Gastroduodenal Biopsies Research Articles

P38 Lupus enteritis as a first presentation of systemic lupus erythematosus in a previously well patient: a very rare occurrence

Abstract Introduction Lupus enteritis is an anecdotally rare condition (with no formal estimates of incidence) which can pose a diagnostic challenge, especially when presenting without other lupus-related symptoms and signs. Here, we present an unusual case where lupus enteritis was the first manifestation of systemic lupus erythematosus (SLE). Case description A 65-year-old South Asian female presented with a 6-month history of intermittent nausea, vomiting and abdominal pain, with the only systemic feature being worsening fatigue. She had no connective tissue disease features, previous miscarriage or venous thromboembolism (VTE). Over six months, she had multiple hospitalisations in different hospitals with recurrent attacks of episodic abdominal pain and vomiting, associated with migratory and reversible intestinal inflammation on serial imaging. Initial investigations revealed lymphopenia (0.99x109/L) and hypoalbuminaemia (25 g/L). During a two-month admission at our centre, she underwent detailed gastrointestinal investigations, including four abdomino-pelvic CT scans during transient episodes of pain and vomiting, showing diffuse wall thickening affecting different parts of the gastrointestinal tract at different times. Following discussion at specialist radiology and inflammatory bowel disease multidisciplinary meetings, these CT scans and an MRI small bowel study were confirmed to demonstrate a transient, migratory, reversible pattern of bowel inflammation affecting the ileum, jejunum and colon at different time points; there were no clinical, endoscopic, histological or imaging features of inflammatory bowel disease. Gastro-duodenal biopsies were normal and negative for amyloidosis and tuberculosis. Colonic biopsies excluded inflammation. C1 esterase inhibitory deficiency was excluded. A vasculitis screen was negative, but immunology was positive for anti-nuclear and anti-chromatin antibodies, with positive crithidia, but normal dsDNA. C3 was normal, but C4 was low at 0.04 g/L. Urinalysis showed significant albuminuria (413.8 mg/mmol). Following multidisciplinary discussion between gastroenterology, clinical immunology and rheumatology, a diagnosis of SLE was made, with an initial presentation of lupus enteritis. She received a tapering dose of corticosteroids and hydroxychloroquine. The patient suffered from a right-sided multi-segmental pulmonary embolus with infarction, but this was felt to be due to her nephrotic syndrome (negative anti-cardiolipin and β2-glycoprotein antibodies). Renal biopsy revealed class I lupus nephritis with podocytopathy. The patient was duly commenced on tacrolimus as a steroid-sparing agent. Discussion Lupus enteritis is a rare, poorly-defined condition, with only small amounts evidence regarding treatment and management in the literature, although a narrative review of 58 papers has recently been published. However, the average time between diagnosis of SLE and presentation with lupus enteritis is around 44 months, meaning that isolated enteritis as a first presentation of SLE is extremely rare. Only two out of 150 patients reviewed by Janssens et al (from a single tertiary lupus centre) presented with enteritis prior to a diagnosis of SLE. Lupus enteritis is potentially serious if left untreated, and can lead to life-threatening complications such as intestinal necrosis and/or perforation. This rare presentation highlights the importance of considering lupus enteritis in the differential in any patient presenting with non-specific gastrointestinal symptoms and a migratory pattern of intestinal inflammation on radiological investigations. This can enable prompt diagnosis and timely management. Key learning points • Lupus enteritis can be a first presentation of SLE without any other classical manifestations. • Lupus enteritis is extremely rare, but can be life-threatening if not identified and rapidly treated. • Radiology can demonstrate transient, migratory bowel inflammation on serial imaging.

Clinicopathological Study of Gastroduodenal Biopsies and Correlate with Endoscopic Findings in Northeast India- One- Year Cross-sectional Study in a Tertiary Care Centre

Background: The gastrointestinal tract (GIT) is a hollow muscular tube extending from the oral cavity to the anus. Acid peptic disease is among the most common disorders affecting this region globally, caused by an imbalance between acid secretion and gastric mucosal defenses. Endoscopy has enhanced the accuracy and early histologic diagnosis of mucosal lesions. This cross-sectional study examines 100 gastroduodenal biopsies over a one-year period. Methods: The study categorized histopathological findings from gastro-duodenal biopsies collected via endoscopy and analyzed their correlation with endoscopic results. Results: Gastroduodenal lesions were more prevalent in males, particularly in the fifth decade of life. Endoscopic findings included 12 normal cases, 31 ulcers, 15 erosions, 4 polyps, and 38 malignancies. Among the 38 malignancies, 10 were premalignant, 23 were diagnosed as gastric carcinoma, and 4 as duodenal carcinoma, demonstrating a strong correlation between endoscopic and histopathological findings. Conclusion: Endoscopic gastroduodenal biopsies are instrumental in diagnosing both benign and malignant lesions across various age groups and sites. The combination of endoscopy and histopathological analysis provides a powerful diagnostic tool for better patient management.

