and gastric biopsies showed malignant lymphoma. In two cases with endoscopic suspicion of malignancy, gastric biopsies showed ACG in one and CAG in the other. Gastric biopsies showed histological changes of CG (+/- IM) or CAG (+/- IM) in 11 cases (73%). In five cases with a radiological diagnosis of various prepyloric or antral lesions, endoscopy and biopsy revealed CG (+/- IM) in all and malignancy in none. It is concluded that fiberendoscopy and gastric biopsy are superior to the single-contrast barium meal in the diagnosis of prepyloric or antral gastric lesions. Direct-vision gastric biopsy should be done in all cases since it increased the diagnostic accuracy of fiberendoscopy.     

Histological assessment of the Sydney classification of endoscopic gastritis.

To determine the significance of the endoscopic classification of gastritis proposed by a working party at the World Congress of Gastroenterology in Sydney 1990, 167 patients undergoing upper alimentary endoscopy were prospectively assessed by comprehensive endoscopic and histological methods. Ninety eight patients had endoscopic mucosal changes of gastritis according to the Sydney classification. Twenty six (27%) of these had histologically normal biopsy specimens. This was not statistically significantly different to the 26 (38%) of 69 with normal endoscopies whose biopsy specimens were histologically normal (chi 2 = 1.857, p > 0.1). Forty three (62.5%) patients with normal endoscopies had histological gastritis. No histological counterpart was found for the macroscopic appearances of the gastric mucosa said to show inflammation proposed by the Sydney classification of gastritis. These findings confirm the inappropriateness of an endoscopic diagnosis of gastritis and it is suggested such a term should be reserved for the histological findings.     

EARLY GASTRIC CANCER: PROPOSAL FOR A NEW DIAGNOSTIC SYSTEM BASED ON MICROVASCULAR ARCHITECTURE AS VISUALIZED BY MAGNIFIED ENDOSCOPY

We have developed a magnified endoscopic technique for observing the microvascular architecture within the gastric mucosa in units as small as capillary and we have reported the characteristic findings of the microvascular architecture in both normal gastric mucosa and early gastric cancer. The findings in the normal stomach were different depending on the section of the stomach. The body mucosa demonatrated a regular honeycomb‐like subepithelial capillary network pattern with a collecting venule, while the antral mucosa demonstrated a regular coil‐shaped subepithelial capillary network pattern. The magnified endoscopic findings of early gastric carcinoma were different depending on the types of histological differentiation. The characteristic findings of differentiated carcinoma were (1) the presence of a demarcation line; (2) the disappearance of the regular subepithelial capillary network pattern; and (3) the presence of an irregular microvascular pattern. The findings of undifferentiated carcinoma showed only a reduction in or else the complete disappearance of the regular subepithelial capillary network pattern. In clinical practice, the magnified endoscopic findings of differentiated carcinoma are useful both for determining the margin of early gastric cancer and for making a differential diagnosis between gastritis and gastric cancer in the case of flat reddened lesions. The microvascular architecture as visualized by magnified endoscopy could be a new diagnostic system for the endoscopic diagnosis of early gastric cancer.     

Cytology of the gastric mucosa in the development of chronic gastritis

Cellular changes were studied in specimens of the gastric mucosa from 131 patients with gastric biopsies from the normal mucosa and from those with various forms of chronic gastritis. The normal gastric mucosa was associated with moderate cell exfoliation and with normal cell structures. In cases of superficial gastritis and interstitial gastritis, the cellular material was more abundant than in smears from the normal stomach. The cells encountered were of surface mucosal and often also of glandular origin and were found together with numerous inflammatory cells. Cases with preatrophic and atrophic gastritis and with gastritis of the stomach remnant presented evidence of cellular metaplasia and nuclear and cytoplasmic alterations in surface mucosal cells. The results from study of gastric cellular changes in smears have led to further clarification of the diagnostic role of cytology which reflects the histologic alterations of gastric disorders and also often complements gastric biopsy findings.     

Collagenous gastrobulbitis and collagenous colitis. Case report and review of the literature.

A case is reported of collagenous gastrobulbitis on collagenous colitis in a 57-year-old woman with a 6-month history of watery diarrhea. Low serum levels of total proteins and albumin and increased fecal elimination of alpha1-antitrypsin were the only abnormal laboratory test results. Biopsy specimens from the colon, rectum, antrum, fundus, and duodenal bulb showed a thick subepithelial band composed of ultrastructurally normal collagen immunohistochemically negative for collagen IV and laminin. The diarrhea resolved with prednisone and responded to this treatment after a relapse 6 months later. One year later the patient developed severe alimentary intolerance and secondary weight loss. This symptom also responded to the same treatment. However, the collagen deposition did not disappear in the second biopsy samples of colonic and gastric mucosa. Only six cases have been previously reported with gastric and/or duodenal subepithelial collagenous deposition. Four were associated with collagenous colitis. One of these presented a subepithelial collagenous band in the terminal ileum. All these features suggest that this collagen deposition may affect the entire digestive tract with variable intensity, extension, and symptoms.     

