S3022 Gluten Free Diet: A Treatment Modality for Idiopathic Lymphocytic Gastritis

Abstract

INTRODUCTION: Lymphocytic gastritis (LG), defined as 25 lymphocytes per 100 gastric epithelial cells, is found in less than 1% of endoscopic biopsies. It can be idiopathic or secondary to a variety of diseases, commonly celiac disease (CD) and Helicobacter pylori (H. pylori). Treatment of secondary LG is aimed at treating the underlying cause, but there is limited literature on the treatment of idiopathic LG. CASE DESCRIPTION/METHODS: A 25-year-old male with Immunoglobulin (Ig) A deficiency presented for chronic diarrhea. He denied smoking, alcohol use, or use of any medications. Workup was negative for anti-Tissue Transglutaminase IgA and IgG, Giardia IgA, and pancreatic elastase levels. Esophagogastroduodenoscopy (EGD) and colonoscopy demonstrated gastritis and diffuse colonic nodularity. Gastric biopsies revealed lymphocytic gastritis without H. pylori. Duodenal biopsies showed increased intraepithelial lymphocytes without crypt hyperplasia or villous atrophy. Colonic biopsies showed patchy lymphoid nodular inflammation insufficient for diagnosis of microscopic colitis. Genetic testing for celiac disease, namely HLA DQ2 and DQ8, was negative. He was diagnosed with idiopathic LG and was initiated on a GFD with improvement in frequency of bowel movements. Months later, patient presented with recurrence of diarrhea. Hydrogen breath test was positive; rifaximin was initiated for small intestinal bacterial overgrowth with improvement in frequency of bowel movements. Patient continued adherence to a GFD, and subsequent EGD showed resolution of gastritis and histologic resolution of LG. DISCUSSION: Our case demonstrates that patients with idiopathic LG can have symptomatic, endoscopic, and histologic recovery following introduction of a GFD. In cases of disease relapse, overlapping conditions should first be considered before attributing relapse to treatment failure of GFD. Furthermore, one can consider gluten sensitivity as a spectrum of disease based on serologic and histologic findings. While CD, classically associated with gluten sensitivity, has both serologic and histologic findings, there also exists a condition called Non-Celiac Gluten Sensitivity that does not have serologic or histologic evidence of CD but may also benefit from a GFD. Idiopathic LG falls in the middle of the spectrum with only histologic findings and, likewise, can be treated with a GFD. Further studies are required to determine whether a GFD is an effective and definitive treatment of idiopathic LG.