Inactive Gastritis Research Articles

A Case Report Identifying the Clinical Significance of Spontaneous Gastrojejunal Fistulization Related to Roux-en-Y Bypass

Within the United States the rise in obesity and related metabolic complications, has led to an increase in the number of bariatric surgeries over the last decade. Roux-en-Y gastric bypass( RYGB) procedure is one of the most common weight-loss procedures performed in the United States. Notwithstanding the improvement in the bariatric surgical procedures, complications do occur. In the early postoperative phase, complications can occur including; obstruction of bypassed bowel, anastomotic leak and nutritional deficiencies to list a few. In rare cases, a gastro-jejunal leakage and fistula can occur. We present a rare complication of RYGB leading to formation of a gastro-jejunal fistula formation. A 51 year old woman with history of gastric bypass in 2007 presented to clinic with worsening epigastric abdominal pain associated with nausea, and unintentional weight loss of ˜8lbs over a 2 week period. She denied vomiting, hematemesis, melena or hematochezia. Physical examination was unremarkable. Laboratory investigation revealed a normal complete blood count and basic metabolic profile. An Esophagogastroduodenoscopy( EGD) showed a small gastric pouch consistent with prior gastric bypass, erythematous mucosa at the gastro-enteric anastomosis and a fistulous opening in distal gastric pouch near the anastomosis (image). The opening into the jejunal loop was narrowed precluding intubation with an upper endoscope. Biopsies of the anastomotic site exhibited mild chronic inactive gastritis, negative for Helicobacter pylori. The patient was managed with a proton pump inhibitor(PPI) daily for 8 weeks. On follow up, she reported complete resolution of her symptoms. A follow up EGD showed healing of the fistilous tract. As reviewed in literature, spontaneous fistulization formation secondary to gastritis (peptic ulcer disease particularly) is a rare complication. Fistulaization typically affects middle aged to elderly females with risk factors; NSAID use, H. Pylori infection, postoperative stress and minimal mesenteric adipose tissue. It is our responsibility as gastroenterologists to be familiar with potential complications after bariatric surgery and management strategies. This case further validates that surgical intervention is not always required in gastroenteric fistulas and that medical therapy with appropriate follow up can be used to manage such complications.1888 Figure 1. Small gastric pouch, erythematous mucosa with a gastro-jejunal fistulous opening (left) near gastro-enteric anastomosis (right).

Gastric Xanthelasma: Innocent Bystander?

Introduction: Gastric xanthoma or xanthelasma are usually benign sharply demarcated yellow deposit of cholesterol underneath the skin, a rare finding during endoscopy. Their clinical significance is unknown; however they have been associated with gastric malignancy. Case Report: _A 62 year old male with a past medical history of colon cancer in 2005 treated with right hemicolectomy and chemotherapy in remission, seroconverted hepatitis C, atrial fibrillation, osteoarthritis, chronic kidney disease stage II was evaluated in the office for a screening colonoscopy. He mentioned his mother was diagnosed with gastric cancer at the age of 60, thus upper endoscopy was recommended. His physical exam was normal. His blood work showed a normal comprehensive metabolic panel with hemoglobin 15.5 and albumin of 4.4.Upper endoscopy showed two small nodular yellow areas, measuring 7-8 mm in size, on the proximal greater curvature of the body of the stomach. On microscopic examination, the lamina propria showed inclusion of foamy histiocytes with hematoxylin and eosin (H&E) staining. Immunohistochemical stain was positive for CD163, and negative for pancytokeratin and PAS stain negative for Whipple's disease. The absence of nuclear atypia and cytokeratins excluded the diagnosis of malignancy. These findings were suggestive of a gastric xanthoma. The surrounding gastric mucosa showed evidence of focal chronic inactive gastritis. Immunohistochemical stain for H. pylori was negative. The duodenum appeared normal. Discussion: Gastric xanthelasma or xanthomas (GX) are incidental relatively rare lesions found on upper endoscopy with the prevalence ranging from 0.23% to 7%. Clinically, the patient is asymptomatic, and most of the time endoscopy is performed for other reasons. Historically, GX has received little attention, maybe because clinically it has been always considered as a benign endoscopic finding. However more recent studies showed that there is a strong association between gastric xanthoma lesions and atrophic gastritis. It appears to be a close relationship between H. pylori infection, and GX. Treating H. pylori did not decrease the risk of gastric adenocarcinoma when GX was present. Some retrospective observational studies have gone as far as associating GX as a predictive marker for metachronous and synchronous gastric cancers, or even the development of gastric cancer. Previous partial gastric resection is associated with an increased incidence of GX.1857_A Figure 1 No Caption available.1857_B Figure 2 No Caption available.

Factors Associated With Detection of Helicobacter pylori in Gastric Biopsies: A Case-Control Study of 396 Biopsies.

Helicobacter pylori (HP) infection is associated with significant gastric mucosal inflammation. We aimed to determine the clinicopathologic features associated with HP in gastric biopsy. Three hundred ninety-six gastric biopsies were evaluated including 165 HP-positive cases and 231 randomly selected HP-negative controls. HP was detected using hematoxylin and eosin (H&E), Giemsa, and immunohistochemistry staining. The univariate and multivariate analyses were conducted to study the relationship of clinicopathologic characteristics and HP infection. Among the HP-positive cases, 131 cases were confirmed by H&E staining and 34 cases were confirmed by Giemsa or immunohistochemistry staining. Compared with chronic inactive gastritis, chronic active gastritis was more likely associated with having HP detected by H&E. Males were more likely to have HP gastritis than females (odds ratio: 1.72, P=0.01). The patients who had chronic active gastritis or chronic gastritis (moderate or severe) were more likely to have HP infection than patients with mild chronic gastritis (P<0.001). Conversely, patients who had intestinal metaplasia were less likely to have HP infection than patients without intestinal metaplasia (odds ratio: 0.22, P<0.001). However, concurrent atrophic gastritis was not related to HP infection (P=0.37). HP infection history was not associated with HP infection (P=0.74). HP detection in gastric biopsies is associated with active inflammation, male sex, and the lack of intestinal metaplasia, but not atrophic gastritis or HP infection history. Routine ancillary staining may not be required for HP detection in all biopsy specimens. We do not recommend ancillary staining for mild chronic inactive gastritis.