Collagenous gastritis: Review

Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands thicker than 10 μm and the infiltration of inflammatory mononuclear cells in the lamina propria. Collagenous colitis and collagenous sprue have similar histological characteristics to collagenous gastritis and are thought to be part of the same disease entity. However, while collagenous colitis has become more common in the field of gastroenterology, presenting with clinical symptoms of chronic diarrhea in older patients,collagenous gastritis is rare. Since the disease was first reported in 1989, only 60 cases have been documented in the English literature. No safe and effective treatments have been identified from randomized, controlled trials. Therefore, better understanding of the disease and the reporting of more cases will help to establish diagnostic criteria and to develop therapeutic strategies. Therefore, here we review the clinical characteristics, endoscopic and histological findings, treatment, and clinical outcomes from case reports and case series published to date, and provide a summary of the latest information on the disease. This information will contribute to improved knowledge of collagenous gastritis so physicians can recognize and correctly diagnose the disease, and will help to develop a standard therapeutic strategy for future clinical trials.     

Distribution of collagenous colitis: utility of flexible sigmoidoscopy.

We investigated the distribution of the collagen band in 33 patients with collagenous colitis to estimate the likelihood of the disease being diagnosed in biopsy specimens from the left side of the colon, such as those obtained using flexible sigmoidoscopy. To be included in this study patients had a subepithelial collagen band greater than or equal to 10 microns, an increase in chronic inflammatory cells in the same specimen, and diarrhoea for which there was no other apparent cause. In 17 patients undergoing full colonoscopy with a thickened collagen band, collagenous colitis was frequently patchy, even though overall the thickened collagen band was almost equally distributed throughout the colon. Rectal biopsy specimens showed a normal collagen band in 73% of patients, while a thickened collagen band was found in 82% of patients in at least one specimen from the left side of the colon. Three patients had a thickened collagen band only in the caecum. In three of eight rectal biopsy specimens with a normal collagen band there was no mucosal inflammation to raise the possibility of proximal disease, although all but one specimen with a normal collagen band from the sigmoid and descending colon were inflamed. Rectal biopsy alone is therefore a relatively poor method of making the diagnosis. Flexible sigmoidoscopy with multiple biopsy specimens from several sites is a reasonable initial investigation but not sufficient to exclude collagenous colitis when based on the presence of a thickened collagen band alone. Should left sided biopsy specimens show a normal collagen band but an inflamed mucosa, total colonoscopy with multiple specimens including the caecum may be required to establish the diagnosis.     

Rapid identification of pyloricCampylobacter in Peruvians with gastritis

PyloricCampylobacter have been reported to colonize the gastric mucosa of many persons, especially in association with gastritis and peptic ulcer disease. These reports have, so far, come from countries in the developed world. We report that pyloricCampylobacter appear to be equally common in persons from a developing country (Peru) who have gastritis. Our examination of the histopathology associated with these organisms suggests that mucin depletion is associated with active colonization. Two simple diagnostic methods have been found which compare favorably to silver staining of biopsy materials and which appear to have value in the rapid and facile identification of these organisms: hematoxylin-eosin staining of biopsies and Gram staining of cytology specimens obtained by brushing the gastric mucosa.     

Varioliform gastritis: frequency and relationship with lymphocytic gastritis

Varioliform gastritis is currently recognized as a special kind of chronic gastritis characterized by nodules, thickened fugal folds and erosions. These features appear to be unusual and different from those seen in chronic gastritis. The frequency of varioliform gastritis rarely exceeds 3% and the diagnosis can be easily made by endoscopic examination. Very little is known about the etiopathogeny, clinical significance and evolution of this disease. The role of Helicobacter pylori still remains unknown, although a close relationship between this gastritis and lymphocytic gastritis was suggested to exist over the last few years. The aim of the present study was to investigate the frequency of varioliform gastritis and its possible correlation with lymphocytic gastritis. To our knowledge, this is the first systematic study of varioliform gastritis in South America. We studied endoscopically 200 consecutive patients and found only one case of varioliform gastritis (0.5%). In a second part of the study, we examined histopathologically mucosa biopsies from 24 patients with varioliform gastritis and studied the presence of intraepithelial lymphocytes to verify the presence of lymphocytic gastritis. No case was found. We conclude that there was no correlation between varioliform gastritis and lymphocytic gastritis in our patients.     

