A Unique Case Presentation of Symptomatic Gastric Telangiectasia in Isolated Granulomatous Gastritis

Abstract

Introduction: Literature has associated granulomatous gastritis with gastric ulcers but not with arteriovenous malformation, leading to transfusion dependent anemia. Case Report: A 32-year-old male patient with chronic blood transfusion and IV iron dependent anemia from chronic gastrointestinal blood loss for 7 years despite repeated cauterization of angiodysplasia in his stomach. He has intermittent melena, one episode of scant hematemesis in past, 40 lbs weight loss, no other GI symptoms, no NSAID/anticoagulants, no coagulopathy; no symptoms to suggest systemic vasculitis, sarcoidosis or inflammatory bowel disease. No contributing past medical, surgical or family history. He denies use of alcohol or recreational drugs; smokes half a pack of cigarettes/day. Uses carafate and omeprazole twice a day. BMI 26.5, unremarkable vitals and physical exam. He has had several endoscopies. Cumulative findings on EGD: several clean base superficial and irregular shaped antral ulcer, multiple spider telangiectasia on all mucosal surfaces of stomach, central portion bled with touch. Stomach biopsy: moderate active gastritis with noncaseating epithelioid granulomas, no microorganisms. Special stains: H. pylori, fungus and AFB were negative; Fungal and AFB cultures of biopsies are negative (3 months). Esophagus and small bowel biopsies were normal. Twice colonoscopy: normal, including terminal ileum. Capsule endoscopy: multiple AVM in stomach, antral ulcer, old hematin in distal small bowel, otherwise normal small bowel. Serology: negative for HIV, normal haptoglobin and ristocetin cofactor; W/u for Von Willebrand syndrome, factor 8 activity 225%; VWF ag normal. Doppler US: no portal vein thrombosis; ESR: 2. Infectious causes: negative for syphilis and schistosomiasis, PCR for Whipple’s bacillus negative, H. pylori IgG Ab positive; Histoplasma Ab negative (no eosinophilia and no eosinophillic granulomas). Normal serum protein electrophoresis. Vasculitis: negative autoantibodies to proteinase 3, myeloperoxidase, ANA. Sarcoidosis: CT chest/abd/pelvis: no lung infiltrate or signs of sarcoidosis; few tiny visible retroperitoneal nodes; normal liver/spleen, ACE level is normal. Assessment: isolated granulomatous gastritis, without recognizable infection, systemic sarcoidosis, or small bowel/colon Crohn’s disease. Plan is aimed to eradicate H pylori, treat with steroids, similar to treatment of Crohn’s disease; if repeat endoscopy shows improvement then slow taper of steroids, if has recurrence then consider azathioprine. Conclusion: This case report will contribute to the limited literature on isolated granulomatous gastritis, with a unique association of symptomatic AVM’s.