A case of collagenous gastritis resembling nodular gastritis in endoscopic appearance

A 25-year-old Japanese female was referred to our clinic for the investigation of moderate iron-deficiency anemia and epigastralgia. Endoscopic examination showed diffuse mucosal nodules in the gastric body resembling nodular gastritis, but this pattern was not observed in the antrum. Histology of the gastric biopsies taken from the gastric body showed mild atrophic mucosa with chronic active inflammation. Some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen. Four years later, the patient showed no clinical symptoms and signs. A follow-up endoscopic examination showed similar findings, which mimicked pseudopolyposis or a cobblestone-like appearance. The biopsy specimens from the depressed mucosa between the nodules revealed a thickened subepithelial collagen band with no improvement, which led to a diagnosis of collagenous gastritis. Treatment with oral administration of proton-pump inhibitors and histamine-2-receptor antagonists had proved ineffective. To make a correct diagnosis of collagenous gastritis, we should determine the characteristic endoscopic findings and take biopsies from the depressed mucosa between the nodules.     

Gastric Carcinoid Tumor Associated with Graves' Disease: A Case Report

Abstract: We report a patient with hyperthyroid Graves' disease associated with type A gastritis and a gastric carcinoid tumor. A 45-year-old female visited our hospital because of exophthalmos, and hyperthyroidism was found. TSH receptor antibody and anti-parietal cell antibody were positive in the patient's serum. An endoscopic examination revealed type A gastritis and a gastric carcinoid tumor. The diagnosis of type A gastritis was determined histologically. The gastric carcinoid tumor was solitary and small (less than 5 mm in diameter), and was removed by biopsy. The patient's hypergastrinemia continued after the thyroid function was normalized by treatment with methimazole. Endoscopic surveillance for metachronous gastric carcinoid tumors will therefore be required. The association of Graves' disease, type A gastritis and a gastric carcinoid tumor is discussed.     

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 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.     

Association between common variable immunodeficiency and collagenous infiltrative disorders of the gastrointestinal tract: A series of four patients

Hypogammaglobulinemia/common variable immunodeficiency (CVID) may lead to disruption of the gut mucosal immune barrier. Collagenous infiltrative disorders of the intestinal tract (colitis, gastritis, sprue) constitute a relatively new spectrum of gastrointestinal disorders. Our aims were (1) to determine the association between immunoglobulin deficiency state like CVID and collagenous infiltrative disorders of the gut and (2) to study the clinic-pathologic characteristics and treatment outcomes in these patients. A retrospective search was conducted to identify cases with concurrence of these two conditions at an academic center from 2007 to 2013. Four such patients were identified from our database: three with collagenous colitis and one with collagenous gastritis. All patients with collagenous colitis had normal colonic mucosa while the patient with collagenous gastritis had nodular gastric mucosa. Only one patient out of four had decreased plasma cells in the submucosa as expected in low immunoglobulin states. All patients had improvement in their symptoms on immunoglobulin therapy with considerable remission on budesonide. Literature search revealed reporting of four similar patients. In conclusion, (1) the association between collagenous infiltrative disorders of the gut and CVID and its prompt response to immunoglobulins with effective maintenance with budesonide are novel findings. Our study also shows that the presence of plasma cells should not rule out the possibility of CVID. (2) In patients with chronic diarrhea, hypogammaglobulinemia and collagenous colitis/sprue should be considered for the available effective treatments such as immunoglobulins and budesonide.     

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.     

Heterotopic Gastric Mucosa in the Distal Part of Esophagus in a Teenager: Case Report

Heterotopic gastric mucosa (HGM) of the esophagus is a congenital anomaly consisting of ectopic gastric mucosa. It may be connected with disorders of the upper gastrointestinal tract, exacerbated by Helicobacter pylori. The diagnosis of HGM is confirmed via endoscopy with biopsy. Histopathology provides the definitive diagnosis by demonstrating gastric mucosa adjacent to normal esophageal mucosa. HGM located in the distal esophagus needs differentiation from Barrett''s esophagus. Barrett''s esophagus is a well-known premalignant injury for adenocarcinoma of the esophagus. Malignant progression of HGM occurs in a stepwise pattern, following the metaplasia–dysplasia–adenocarcinoma sequence.We present a rare case of a teenage girl with HGM located in the distal esophagus, associated with chronic gastritis and biliary duodenogastric reflux. Endoscopy combined with biopsies is a mandatory method in clinical evaluation of metaplastic and nonmetaplastic changes within HGM of the esophagus.     