Surveilling Russell body Helicobacter pylori-negative gastritis: A case report and review of literature

BACKGROUND Russell body gastritis(RBG) is very rare type of chronic inflammation of gastric mucosa. The pathologic hallmark of the disease is Russell bodies(RB) which represent accumulation of eosinophilic cytoplasmic inclusions in endoplasmic reticulum of mature plasma cells(Mott cells). Most published cases are associated with Helicobacter pylori(H. pylori) infection because of correlation between plasma cell activation and antigenic stimulation. There are insufficient data about H. pylori-negative RBG and very little is known about the natural course of the disease.CASE SUMMARY A 51-year-old male patient underwent endoscopic screening for mild iron deficiency anemia. Gastroscopy revealed diffuse hyperemia, edema and nodularity of the fundic and corpus mucosa. Due to non-specific endoscopic findings and iron-deficiency anemia our preliminary diagnosis was diffuse type of gastric carcinoma or gastric lymphoma. Biopsy specimens of gastric mucosa showed inflammatory infiltrate rich in Mott cells, consisting entirely of cytoplasmic RB. Absence of nuclear atypia and mitosis of the plasma cells, polyclonal pattern of the Mott cells and negative staining for cytokeratins favored diagnosis of RBG. The patient was treated with proton-pump inhibitor for 8 wk. Long-term clinical and endoscopic surveillance was scheduled. Albeit, there was no improvement in endoscopic features of the gastric mucosa in three consecutive gastroscopies, histopathological findings demonstrated that the chronic inflammatory infiltrate in the fundic mucosa is less pronounced, rich in plasma cells, with almost absent RB and Mott cells.CONCLUSION The prognosis of this entity is uncertain, that is why these patients are subjects of continuous follow up.     

Significance of endoscopically visible blood vessels as an index of atrophic gastritis.

The endoscopic criteria for atrophic gastritis are. 1. pale mucosa; 2. shiny surface and 3. prominent submucosal vessels. To evaluate the diagnostic accuracy of circumscribed atrophic gastritis based on these findings, we studied 184 consecutive upper gastrointestinal endoscopies. The endoscopic diagnosis of atrophic gastritis was made only if two endoscopists both agreed on the findings and interpretation. The location of the atrophic pattern and whether it was circumscribed or diffuse were recorded. Two biopsy specimens were than obtained. Histologic material was interpreted by a pathologist who had no prior knowledge of the endoscopic findings. Twenty-five patients (13%) had atrophic gastritis endoscopically; in four it was diffuse and in 21 it was circumscribed. Utilizing the criteria of Whitehead, et al, atrophic gastritis was diagnosed histologically in three of four patients with diffuse gastritis but in one of those considered to have circumscribed atrophic gastritis. It is concluded from these preliminary data that a circumscribed atrophic mucosal pattern is a frequent endoscopic finding that does not necessarily represent atrophic gastritis histologically.     

Magnifying gastroendoscopy for diagnosis of histologic gastritis in the gastric antrum

BACKGROUND: We investigated the potential of magnifying endoscopy for diagnosis of histologic gastritis in the gastric antrum. In addition, we investigated whether magnifying endoscopy can be applied for evaluation of Helicobacter pylori eradication therapy. METHODS: We examined 176 Japanese patients including 53 with H. pylori eradication. We evaluated the antrum by magnifying observation and ordinary endoscopic findings, and compared these results. Biopsy specimens were taken from the sites observed. RESULTS: The magnified views were classified into four types. Histology of the biopsy specimens allowed us to match the four magnified views with normal mucosa with fundic glands, normal mucosa with pyloric glands, mucosa with gastritis and intestinal metaplasia/epithelial hyperplasia. The types of magnifying appearances were specific enough for the diagnosis of histologic gastritis (148 out of the 176 (82.4%) cases; sensitivity, 96.3%; specificity, 73.7%). We could accurately diagnose the histologic gastritis by magnifying endoscopy in 49 out of the 53 (92%) cases with H. pylori eradication, while only in 38% by ordinary endoscopy. The accuracy of diagnosis was statistically higher with the use of magnifying endoscopy than with ordinary endoscope (P < 0.001). CONCLUSION: Magnifying gastroendoscopy is useful to judge the histologic gastritis, especially, in cases with H. pylori eradication.     

