Lymphocytic Gastritis in Iron Deficiency Anemia - A Case Report

Abstract

Purpose: Case Report: A 58 year old lady with no prior history of colonoscopy was referred to the gastroenterologist for evaluation of treatment resistant iron-deficient anemia. She denied any change in bowel habits, constipation, diarrhea, rectal bleeding or weight loss. There was no personal or family history of colorectal neoplasia, celiac disease or inflammatory bowel disease. She was on iron and vitamin C supplementation for persistent iron deficiency anemia. Physical examination revealed a thin female with normal vitals and a benign abdomen. Laboratory studies showed microcytic anemia with mild elevation of liver transaminases. She underwent colonoscopy, which was essentially negative for any source of occult bleeding. Upper endoscopy revealed a normal gastric picture and flattening of villous processes in the duodenum. The duodenal biopsy was consistent with celiac disease and antral biopsy showed a lyphoplasmocytic infiltrate in the lamina propria, consistent with lymphocytic gastritis. Discussion: Lymphocytic gastritis, defined as a dense lymphocytic infiltration (≥25 lymphocytes/100 epithelial cells) of the gastric foveolar epithelium, was first described by Haot, et al over 2 decades earlier. It is a relatively rare disorder, occurring in <5% of gastric mucosal biopsies but has been shown to be more common in patients with concomitant celiac disease. Such patients typically have mild dyspepsia and normal endoscopic findings, although advanced cases might present with severe dyspepsia, vomiting, weight loss and demonstrate large mucosal folds and varioliform (octopus like) gastritis on endoscopy. Chronic inflammatory infiltrate has been found in a variety of conditions including H. pylori infection, syphilis, tuberculosis, crohn's disease, chronic use of NSAIDs, etc. The term ‘primary’ lymphocytic gastritis is however reserved for cases without such known causes of chronic inflammation. While the etiology remains unclear, the resolution of its features for example, with the initiation of gluten free diet suggests a common immune mediated etiology. Incidentally, celiac disease remains the most common association with lymphocytic gastritis, especially in the antral distribution. Once diagnosed, the treatment remains mainly supportive, besides dietary modification and periodic follow up. The role of empiric proton pump inhibitors or empiric H. pylori eradication regimens is less well established at present.