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.     

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.     

A case of emphysematous gastritis in a patient with end-stage renal disease

Emphysematous gastritis is a rare infection of the stomach wall with high mortality rate. It is caused by gas forming organisms and may arise by local spread through the mucosa or hematogenous dissemination from distant focus. Clinical manifestation includes acute abdomen with systemic toxicity, and diagnosis is based on radiologic demonstration of gas within the gastric wall. Treatment should be aimed to cover gram-negative organisms and anaerobes using wide-spectrum intravenous antibiotics, and sometimes surgical management may be needed in order to enhance survival. Herein, we report a case of emphysematous gastritis in a patient with end stage renal disease on hemodialysis.     

Progression of gastric enterochromaffin-like cells growth in Zollinger-Ellison syndrome and atrophic body gastritis patients

BACKGROUND: Enterochromaffin-like cell hyperplasia of the gastric body mucosa occurs in hypergastrinaemic conditions such as atrophic body gastritis and Zollinger-Ellison syndrome. However, the time course of change or factors involved are not known. AIMS: To compare the rate of change of enterochromaffin-like cell proliferation in patients with atrophic body gastritis and Zollinger-Ellison syndrome. PATIENTS: From a consecutive series of atrophic body gastritis and Zollinger-Ellison syndrome patients, studied at the time of first diagnosis, 10 atrophic body gastritis (4 with pernicious anaemia) and 14 Zollinger-Ellison syndrome (4 with multiple endocrine neoplasia type 1) patients were followed-up for a median time of 48 months. METHODS: At entry and during follow-up patients underwent: plasma gastrin determination, endoscopic sampling of body mucosa for qualitative assessment of enterochromaffin-like cell hyperplasia pattern and degree of glandular atrophy, qualitative and morphometric analyses of body mucosa endocrine cells. RESULTS: At time of diagnosis, enterochromaffin-like cell lesions were more severe in atrophic body gastritis than in Zollinger-Ellison syndrome. During follow-up, no significant variations were observed in gastrin values, enterochromaffin-like cell patterns and grade of body mucosa atrophy in atrophic body gastritis. In contrast, gastrin levels were significantly increased [median 1200 (235-2625) vs 1947 (225-5200) pg/ml; p<0.001)] as was total volume density of enterochromaffin-like cells [median 1.60 (0.53-4.06) vs 3.18 (1.35-21.13)% of mucosal epithelial component; (p<0.005)] in Zollinger-Ellison syndrome. Micronodular hyperplasia of enterochromaffin-like cells, present in only one patient at diagnosis, was observed in 8 Zollinger-Ellison syndrome patients at follow-up. CONCLUSIONS: These data suggest that the progression of enterochromaffin-like cell growth in human gastric mucosa requires an increase of and/or a prolonged exposure to severe hypergastrinaemia.     

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.     

Heterogeneity in susceptibility to chronic gastritis in relatives of gastric cancer patients with different histology of carcinoma.

The morphological state of gastric body mucosa was examined in 269 first-degree relatives of 64 index patients with gastric carcinoma and in 142 subjects selected at random. Gastric carcinoma was divided into three groups according to histological properties: carcinoma mucocellulare, carcinoma adenomatosum, and carcinoma anaplasticum. The state of gastric body mucosa was divided into five stages: normal, superficial gastritis, slight moderate, and severe atrophic gastritis. The results were subjected to the numerical analysis based on the stochastic theory. The term 'age-adjusted score' (AAS) employed therein defines the individual susceptiability to chronic gastritis. In terms of AAS, the material could be divided into 'high' and 'low' gastritis risk families. It appeared that the subjects belonging to carcinoma mucocellulare index patient families had a significantly higher susceptibility to chronic gastritis than the other relatives examined. These families were also significantly concentrated in the group of 'high risk' families. The heterogeneity of the relatives of gastric cancer patients as regards their gastritis risk should obviously be taken into account in future epidemiological studies. These findings constitute further justification of the genetic approach in studies concerning gastritis-gastric cancer relationship.     