P507 Can systematic upper gastrointestinal endoscopy benefit patients with Inflammatory Bowel Disease?

Abstract Background In the context of Inflammatory Bowel Disease (IBD), a comprehensive understanding of disease extent and related complications is essential for effective clinical care. While Crohn’s disease (CD) can affect the digestive tract from mouth to anus, ulcerative colitis (UC) is limited to the rectum and colon. This study investigates the potential utility of systemic gastroscopy in IBD management. Methods We conducted a retrospective cohort study using data from our gastroenterology department. Patients diagnosed with IBD who underwent systematic upper gastro-intestinal endoscopy (UGE) were included. Clinical, endoscopic, and histopathological data were gathered and analyzed. Results 141 CD and 61 UC patients were included. The mean age was 40,7 years, and the female to male ratio was 1,33. 95.5% of these patients had no upper gastrointestinal symptoms prior to undergoing UGE. Among the symptomatic participants, the most frequent complaints were dyspepsia and pyrosis. In 73.9% of asymptomatic patients, UGE showed a normal mucosa, the abnormalities found in these patients were: non-specific gastro-duodenal erosions and ulcerations (8.5% of cases), mild esophagitis (4% of cases), aphthoid ulcerations (2% of cases) and duodenal stenosis (0.5% of cases). In symptomatic participants, UGE was normal in 4 cases, it showed atrophy of the fundus mucosa in 1 case, esophageal hernia in 2 cases, and esophageal aphthoid ulcerations in 1 case. Gastro-duodenal biopsies were consistently undertaken, among asymptomatic patients, histopathological abnormalities included: lymphoplasmacytic Infiltrate (47,7%) and helicobacter pylori (HP)(38,1 %), nonspecific duodenitis (44,7%), gastric metaplasia, focal gastritis, atrophic villi and crypt hyperplasia were objectified in 3,5%, 3%, 1,5% and 0,5% of cases. Granulomas were noted in only 1% of cases, and Cryptitis and crypt abscess in 0,5%. In symptomatic participants, histologic abnormalities included metaplasia in the fundus (0.5%), lymphoplasmacytic infiltrate (2.5%), HP (2,4%), atrophic villi in the duodenum (0.5%) and glandular atrophy (0.5%). Our analysis did not reveal any significant associations between endoscopic lesions and UC (p=0.36) or CD (p=0.09) nor the presence of symptoms (p=0.08), however, a significant association was identified between male gender and the presence of endoscopic lesions (p=0.033). Conclusion Although IBD patients might be asymptomatic, UGE and histopathological examination may reveal upper gastrointestinal abnormalities and aid to a better assessment and management of IBD patients.

Comparison of Different Diagnostic Methods of Helicobacter Pylori Infection in Children

Background: Helicobacter Pylori Infection (HPI) is usually acquired during childhood, without specific treatment this infection rarely resolves spontaneously. Therefore, correct diagnosis is necessary for the effective eradication and there is no single test can be regarded as the gold standard for the identification of H. pylori.Objective: To compare the sensitivity, specificity, and accuracy of the stool antigen test, serologic test, rapid urease test, and histology for the diagnosis of H. pylori infection.Materials and Methods: This cross-sectional descriptive study was conducted at the Department of Pediatric Gastroenterology & Nutrition, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from April 2019 to October 2021 on 54 children aged less than 18 years suspected to be H. pylori infection, who attended the outpatient as well as admitted. In a typical data sheet, a complete clinical history, exam results, and investigation reports were documented. Results were expressed as sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy.Results: The gastro-duodenal biopsy and Rapid Urease Test (RUT) (100%) have the highest sensitivity, followed by serology (95%), and Saturation (SAT) (70%). Highest specificity was found in gastro-duodenal biopsy 88.2% followed by RUT 67.6% & SAT 41.2% and only 32.4% by serology. The gastro-duodenal biopsy had the highest diagnosis accuracy (92.6%), followed by RUT (79.6%), serology (55.6%) and SAT (51.9%).Conclusion: In the study, the gastro-duodenal biopsy and rapid urease test both showed high sensitivity, specificity, and negative predictive value; as a result, the combination of these tests constituted the best alternative for making the diagnosis. Because of their high sensitivity, serological tests may be useful non-invasive screening methods. KYAMC Journal Volume: 14, No: 03, October 2023: 130-137.

