Gastrointestinal Hemorrhage Due to Biopsy in Collagenous Gastritis and Subsequent Prevention Using Argon Plasma Coagulation

Abstract

Collagenous gastritis (CG) is a rare condition characterized by gastric subepithelial collagen deposition. The condition has been linked to iron-deficiency anemia, hypothesized due to bleeding from superficial capillaries entrapped in collagen. One case of mucosal friability and one case of upper GI bleeding due to CG have been reported. To our knowledge, bleeding from gastric biopsy sites and the management with argon plasma coagulation (APC) have not been previously described. A 40-year-old woman with a history of fibromyalgia presented with complaint of epigastric pain and nausea. Physical examination was normal. Her medications included ibuprofen 600 mg for musculoskeletal pain. Hemoglobin (Hb) was 13.2 g/dL, platelet count 270,000 cells/ul, prothrombin time 11.1 seconds, and activated partial thromboplatin time 21 seconds. Ibuprofen was discontinued. Upper endoscopy was performed 1 week later demonstrating a nodular gastric mucosa. There was mucosal friability and post biopsy bleeding that resolved slowly. Two days later, the patient returned with hematemesis. The Hb was 8.8 g/dL. Upper endoscopy demonstrated red blood oozing over multiple gastric biopsy sites. Hemostasis was achieved with epinephrine injection, bipolar cautery and endoclips. A hematologic evaluation for bleeding disorders was negative. The gastric biopsies showed increased subepithelial collagen deposition with capillary entrapment. Collagen fibers stained intensely blue by Masson trichrome. She was diagnosed with CG. Follow up endoscopy 1 year later showed persistence of the nodular gastropathy. Disproportionate bleeding and friability was noted again after gastric biopsy. Hemostasis was achieved using APC, preventing post-biopsy hemorrhage. Gastric biopsies showed persistent subepithelial collagen deposition. CG is characterized by irregular thickening of the subepithelial collagen band with entrapment of capillaries. CG may present with isolated gastric involvement or concurrent extragastric involvement. Celiac disease, collagenous sprue or collagenous colitis is found in approximately 30% of cases. CG has been reported in association with anemia and upper GI bleeding. Management of bleeding in CG has not been described. The pathophysiology of bleeding is not understood. Biopsies in this case were mucosal with no exposed vessels, suggesting a defect in platelet plug formation. We describe a patient with biopsy-site hemorrhage associated with CG, managed successfully with APC. APC was useful in this case due to the mucosal friability associated with CG.Figure 1Figure 2Figure 3