Incidence and significance of the gastric mucosal constellation in pernicious anemia

1977 cases with gastric complains but without localized findings like ulcer or cancer were investigated by gastroscopy with biopsies of corpus and antrum ventriculi. We found in 5.5% an isolated mucosal atrophy of the gastric corpus (mean age 67.2 years compared to 59.4 years in cases with normal mucosa). 0.7% showed an atrophic gastritis of the antral mucosa, 0.9% an atrophic gastritis of the body and the antrum. Most of the cases with an isolated atrophy of the gastric body gave findings of hematologic disturbances. In all cases with isolated atrophy of the gastric body, including localized findings in the stomach, we found in 10.8% neoplastic processes, in another 3.9% hyperplasiogenic polyps. It seems to us of clinical importance to evaluate the gastric histology of the antral and body mucosa routinely because of the high incidence of pernicious anemia-like gastric atrophy and its relation to gastric neoplasias.     

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.     

深在性囊性胃炎的临床研究进展

深在性囊性胃炎，又称囊性息肉状胃炎，是一种罕见的胃黏膜下病变。其发病为各种原因导致的胃黏膜破坏，胃黏膜腺体向黏膜肌层以下生长并形成囊性扩张所致。既往认为该病是一种良性病变，但现在越来越多的研究认为深在性囊性胃炎是一种癌前病变、具有恶性进展的潜能。近年来，随着消化内镜诊治技术的迅猛发展以及病理诊断水平的不断提高，对深在性囊性胃炎的认识及诊治都取得了长足的进展。本文将从深在性囊性胃炎的病因、发病机制、疾病性质、诊断与鉴别诊断、治疗与预后等方面作一综述，为临床合理诊治该疾病作一参考。     

Collagenous colitis and collagenous gastritis in a 9 year old girl: a case report and review of the literature

Collagenous gastritis is a rare disease in the general population and collagenous colitis has seldom been reported in children. We report a girl with both diseases and review the literature on this association afetr a systematic search of Pubmed, Medline and Embase databases.. The girl, diagnosed of collagenous colitis at the age of 2 years, started with abdominal pain and anaemia at the age of 9 years and was diagnosed of collagenous gastritis in the gastric biopsies. After review of the literature, we found 66 reported cases (33 children, 33 adults, 68% females), 56 patients with collagenous gastritis and 16 children with collagenous colitis. Both disorders coexisted in 20 patients. The main presenting symptoms are abdominal pain and anaemia in patients with collagenous gastritis and diarrhoea and weight loss in patients with both disorders. Hypoalbuminemia was found in 9 patients with both diseases and protein losing enteropathy was demonstrated in 3 cases. Deposits of collagen in the duodenum were observed in 13 of 19 patients with both diseases. Seventeen of 66 patients had associated autoimmune disorders, particularly in patients with both diseases (35%). These conditions have a chronic course but gastric or colonic malignancies have not been communicated to date. In conclusion, collagenous gastritis and collagenous colitis mainly affects women and can occur at any age. Their association is exceptional. These disorders, although rare, should be considered in patients with anaemia and epigastric pain, watery diarrhoea or protein losing enteropathy.     

Unsedated transnasal ultrathin esophagogastroduodenoscopy may provide betterdiagnostic performance in gastroesophageal reflux disease