Surveillance of Helicobacter pylori resistance over 22 Years (2000-2021) in Northern Spain

Helicobacter pylori gastritis is considered an infectious disease, regardless of symptoms and stage of disease. Most consensus documents recommend empirical therapy based on local antimicrobial susceptibility patterns. We aimed to provide clinically useful information about primary and secondary antimicrobial resistance to antimicrobials commonly prescribed for H. pylori. Overall, 31,406 gastroduodenal biopsies and 2,641 string tests from patients over 15 years of age were plated on selective media, isolating H. pylori in 36.7% of biopsies and 50.7% of string tests. Susceptibility testing could be performed in 96.6% (12,399/12,835) of H. pylori isolates. Polymerase chain reaction (PCR) was also used to detect H. pylori and its resistance to clarithromycin, providing susceptibility data for 112 patients with negative culture results. Resistance to amoxicillin and tetracycline was unusual (0.6% and 0.2%, respectively). Rates of primary resistance to clarithromycin and metronidazole remained steady over the 22-year study period, at around 14% for clarithromycin and 30% for metronidazole, while primary resistance to levofloxacin tripled (from 7.6% in 2000 to 21.7% in 2021, P < 0.001) and increased with patient age. Notably, 1.8% of isolates were multiresistant to clarithromycin, metronidazole, and levofloxacin. Overall, secondary resistance rates were higher (P < 0.0001) than primary resistance rates for clarithromycin (42.5% vs 14.1%), metronidazole (40.9% vs 32%), and levofloxacin (21.5% vs 17.1%). Determination of susceptibility for H. pylori by culture and/or PCR in patients undergoing endoscopy could facilitate the implementation of tailored therapy and guide the choice of empirical therapy when susceptibility testing cannot be performed, potentially helping limit the emergence of antimicrobial resistance.

The Relationship between AB0/Rhesus Blood Group Antigens with the Presence of Helicobacter pylori in Gastroduodenal Biopsy- Retrospective Analyze of 1774 Patient Data

The Relationship between AB0/Rhesus Blood Group Antigens with the Presence of Helicobacter pylori in Gastroduodenal Biopsy- Retrospective Analyze of 1774 Patient Data

Spectrum of Histopathological Lesions in patients undergoing Gastroduodenal Biopsies in a Tertiary Care Centre in North Karnataka, India

Introduction: Patients with Gastrointestinal (GI) symptoms usually present with alarming symptoms. The use of modern flexible gastroduodenoscope and the acquisition of the mucosal biopsy specimens have opened a window to the living tissues and have greatly improved the diagnostic facility for the GI lesions. It provides an in depth visual assessment of GI mucosa and allows sampling of tissue to the pathologist for further assessment. Aim: The aim of this study was to evaluate the spectrum of histopathological incidence of neoplastic and non-neoplastic lesions in patients undergoing gastroduodenal biopsy. Materials and Methods: This was a prospective study of 100 patients conducted over a period of one year and seven months, December 2010 to June 2012 with symptoms of gastroduodenal diseases who attended endoscopic unit of the tertiary care hospital in Bellary North Karnataka, South India. All biopsies done for various upper abdominal symptoms like pain abdomen, dyspepsia, haematemesis, mass per abdomen, and vomiting were included. Routine haematoxylin and eosin, special stains like Periodic Acid-Schiff (PAS) and Giemsa were done. Histopathological parameters evaluated included mucosa evaluation (ulceration, metaplasia, dysplasia, atrophy), type of inflammatory infiltrate, H.pylori infection and type of tumour. Data was analysed using descriptive analysis. Results: Among 100 patients, 76 were males and 24 were females. Highest percentage of study participants were in the age group of more than 58 years 30 (30%). The most common endoscopic presentation was gastric erythema in 42 (42%) cases followed by benign gastric ulcer 16 (16%) cases, ulcero proliferative growth 15 cases, and duodenal erythema 13 (13%) cases. The most common histopathological diagnosis amongst non-neoplastic lesions were chronic gastritis 44 (44%) cases chronic duodenitis 15 cases, and benign gastric ulcer 11 (11%) cases and amongst neoplastic lesions, most common was gastric adenocarcinoma 15 (15%) cases. Conclusion: Endoscopy gross findings are not disease specific hence, histopathological study of biopsy specimen can help in confirmation of the diagnosis.

