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소화기내과(위장관)/위내시경

Lymphocytic gastritis

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http://www.pathologyoutlines.com/topic/stomachlymphocyticgastritis.html

 

Stomach

Gastritis

Lymphocytic gastritis

Author: Matthew Morrow, M.D.

Senior Author: Raul S. Gonzalez, M.D.

Editor-in-Chief: Debra Zynger, M.D.

Topic Completed: 7 May 2019

Revised: 7 May 2019

Copyright: 2003-2019, PathologyOutlines.com, Inc.

PubMed Search: lymphocytic gastritis[title]

Definition / general

A pattern of gastric mucosal injury characterized by increased intraepithelial lymphocytes (> 25 per 100 epithelial cells) and increased chronic inflammatory cells in the lamina propria

Essential features

Associated with Helicobacter pylori infection and celiac disease, among other etiologies

Variable clinical presentation

Uncertain pathogenesis

Terminology

The older entity “varioliform gastritis” (endoscopic mucosal appearance of small nodules with central erosions and enlarged rugal folds) appears to represent a subset of lymphocytic gastritis (J Pathol 1989;158:19)

ICD coding

ICD-10: K52.89 - other specified noninfective gastroenteritis and colitis

Epidemiology

Rare, with a prevalence of < 0.3% in gastric biopsies (Odze and Goldblum: Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas, 3rd Edition, 2015)

Presents around the sixth decade of life (Am J Surg Pathol 1999;23:153)

No sex predilection

Common etiologic associations include celiac disease (Am J Surg Pathol 1999;23:153)

Also associated with HIV infection, Crohn disease, Ménétrier disease, NSAIDs and lymphocytic or collagenous colitis

Unknown etiology in up to 20% of cases (Am J Surg Pathol 1999;23:153)

Rare in children but seen predominately with celiac disease; may suggest a more severe disease course in this setting (Pediatr Dev Pathol 2011;14:280)

Sites

Antral predominance or diffuse involvement may be associated with celiac disease (J Clin Pathol 1999;52:815)

Corpus predominance may be associated with H. pylori infection (Am J Surg Pathol 1999;23:153)

Pathophysiology

Uncertain pathogenesis overall

Due to its association with celiac disease and H. pylori, it has been proposed to be a local immune response to luminal antigens such as gliadin and Helicobacter antigens (Am J Surg Pathol 1999;23:153)

Clinical features

Dyspepsia, abdominal pain and iron deficiency anemia have been reported but presenting symptoms are variable (Pathol Case Rev 2008;13:167)

Predominately recurrent vomiting, epigastric pain or chronic diarrhea is seen in pediatric patients (J Pediatr 1994;124:57)

Cases associated with endoscopic varioliform gastritis may present with weight loss and anorexia (Gut 1990;31:282)

Cases associated with Ménétrier disease may present with protein losing enteropathy (Hum Pathol 1991;22:379)

Diagnosis

Established by gastric biopsy

Case reports

2 year old child autopsy findings after presenting with hepatic failure (Ann Diagn Paed Pathol 1998;2:27)

47 year old woman and 57 year old man with H. pylori and associated gastric MALT lymphoma (Korean J Gastroenterol 2005;45:354)

63 year old man with gastric adenocarcinoma and total gastrectomy (Gut 1991;32:1565)

77 year old man with worsening anemia (Gastrointest Endosc 2001;54:251)

84 year old man with abdominal pain and varioliform gastritis seen on EGD (Ann Gastroenterol 2018;31:520)

Treatment

Targets the underlying associated etiology

Can spontaneously regress (Aliment Pharmacol Ther 2006;23:473)

Clinical images

Images hosted on other servers:

Varioliform gastritis:

multiple nodules with

central mucosal

atrophy / erosion

Gross description

Small nodules with central erosions and enlarged rugal folds (“varioliform gastritis”)

Early studies suggested this finding in 80% of cases

Subsequent articles reported incidence of 4% to 30% (Pathol Case Rev 2008;13:167)

Additional findings: small elevated plaques, superficial erosions, nodular appearance, thickened folds

Unremarkable appearance in up to 50% of cases (J Clin Pathol 1995;48:939, Gut 1988;29:1258)

Hypertrophic gastric folds has been described in cases of Ménétrier disease (Hum Pathol 1991;22:379)

Microscopic (histologic) description

Defined by increased gastric intraepithelial lymphocytes (> 25 per 100 epithelial cells)

Intraepithelial lymphocytosis is typically greater in the surface epithelium

Most cases show around 35 - 75 surface intraepithelial lymphocytes per 100 epithelial cells (Gut 1990;31:282)

Lymphoplasmacytic expansion of the lamina propria can be additionally seen

Intraepithelial neutrophils may be seen, especially in the setting of H. pylori infection or mucosal erosion

Lymphoepithelial lesions are not present

Microscopic (histologic) images

Contributed by Matthew Morrow, M.D.

Increased intraepithelial lymphocytes

Increased intraepithelial lymphocytes, expanded lamina propria

Biopsy from area of nodular gastric mucosa

Positive stains

Lymphocytes are predominately CD3 positive T cells with CD8 co-expression

Sample pathology report

Stomach, biopsy:

Corpus and antral mucosa with chronic inactive gastritis with increased intraepithelial lymphocytes (see comment)

Immunostain for Helicobacter species is negative

Comment: The finding of intraepithelial lymphocytosis is consistent with lymphocytic gastritis, which may be associated with celiac disease, H. pylorigastritis, viral infection, Crohn disease, certain medications and other etiologies

Differential diagnosis

Gastric lymphoma

Often causes a mass lesion, unlike lymphocytic gastritis

Patchy increased intraepithelial lymphocytes can be seen in MALT lymphoma (Korean J Pathol 2007;41:289)

Lymphocytes in MALT lymphoma are CD20+ B cells

Lymphoma may display an infiltrative pattern with lymphoepithelial lesions and architectural distortion

Cytologic atypia may be present

Helicobacter pylori gastritis

Curved slender bacteria present in the superficial mucus layer and along the surface of gastric epithelial cells

Neutrophils and germinal centers may be seen

Chronic gastritis, such as mononuclear expansion of the lamina propria seen in lymphocytic gastritis, should prompt scrutiny for Helicobacter organisms

Helicobacter immunostain, Giemsa and silver stains highlight organisms

Additional references

J Clin Pathol 1998;51:207

Board review question #1

 

The image above is from an antral biopsy from a 9 year old boy. What additional histological finding is most likely to be present in this patient?

A. Increased intraepithelial eosinophils with eosinophilic microabscesses in the upper esophagus

B. Curved bacteria rods present in the superficial mucus layer of the stomach

C. Duodenal increased intraepithelial lymphocytes, crypt hyperplasia and villous blunting

D. Duodenal villous blunting, crypt hyperplasia and focal surface epithelial “tufting”

Board review answer #1

C. Lymphocytic gastritis is most commonly seen in a background of celiac disease in children (intraepithelial lymphocytes, crypt hyperplasia and villous blunting in the duodenum) and may portend a more severe disease course. Helicobacter infection (choice B) would be more likely in an adult patient.

Board review question #2

Aside from increased intraepithelial lymphocytes, what other histologic feature in the stomach is commonly described in lymphocytic gastritis?

A. Lymphoepithelial lesions

B. Lymphoplasmacytic expansion of the lamina propria

C. Loss of parietal cells

D. Increased subepithelial collagen deposition

Board review answer #2

B. Lymphoplasmacytic expansion of the lamina propria is also commonly seen in lymphocytic gastritis.

 

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