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chemical gastritis

Wednesday 2 January 2013

Reactive gastropathy, Chemical gastritis, Type C gastritis

Definition: Nonspecific reactive epithelial changes in response to variety of gastric mucosal irritants.

Synopsis

- Nonspecific reactive epithelial changes
- Etiology

  • Reflux of alkaline duodenal contents
  • Chronic usage of NSAIDs and corticosteroids
  • Periphery of mucosal ulceration

- Microscopic Pathology

  • Foveolar hyperplasia with mucin depletion and serrated gastric pits
  • Mucosal edema with dilated capillaries and little inflammation

- Top Differential Diagnoses

  • Low-grade dysplasia

Etiology

- Bile Reflux (bile reflux gastritis)
- Post partial gastrectomy
- Post-cholecystectomy
- Post ampullary sphincterotomy
- Drugs

  • Corticosteroids
  • Chronic use of NSAIDs (30-40% of chronic NSAID users present with mucosal changes)

- Toxic

  • Chemoradiation therapy
  • Alcohol (large consumption)

- Periphery of mucosal ulceration
- Underlying mass

Clinical synopsis

- May be asymptomatic
- Dyspepsia
- Nausea
- Bloating

Endoscopy - Macroscopy

- Erythema, edema, and friability

- Enlarged folds

- Stromal polyps

Treatment

- Withdrawal of causative factor(s), if possible

Prognosis

- Excellent if causative factors can be withdrawn

Endoscopic Appearance

- Mucosa can be normal

- If present, lesions are generally confined to antrum and include
Patchy erythema
Polypoid mucosal changes
Superficial erosions

- Bile can also be seen in cases of reflux

Microscopy

- Foveolar hyperplasia
- Serrated gastric pits
- Mucin depletion

  • Cuboidal cells
  • Hyperchromatic nuclei
  • Subnuclear cytoplasmic vacuolization reported in operated stomach

- Mucosal edema with dilated capillaries and little inflammation
- Splaying of muscularis mucosa
- Eosinophilic infiltrate (mild)

Differential diagnosis

- Low-Grade Dysplasia

  • Absence of atrophy and intestinal metaplasia
  • Cuboidal epithelial cells with round nuclei (Dysplasia has tall columnar epithelium with penicillate hyperchromatic nuclei)
  • Seamless transition with surrounding epithelium (Dysplasia has sharp transition)
  • Mitoses limited to transition zone (Dysplasia has mitoses on surface)

- Helicobacter pylori Gastritis

  • Foveolar hyperplasia can be seen in subset of patients
  • H. pylori should have much more inflammation
    • Plasma cells in lamina propria
    • Foci of neutrophils in epithelium (neck region)

Diagnostic Checklist

- Cuboidal, mucin-poor, reactive foveolar cells with hyperchromasia should not be mistaken for low-grade dysplasia
- Neutrophilic infiltrate is not feature of diagnosis

- Mucosal atrophy and intestinal metaplasia are not features of chemical gastropathy

  • However, can develop over time in
    • Operated stomachs with bile reflux
    • Elderly patients

References

- Genta RM: Differential diagnosis of reactive gastropathy. Semin Diagn Pathol. 22(4):273-83, 2005

- Haber MM et al: Gastric histologic findings in patients with nonsteroidal anti-inflammatory drug-associated gastric ulcer. Mod Pathol. 12(6):592-8, 1999

- Wolfe MM et al: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 340(24):1888-99, 1999

- Wallace JL: Nonsteroidal anti-inflammatory drugs and gastroenteropathy: the second hundred years. Gastroenterology. 112(3):1000-16, 1997

- El-Zimaity HM et al: Histological features do not define NSAID-induced gastritis. Hum Pathol. 27(12):1348-54, 1996

- Quinn CM et al: Gastritis in patients on non-steroidal anti-inflammatory drugs. Histopathology. 23(4):341-8, 1993

- Sobala GM et al: Reflux gastritis in the intact stomach. J Clin Pathol. 43(4):303-6, 1990

- Dixon MF et al: Reflux gastritis: distinct histopathological entity? J Clin Pathol. 39(5):524-30, 1986