THE DIAGNOSTIC ACCURACY OF H. PYLORI CULTURE AND RAPID UREASE TEST IN THE DIAGNOSIS OF H.PYLORI INFECTION KEEPING HISTOPATHOLOGY AS THE GOLD STANDARD

Objective: The aim of this study was to determine the diagnostic accuracy of biopsy-based tests in the detection of Helicobacter Pylori infections keeping histopathology as a gold standard. Materials and Methods: This validation study was conducted from August 2018 to February 2019 at Khyber medical college, pathology department, Peshawar, and comprised biopsy samples of 87 patients obtained via endoscopy which was done at the gastrointestinal endoscopy department, Hayatabad medical complex (HMC). Patients with a history of prior antibiotics and PPIs were excluded from the study. Rapid urease test (RUT) and culture of gastroduodenal biopsies were validated against the histopathological examination of gastroduodenal mucosa. Results: Out of 87 patients, 57.47% (50/87) were male and 42.52% (37/87) were female patients with an age range of 18 -80 years and a mean age of 45 years. Endoscopic findings showed 64.36% (56/87) of patients with gastritis, duodenitis with 6.89% (6/87), peptic and duodenal ulcers with 22.98% (20/87), erosion with 4.59% (4/87) and adenocarcinoma of stomach with 2.29% (2/87). The sensitivity and specificity of culture were 45.45% and 90.7% respectively, while positive and negative predictive values were 62.5% and 83% respectively. The sensitivity and specificity of the rapid urease test (RUT) were 81.81% and 90% while positive and negative predictive values were 90% and 94% respectively. Conclusion: The sensitivity and specificity of the rapid urease test were 82 and 90% respectively, while that of culture was 45 and 91% respectively. Keys Words: Helicobacter Pylori, Gastritis, Rapid urease test, Adenocarcinoma

High Discovery Rate of Duodenal and Gastric Eosinophilia in Patients With Unexplained Moderate–Severe Abdominal Symptoms: A Prospective US Multisite Study

High Discovery Rate of Duodenal and Gastric Eosinophilia in Patients With Unexplained Moderate–Severe Abdominal Symptoms: A Prospective US Multisite Study

Detection of Helicobacter pylori and its Antimicrobial Susceptibility Pattern from Gastric Biopsy Specimens

Background: Early detection of Helicobacter pylori (H. pylori) infection is essential for its treatment. Resistance to amoxicillin, clarithromycin and metronidazole has been on the increase in many countries. Phenotypic resistance is correlated with treatment failure. So, there is an urgent need to explore sensitivity of other antibiotics, such as levofloxacin to combat H. pylori infection. Objective: The study was aimed to detect H. pylori from gastric biopsy samples and its susceptibility profile to commonly used antimicrobial drugs. Methods: Gastroduodenal biopsy specimens were collected from 143 adult dyspeptic patients during March 2018-February, 2019, who attended the outpatient department of gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH), for endoscopy. H. pylori was identified by rapid urease test (RUT), ureC gene PCR, histological staining (Giemsa) and culture. From culture isolates antimicrobial susceptibility of clarithromycin, levofloxacin, amoxicillin and metronidazole were detected by disk diffusion method. Results: The highest rate of H. pylori infection was found in the age group between 41-50 years (25.5%). According to case definition, H. pylori positive cases were 47 (32.9%) and H. pylori negative cases were 96 (67.1%). Thirty five H. pylori positive samples were subjected to culture and only 10 (28.6%) were positive. Among 10 culture positive H. pylori isolates, clarithromycin exhibited 20% resistance, levofloxacin 30%, metronidazole 30% and no resistance found to amoxicillin. Conclusion: PCR based assays can be an alternative rapid approach for the detection of H. pylori. In this study, levofloxacin showed high resistance, a further larger study is required to confirm this finding. Bangladesh Med Res Counc Bull 2022; 48(1): 3-9

Diagnosis and Comparison of Three Invasive Detection Methods for Helicobacter pylori Infection.

The purpose of this study was to compare different invasive methods for Helicobacter pylori (H. pylori) detection, namely PCR for H. pylori specific ureC gene, Rapid urease test (RUT), and histopathological examination by modified Giemsa staining. Endoscopic gastroduodenal biopsy materials were collected from dyspeptic patients who underwent endoscopic examination upon fulfilling the inclusion criteria. Three to four samples were collected from each patient after taking informed consent and proper clinical history. A rapid urease test (RUT) was done on spot with in-house RUT media from 1 specimen. One to two specimens were preserved in 10% formaldehyde for histopathology and PCR for ureC gene was done from 1 specimen. Collected biopsy specimens from gastric and duodenal mucosa of 142 patients were categorized as H. pylori-positive cases and H. pylori-negative cases based on the case definition used in the study upon positivity of 3 diagnostic tests. Among 142 biopsy specimens, 34.5% were categorized as H. pylori-positive cases, 35.2% as H. pylori-negative cases, and finally 30.2% as doubtful or indeterminate cases. Rapid urease test was the most sensitive method, closely followed by ureC gene PCR and histopathology, with a sensitivity of 94.2%, 83.0%, and 76.5%, respectively. Whereas histology was the most specific, having 98.0% specificity followed by 83.0% in PCR. RUT was the least specific, with 55.5% specificity. While histopathology could detect H. pylori infection with the highest specificity, for definitive diagnosis combination of any 2 methods should be used, if available.