Transnasal ultrathin esophagogastroduodenoscopy (N‐EGD) with less gagging reflexes under non‐sedation is likely suitable for the diagnosis of gastroesophageal reflux disease (GERD), however, N‐EGD might have drawbacks, including its low image resolution. Limited information is available regarding the diagnosability of N‐EGD for GERD. We compared the utility and gagging reflexes of three different endoscopies, including N‐EGD, ultrathin transoral EGD (UTO‐EGD) and conventional oral EGD (CO‐EGD), in the diagnosis of GERD. We performed screening endoscopy in 1580 patients (N‐EGD n = 727, UTO‐EGD n = 599, CO‐EGD n = 254) and compared the frequency distributions of the severity of reflux esophagitis, hiatus hernia, and Barrett's epithelium to estimate the diagnostic performance of each endoscopy. We also analyzed patients' tolerability of endoscopy by the subjective evaluation of gagging reflexes. In the diagnosis of reflux esophagitis and Barrett's epithelium, there was no significant difference in the frequency distributions of the severity of the diseases among three EGDs. However, the incidence of Barrett's epithelium was higher than that in the previous nationwide survey of GERD in Japan. The evaluated size of hiatus hernia was smaller in N‐EGD than in two other peroral endoscopies. The size of hiatus hernia correlated significantly with severity of gagging reflexes that was also lowest when diagnosed with N‐EGD. N‐EGD had an equivalent performance in the diagnosis of reflux esophagitis and Barrett's epithelium compared with CO‐EGD. Enlargement of hiatus hernia induced by gagging reflexes was minimal in N‐EGD, resulting in its better performance in the diagnosis of Barrett's epithelium.     

Does a small biopsied gastric specimen limit the usage of two directional transnasal esophagogastroduodenoscopy?

Background and Aims: It is difficult to approach certain gastric regions due to the limited bending ability of transnasal esophagogastroduodenoscopy (TN‐EGD). We analyzed the TN‐EGD biopsied specimens according to where they were obtained inside the stomach. Methods: Two hundred and eighty‐nine gastric biopsy specimens were obtained during diagnostic TN‐EGD. The gastric biopsied specimens were quantified according to their diameter and depth in micrometers, and depth in layers (superficial mucosa, deep mucosa, muscularis mucosa and submucosa). The quality was measured by the degrees of anatomical orientation (good, intermediate and poor), presence of crush artifact (none to minimal, mild and moderate) and overall diagnostic adequacy (adequate, suboptimal and inadequate). Results: Poor orientation, presence of crush and overall diagnostic inadequacy were present in 33 (11.4%), 26 (9.0%) and 37 (12.8%) of the 289 specimens, respectively. Deep mucosa was present in 211 specimens (73.0%), while muscularis mucosa was present in only 75 specimens (26.0%). Specimens taken from the posterior aspect of the cardia exhibited the shallowest depth (P = 0.011), poorest orientation (P < 0.001) and poorest diagnostic adequacy (P < 0.001). Fluoroscopic findings demonstrated that the posterior aspect of the cardia was difficult to approach closely and perpendicularly because of the anatomical configuration of the stomach in nature. Conclusion: TN‐EGD biopsied specimens obtained from the posterior aspect of the cardia exhibit limitations in both quality and quantity. When performing a biopsy using two directional TN‐EGD, special attention should be paid to gastric lesions located on the posterior aspect of the cardia.     

ENDOSCOPIC IDENTIFICATION OF HELICOBACTER PYLORI GASTRITIS IN CHILDREN

Aim: The role of endoscopic findings in deciding whether to biopsy the gastric mucosa of children remains unclear. The present study attempted, for the first time, to identify the value of endoscopic features for diagnosis of Helicobacter pylori (Hp) infection in children. Methods: Hp status of consecutive children receiving esophagogastroduodenoscopy (EGD) was established by combinations of histology, ¹³C‐urea breath test, and serum Hp immunoglobulin (Ig)G antibody. After routine EGD using a conventional endoscope, the presence of RAC (regular arrangement of collecting venules) was scored by close observation, which was carried out at two sites of lower corpus lesser curvature and upper corpus greater curvature. RAC‐positive was defined as the presence of minute red points in a regular pattern. Antral nodularity was also scored as present/absent. Results: Eighty‐seven consecutive children (38 boys, median age 13 years, range 9–15 years) were evaluated; 25 (29%) were Hp positive. Antral nodularity was seen in 21 (84%) all of whom were Hp positive. The RAC‐negative pattern based on examination of the upper and lower corpus yielded a sensitivity, specificity, positive predictive value and negative predictive value for the presence of Hp infection of 100%, 90%, 81%, and 100%. Magnifying endoscopy confirmed that the RAC pattern corresponded to collecting venules in the gastric corpus. Conclusions: The absence of RAC pattern suggests that gastric mucosa biopsies should be taken despite otherwise normal‐appearing gastric mucosa for the diagnosis of Hp infection in children.