Hypertrophic Hypersecretory Protein-losing Gastropathy: A Rare Cause of Gastrointestinal Bleeding

Abstract

A 56-year-old female presented after one episode of hematemesis. Symptoms were preceded by twenty-four hours of non-bloody, non-bilious emesis. She endorsed one episode of melena. There was lightheadedness, but no abdominal pain. Past medical history was significant for prior cerebrovascular accident for which she was taking full dose aspirin daily. There was no history of liver disease. She was not on anticoagulation and denied use of non-steroidal anti-inflammatory agents. Vital signs were significant for hypotension and tachycardia. Physical exam revealed a cachectic female without abdominal distension or tenderness. Laboratory analysis was significant for hemoglobin 6.4 g/dL, albumin 1.9 g/dL and total protein 3.6 g/dL. There was no protein on urinalysis. The patient was resuscitated and placed on a protein pump inhibitor (PPI) infusion. Esophagogastroduodenoscopy demonstrated giant gastric folds with friability and oozing throughout the gastric cardia, fundus, and body that persisted despite air insufflation with antral sparing [Figure 1]. Gastric pH was 5.0 (on PPI). Gastric endoscopic mucosal resection after banding of the gastric folds revealed mild inactive chronic gastritis with foveolar, parietal and chief cell hyperplasia [Figure 2]. Helicobactor pylori (H. pylori) staining was negative. Fasting serum gastrin level was 294 pg/mL (on PPI). Computed tomography demonstrated diffuse thickening of the gastric folds without evidence of malignancy [Figure 3]. She was diagnosed with hypertrophic hypersecretory protein-losing gastropathy (HHPG) and transitioned to high dose oral PPI without recurrent bleeding. HHPG is a rare clinical entity. The enlargement of gastric folds with hypoalbuminemia can be confused with malignancy or Menetrier's disease, but can be distinguished on full thickness mucosal biopsy. HHPG has foveolar, glandular and parietal cell hyperplasia1. Both diseases can present with nausea, vomiting, abdominal pain and edema. Treatment is not well established but is aimed at controlling symptoms and can include high protein diet, anti-secretory medications, eradication of H. pylori, monoclonal antibodies and in rare cases, gastrectomy1. Bleeding has not been previously described with HHPG, but appears to respond well to twice daily oral PPI.Figure: Esophagogastroduodenoscopy findings of enlarged gastric folds.Figure: Full thickness gastric biopsy demonstrating foveolar, glandular and parietal cell hyperplasia.Figure: Computed tomography demonstrating thickened gastric folds.