Endoscopic and histopathological findings in adult dyspeptic patients, and their association with Helicobacter pylori infection in Dhaka, Bangladesh

Conventional upper-intestinal endoscopy is usually performed to diagnose Helicobacter pylori (H. pylori) associated diseases, using gastric mucosa from the biopsy. The objective of our study was to identify the prevalence of H. pylori and its relation with endoscopic findings and histopathological features in dyspeptic adult patients. Gastroduodenal biopsy specimens were collected from 143 adult dyspeptic outpatients who attended the Department of Gastroenterology, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH), for endoscopy. H. pylori was identified by rapid urease test (RUT), ureC gene PCR, and histological staining (Giemsa). The study population was divided into H. pylori-positive cases (47; 32.9%) and H. pylori-negative cases (96; 67.1%), based on the case definitions used in the study. The highest rate of H. pylori infection was found in the 41-50 years age group (25.5%). Endoscopically, 101 (97.1%) dyspeptic patients had gastritis, with the majority of H. pylori infections found among histopathologically diagnosed duodenal ulcer patients. Endoscopic findings were significantly correlated with histological findings (p < 0.001). Significant correlations between endoscopic and histopathological findings were observed. Early detection and prompt treatment of H. pylori infection are essential for the prevention of serious complications.

S376 Patients With Eosinophilic Esophagitis and Gastrointestinal Symptoms May Have Eosinophilic Gastritis and/or Duodenitis, Not Associated With Peak Esophageal Eosinophil Count

Introduction: Many patients with eosinophilic esophagitis (EoE) present with extra-esophageal or atypical symptoms. We previously evaluated gastric and duodenal biopsies from patients with EoE with and without persistent extra-esophageal gastrointestinal (GI) symptoms to determine if they had eosinophilic gastritis and/or duodenitis (EG and/or EoD)1. In this study, we investigated correlations between peak esophageal eosinophil counts and concomitant EG and/or EoD. Methods: We studied 45 patients with EoE and GI symptoms (abdominal pain, nausea, bloating) and/or a previous diagnosis of irritable bowel syndrome (EoE+S) and 12 patients with EoE without extra-esophageal symptoms (EoE–S). All had initial gastric and duodenal biopsies interpreted as non-specific inflammation or normal. Gastric and duodenal eosinophils were systematically counted in biopsies by a blinded GI pathologist; EG and EoD were defined as ≥30 eosinophils/high-power field (hpf) in ≥5 hpfs in gastric and ≥3 hpfs in duodenal specimens, respectively. Results: Thirty-one of the 45 EoE+S patients (69%) met histologic criteria for EG and/or EoD: 8 (18%) met histologic criteria for EG and 23 (51%) met histologic criteria for EoD. None of the EoE–S patients met histologic criteria for EG and 3 met histologic criteria for EoD. Peak esophageal eosinophil counts did not differ significantly between patients with EoE+S vs EoE–S, and were not associated with the presence of EG or EoD (Figure 1). Conclusion: Sixty-9 percent of patients with EoE and extra-esophageal GI symptoms met the histologic criteria for EG and/or EoD. Peak esophageal eosinophil counts were not associated with the presence of EG or EoD and therefore should not be used to guide gastroduodenal biopsy. Patients with EoE and persistent extra-esophageal GI symptoms, regardless of peak esophageal eosinophil counts, should undergo systematic collection and histologic analysis of gastric and duodenal biopsies to identify those with concomitant EG and/or EoD.Figure 1.: Peak Esophageal Eosinophil Counts in Patients With EoE, With vs Without GI Symptoms EoE+S EG: patients with EoE and extra-esophageal GI symptoms who met criteria for EG (≥30 eos in ≥5 gastric hpfs) EoE+S EoD: patients with EoE and extra-esophageal GI symptoms who met criteria for EoD (≥30 eos in ≥3 duodenal hpf) EoE–S: patients with EoE without extra-esophageal GI symptoms Dotted line indicates histologic threshold for EG and/or EoD Caps indicate minimum and maximum; box, 25th and 75th percentile; center line, median P value from unpaired t test of simple 1-way ANOVA, compared with EoE-S Note: Some patients were receiving treatment for EoE at the time of esophageal biopsy collection.