Helicobacter pylori infection, glandular atrophy and intestinal metaplasia in superficial gastritis, gastric erosion, erosive gastritis, gastric ulcer and early gastric cancer

AIM: To evaluate the histological features of gastric mucosa, including Helicobacter pylori infection in patients with early gastric cancer and endoscopically found superficial gastritis, gastric erosion, erosive gastritis, gastric ulcer. METHODS: The biopsy specimens were taken from the antrum, corpus and upper angulus of all the patients. Giemsa staining, improved toluidine-blue staining, and Hpylori-specific antibody immune staining were performed as appropriate for the histological diagnosis of H pylori infection. Hematoxylin-eosin staining was used for the histological diagnosis of gastric mucosa inflammation, gastric glandular atrophy and intestinal metaplasia and scored into four grades according to the Updated Sydney System. RESULTS: The overall prevalence of H pylori infection in superficial gastritis was 28.7%, in erosive gastritis 57.7%, in gastric erosion 63.3%, in gastric ulcer 80.8%, in early gastric cancer 52.4%. There was significant difference (P<0.05), except for the difference between early gastric cancer and erosive gastritis. H pylori infection rate in antrum, corpus, angulus of patients with superficial gastritis was 25.9%, 26.2%, 25.2%, respectively; in patients with erosive gastritis 46.9%, 53.5%, 49.0%, respectively; in patients with gastric erosion 52.4%, 61.5%, 52.4%, respectively; in patients with gastric ulcer 52.4%, 61.5%, 52.4%, respectively; in patients with early gastric cancer 35.0%, 50.7%, 34.6%, respectively. No significant difference was found among the different site biopsies in superficial gastritis, but in the other diseases the detected rates were higher in corpus biopsy (P<0.05). The grades of mononuclear cell infiltration and polymorphonuclear cell infiltration, in early gastric cancer patients, were significantly higher than that in superficial gastritis patients, lower than that in gastric erosion and gastric ulcer patients (P<0.01); however, there was no significant difference compared with erosive gastritis. The grades of mucosa glandular atrophy and intestinal metaplasia were significantly highest in early gastric cancer, lower in gastric ulcer, the next were erosive gastritis, gastric erosion, the lowest in superficial gastritis (P<0.01). Furthermore, 53.3% and 51.4% showed glandular atrophy and intestinal metaplasia in angular biopsy specimens, respectively; but only 40.3% and 39.9% were identified in antral biopsy, and 14.1% and 13.6% in corpus biopsy; therefore, the angulus was more reliable for the diagnosis of glandular atrophy and intestinal metaplasia compared with antrum and corpus (P<0.01). The positivity rate of glandular atrophy and intestinal metaplasia of superficial gastritis with H pyloripositivity was 50.7%, 34.1%; of erosive gastritis 76.1%, 63.0%; of gastric erosion 84.8%, 87.8%; of gastric ulcer 80.6%, 90.9%; and of early gastric cancer 85.5%, 85.3%, respectively. The positivity rate of glandular atrophy and intestinal metaplasia of superficial gastritis with H pylorinegativity was 9.9%, 6.9%; of erosive gastritis 42.5%, 42.1%; of gastric erosion 51.1%, 61.9%; of gastric ulcer 29.8%, 25.5%; and of early gastric cancer 84.0%, 86.0%, respectively. The positivity rate of glandular atrophy and intestinal metaplasia of superficial gastritis, erosive gastritis, gastric erosion, and gastric ulcer patients with H pylon positivity was significantly higher than those with H pylori negativity (P<0.01); however, there was no significant difference in patients with early gastric cancer with or without H pylori infection. CONCLUSION: The progression of the gastric pre-cancerous lesions, glandular atrophy and intestinal metaplasia in superficial gastritis, gastric erosion, erosive gastritis and gastric ulcer was strongly related to H pylori infection. In depth studies are needed to evaluate whether eradication of H pylori infection will really diminish the risk of gastric cancer.     

Collagenous gastroduodenitis

Collagenous gastroduodenitis is a rare histopathologic entity characterized by marked subepithelial collagen deposition with associated mucosal inflammatory infiltrate. Only 4 cases have been reported, of which 3 had associated collagenous colitis. Collagenous gastroduodenitis without colonic involvement is exceptionally rare with only 1 case reported so far in the literature. We present a case of a 68-year-old woman with dyspepsia and mild anemia, who was found to have nodular gastric and duodenal mucosa on endoscopic examination. Histopathology showed collagenous gastroduodenitis. To the best of our knowledge, this is the second (and first in English literature) reported case of isolated collagenous gastroduodenitis.