619 HIGH DISCOVERY RATE OF GASTRODUODENAL EOSINOPHILIA BUT NOT EOSINOPHILIC ESOPHAGITIS IN PATIENTS WITH CHRONIC GASTROINTESTINAL SYMPTOMS

Abstract Although the prevalence of eosinophilic gastrointestinal disorders (EGIDs) is increasing, there is evidence that eosinophilic gastritis and/or duodenitis (EG/EoD) are underdiagnosed. Patients with EG/EoD often present with chronic, non-specific gastrointestinal (GI) symptoms, similar to patients with functional GI disorders. We hypothesized that systematic evaluation, including multiple esophageal, gastric and duodenal biopsies, of patients with chronic GI symptoms might reveal a high rate of gastroduodenal eosinophila, with or without eosinophilic esophagitis (EoE). Methods We performed a prospective multi-center study of patients with non-specific GI symptoms for ≥6 months, from 20 sites. Patients completed a questionnaire assessing abdominal pain, abdominal cramping, early satiety, bloating, nausea, vomiting, diarrhea, and loss of appetite. Those with daily average symptom severity scores ≥3/10 for any single symptom underwent esophagogastroduodenoscopy (EGD) with collection of 4 esophageal (EoE), 8 gastric, and 4 duodenal biopsies, analyzed by central pathologists. Histologic criteria for EoE was ≥15eos/hpf in ≥1 esophageal site and for EG/EoD was peak eosinophil counts ≥30/hpf in ≥5 gastric hpfs and/or 3 duodenal hpfs—criteria used in randomized trials. Results Of 556 patients screened, 405 (73%) met symptom criteria and underwent EGD; 181 patients (45%, mean age 45, 73% female) who underwent EGD met the histologic criteria for EG/EoD, and of these, 7% also had EoE diagnosed. Overall 2% met histologic criteria for EoE alone. Of patients who met the histologic criteria for EG/EoD, 93% were previously diagnosed with gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), or functional dyspepsia (FD) (Figure 1). The average duration of GI symptoms in the screened population as well as those that met histologic criteria for EG/EoD was 11 years. Conclusion Forty-five percent of patients with moderate-to-severe GI symptoms who underwent EGD met histologic criteria for EG/EoD. Over 90% of these patients had previously been diagnosed with GERD, IBS, and/or FD, and had minimal overlap with EoE. EGD with systematic gastroduodenal biopsies, and intentional evaluation for tissue eosinophilia, should be performed in patients with chronic GI symptoms. Accurate diagnosis of EG/EoD is required for appropriate, targeted treatment and improved outcomes of patients with moderate-to-severe GI symptoms.

Is Gastric Involvement by Strongyloides stercoralis in an Immunocompetent Patient a Common Finding? A Case Report and Review of the Literature

PurposeGastric infection with Strongyloides stercoralis (SS) usually occurs in immunocompromised patients. The unexpected observation of this parasite in an otherwise healthy young lady who had undergone upper endoscopy and biopsy sampling of the gastro-duodenal mucosa, prompted us to review the literature to ascertain the conditions favouring gastric colonization by SS.MethodsPathology files of gastroduodenal biopsies received at St. Mary’s hospital, Northern Uganda, between 2007 and 2017 were reviewed. Pubmed search was performed under the headings “Strongyloides stercoralis”, “Gastric parasitosis”.ResultsHistology of the only gastroduodenal biopsy with SS infection showed parasite eggs, immature rhabditiform larvae, and numerous adult worms in gastric pits and rhabditiform larvae in interepithelial parasitic tunnels, causing reactive changes of the glandular epithelium. There was no significant acute inflammatory cell infiltrate surrounding the parasites. Literature review showed that gastric SS infection appears to be very uncommon and was, as expected, largely prevalent in immunodeficient individuals (84.2% of published cases). The rare gastric SS infection is a complication of systemic strongyloidiasis, either hyperinfective, or disseminated form. It is also commonly associated with duodenal infection at microscopical examination.ConclusionInvolvement of gastric mucosa in the absence of duodenal strongyloidiasis appears to be quite rare and false-negative histopathological exams are reported if only the stomach is biopsied.

Insight in the diagnosis and treatment of coeliac disease in general practice: A survey and case vignette study among 106 general practitioners

Background Coeliac disease (CD) is a highly prevalent (∼1%) disease that allegedly remains undiagnosed in over 80% of the cases because of atypical symptoms or silent disease. Currently, it is unknown how GPs deal with (suspected) CD. Objectives This study aimed to better understand the diagnostic approach and the clinical reasoning process of GPs concerning CD and concurrently address diagnostic pitfalls. Methods A questionnaire with case vignettes to assess the knowledge, diagnostic reasoning pattern and practice for CD by GPs was developed. It was sent through academic GP research networks (encompassing over 1500 GPs) in two large cities and to smaller practices in rural areas. The questionnaire was composed of seven background questions, 13 questions related to four case vignettes and six additional CD-related questions Results Responses were received from 106 GPs. Knowledge on risk factors for CD and appropriate testing of at-risk populations was limited. Twenty-two percent would diagnose CD in adults exclusively based on serology, without histopathological confirmation. In total, 99% would refer a newly diagnosed patient to a dietitian to initiate a gluten-free diet (GFD). In the absence of symptoms, only 33% would initiate a GFD. Conclusion The results of this study have given us insight into the diagnostic process of GPs encountering patient with gluten-related complaints. Multiple serology test is available and used, while a positive serology test is not always followed up by a gastroduodenal biopsy to confirm the diagnosis. Most GPs would refer a symptomatic CD patient to a dietician for a GFD.

S3024 No Dermatologist Needed for This Collagen Filler: The Rare Presentation of Collagenous Gastritis in a Patient With Eosinophilic Esophagitis

INTRODUCTION: Collagenous gastritis is a rare disease characterized by subepithelial collagen deposits within the gastric mucosa and chronic inflammation. While this disorder has similar histologic characteristics to the more common collagenous colitis, little is known about collagenous gastritis given its rarity. Fewer than 100 cases of collagenous gastritis have been reported to date, and our understanding of the disease is limited. The disease typically manifests with nonspecific symptoms including abdominal pain, diarrhea, and iron deficiency anemia (IDA). It is diagnosed histologically, and has been linked to various autoimmune disorders. We will describe a case of collagenous gastritis to further knowledge of this rare disease. CASE DESCRIPTION/METHODS: A 32-year-old man with a history of partial right lower lobectomy for carcinoid tumor 11 years prior, was referred for IDA, upper abdominal pain, and dysphagia. Initial endoscopy with biopsies revealed esophageal eosinophilia, consistent with eosinophilic esophagitis ( EoE). Gastroduodenal biopsies were unremarkable, and colonic biopsies revealed no collagenous or lymphocytic colitis. He was started on a PPI for 8-weeks and iron supplements, with improvement of symptoms. Following treatment, repeat EGD demonstrated resolution of his esophageal eosinophilia, and iron supplementation was discontinued. He re-presented 2 years later, with similar symptoms and recurrence of IDA. Repeat EGD demonstrated esophageal eosinophilia consistent with EoE. Endoscopy also revealed gastric erythema with nodularity (Figure 1), and subepithelial collagen deposition within the gastric body and fundus, consistent with collagenous gastritis (Fig 2a, 2b). He was restarted on iron supplement and a PPI, with improvement of symptoms. DISCUSSION: Collagenous gastritis has been associated with autoimmune disorders, and may be linked to EoE as described in this case. While diagnosis is histological, endoscopic features include gastric mucosal nodularity and erythema. Currently there is no clear consensus on the treatment of collagenous gastritis. Multiple therapies have been attempted including acid suppression, iron supplementation, hypoallergenic diets, among others, however to date there are no randomized control trials demonstrating treatment efficacy, and overall prognosis remains unclear. Awareness of this disorder is essential in its recognition. More information is needed to understand collagenous gastritis and determine how best to treat patients affected by this rare disease.Figure 1.: Endoscopic view of the gastric body, depicting moderately erythematous mucosa, with slight mucosal nodularity as seen (arrow).Figure 2a.: Gastric antrum/body endoscopic biopsy demonstrating thickened subepithelial collagen deposition (arrow) and inactive chronic gastritis. (H&E stain, 200x).Figure 2b.: Gastric antrum/body endoscopic biopsy with trichrome stain, demonstrating thickened subepithelial collagen. (Trichrome stain 2A, 200x).

Study of histopathological findings of gastroduodenal biopsies and prevalence of helicobacter pylori infection in a tertiary care hospital

study of histopathological findings of gastroduodenal biopsies and prevalence of helicobacter pylori infection in a tertiary care hospital

Usefulness of gastroduodenal biopsy in the differential diagnosis of systemic AH amyloidosis from systemic AL amyloidosis.

The aim of this study is to examine the usefulness of gastroduodenal biopsy for the detection of immunoglobulin (Ig) heavy-chain amyloid deposition. Ig heavy-chain amyloidosis (AH amyloidosis) is Ig-related amyloidosis classified together with Ig light-chain amyloidosis (AL amyloidosis). Compared with AL amyloidosis, patients with AH amyloidosis exhibit a better prognosis and they may not need an aggressive treatment. Thus, the accurate diagnosis is essential for management of Ig-related amyloidosis patients. For the definite diagnosis of AH amyloidosis, biochemical analyses are usually needed. However, these analyses are not widely available. Therefore, the characteristic deposition pattern of AH amyloidosis in routine histopathological examination of biopsy specimens, such as gastrointestinal biopsy, if present, may help in the selection of cases for further biochemical analyses. Gastroduodenal biopsy specimens obtained from three cases of biochemically confirmed AH amyloidosis and 21 cases of immunohistochemically confirmed AL amyloidosis were examined, and the following distinctive histopathological features of AH amyloidosis were pointed out: (i) AH amyloid deposition was detectable with Congo red staining in the gastroduodenal biopsy specimens; and (ii) AH amyloid deposition was observed characteristically on the capillary wall of duodenal villi (dotted line-like deposition in the villi), and this pattern was not observed in AL amyloidosis. These findings help to select cases for biochemical analyses for definite diagnosis of AH amyloidosis, and may lead to the accumulation of cases and improve our understanding of systemic AH amyloidosis.

Immunopathological and Modulatory Effects of Cag A+ Genotype on Gastric Mucosa, Inflammatory Response, Pepsinogens, and Gastrin-17 Secretion in Iraqi Patients infected with H. pylori.

OBJECTIVE:To determine the immunopathological correlation between Cag A+ H. pylori-specific IgG; pepsinogen I&II (PI&PII); gastrin-17 (G-17); status of gastric and duodenal mucosa and inflammatory activities on different gastroduodenal disorders.METHODOLOGY:Eighty gastroduodenal biopsies were taken from patients with gastroduodenal disorders for histopathological evaluation and H. pylori diagnosis. Serum samples were used for evaluation of gastric hormones and detection of H. pylori-specific IgG antibodies. The tissue expression of H. pylori Cag A gene was detected by in situ hybridisation.RESULTS:H. pylori IgG antibodies were detected in (88.8%) of enrolled patients. According to Cag A gene expression, Significant difference (P value ˂ 0.05) was detected in levels of PG I; PGII, PG I/PG II among patients with gastric disorders. Serum G-17 level was negatively correlated with Cag A gene expression (P-value = 0.04). There was a significant correlation between H. pylori IgG and PG I; PG II; G-17. The current study revealed that corpus atrophic gastritis was diagnosed histologically with (5%) gastric ulcer cases; (3.75%) of duodenal ulcer cases; (3.75%) of duodenitis cases; (1.25%) of gastropathy cases and (8.75%) of gastritis cases. At the same time H. pylori gastritis diagnosed concurrently with (8.75%) of gastric ulcer cases; (11.25%) of duodenal ulcer cases; (17.5%) of gastropathy cases; (3.75%) of duodenitis cases and (2.5%) of prepyloric ulcer cases. A significant correlation was reported between the Immunopathological status of gastric mucosa and endoscopic mucosal finding among duodenal ulcer cases and gastritis cases only. A positive correlation was reported between serum levels of PGI; PGII; PGI/PGII; G-17; PMNs grade and Immunopathological status of the gastroduodenal mucosa of H. pylori Infected patients. A significant difference was reported in lymphocyte grades among gastric disorders without correlation with immunohistopathological changes in the mucosa (P-value = 0.002). A significant difference was reported in lymphocyte grades among different disorders according to H. pylori IgG. A significant difference was reported in serum level of PG I; PG II; PG I/PG II; G-17 according to PMN and lymphocyte grades (P-value ˂ 0.01). PMNs grades positively correlated with gastric Cag A expression; H. pylori IgG; PG II; G-17 levels. PG I; PG I/ PG II correlated with lymphocyte grades (P-value ˂ 0.05); while PGII has a negative correlation (P-value = 0.039).CONCLUSION:Endoscopic mucosal finding does not reflect exactly the actual immunopathological changes of gastric mucosa during H. pylori infection. Secretion of gastrin was not affected by the presence of Cag A in gastric tissue. Instead, the fluctuation in the hormone level appears to be due to the presence of H. pylori infection in gastric tissue. Gastric tissue infiltration with PMNs & lymphocytes inflammatory infiltrates has a direct effect on PGs and gastrin levels in serum of infected patients. The level of PG I; PG II; G-17 secretion correlated with the development of immune response against H. pylori and production of specific H. pylori IgG. Finally, H. pylori can modulate gastric secretions through Cag A dependent and independent pathways.