Histopathology Findings in Patients Undergoing Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has gained popularity in the last 10years for its good results in weight loss and comorbidity control. However, guidelines on the pathological examination of the specimen are lacking. The aim of this retrospective study was to determine the usefulness of the routine specimen examination when presurgery endoscopy (upper gastrointestinal endoscopy, UGIE) and multiple gastric biopsies are part of the preoperative work-up. A retrospective review of records of the patients submitted to LSG between January 2012 and August 2017 was carried out. Sex, age, histopathology findings in the presurgery endoscopy biopsies and surgical specimen, and the prevalence of Helicobacter pylori infection were analyzed. A total of 925 patients entered the study group (mean age = 44.1years, Females = 80.3%, BMI = 44.58kg/m2). The most common histopathology pattern in the endoscopy biopsies and in the surgical specimens was inactive chronic gastritis (64.4 and 55.6%, respectively). Helicobacter pylori infection was 24.6 and 2.48%, respectively. Ninety-nine percent (n 796) of patients with non-significant endoscopy biopsy findings showed the same patterns in specimen analysis. Only three patients (0.3%) who had intestinal presurgery metaplasia were positive in the specimen analysis, and two cases of gastric stromal neoplasms (gastrointestinal stromal tumor and gastric leiomyoma) were found intraoperatively. Most of the findings are non-significant and can be predicted if UGIE plus multiple biopsies is routinely included in the bariatric work-up with significant cost reduction. In those patients who had a significant finding prior to the surgery or intraoperatively, the pathological examination of the specimen is recommended.

Частота выявления дуоденогастрального рефлюкса у больных хроническим неактивным гастритом с дискинезией желчевыводящих путей

Частота выявления дуоденогастрального рефлюкса у больных хроническим неактивным гастритом с дискинезией желчевыводящих путей

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

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.

Utility of Gastric and Duodenal Biopsies During Follow-up Endoscopy in Children With Eosinophilic Esophagitis.

Eosinophilic esophagitis (EoE) is a chronic antigen-mediated immune disorder of the esophagus. Consensus guidelines recommend obtaining esophageal, gastric, and duodenal biopsies at diagnostic endoscopy when EoE is suspected. The utility of repeated gastric and duodenal biopsies during follow-up endoscopy in patients previously diagnosed with EoE is not established. The aim of the present study was to explore the role of gastric and duodenal biopsies in children with an established diagnosis of EoE undergoing repeat endoscopy to assess histological response to treatment. Retrospective chart review of children diagnosed with EoE at a tertiary care center was conducted. A total of 160 patients with EoE with demographic clinical, endoscopic, and histological data at diagnosis and follow-up endoscopy were included. The frequency of gastric and duodenal biopsies at follow-up endoscopy with abnormal histology and their correlation to endoscopic findings was determined. At follow-up endoscopy, 83% (132/160) of patients had gastric and 74% (118/160) had duodenal biopsies. Histology was normal in 81% of gastric and 92% of duodenal biopsies. The most frequent gastric abnormalities were chemical and inactive chronic gastritis. The most frequent duodenal abnormality was villous blunting with increased intraepithelial lymphocytes. Two patients with normal gastric and duodenal histology progressed to eosinophilic gastroenteritis at follow-up endoscopy. Gastric and duodenal biopsies obtained in EoE patients during follow-up endoscopy show pathology in a minority of patients, increase costs, and may add potential risk of adverse events. Large multicenter, prospective studies of endoscopic practice during follow-up of EoE are warranted to provide evidence supporting best practices.

Subtypes of chronic gastritis in patients with celiac disease before and after gluten-free diet.

Celiac disease (CD) often manifests with dyspeptic symptoms and chronic gastritis is a common finding. To evaluate the frequency of lymphocytic gastritis (LG), chronic active gastritis (CAG), and chronic inactive gastritis (CIG) in patients with CD, before and after gluten-free diet (GFD). A five-year prospective study including all consecutive patients with a new diagnosis of CD was conducted. Gastric and duodenal biopsy specimens taken both at the time of the CD diagnosis and at the first endoscopic control after 18-24 months on GFD were evaluated. 213 patients with CD were enrolled. At the time of the diagnosis, 42 patients (19.7%) showed normal gastric mucosa, 34 (15.9%) LG, 67 (31.5%) CAG, and 70 (32.9%) CIG. Out of the 34 patients with LG, all were Helicobacter pylori negative and the majority of them showed an improvement both of gastritis (94.1%) and duodenal lesions (82.3%) after GFD. GFD did not show significant effects on CAG and CIG. LG is present in 16% of CD patients, it is not associated with H. pylori infection, and it improves after GFD. Both CAG and CIG are also frequently associated with CD, but fail to respond to a GFD.

A Rare Case of Cronkhite-Canada Syndrome

Introduction: Cronkhite-Canada Syndrome (CCS) is a rare non-hereditary polyposis condition with unclear etiology. Estimated incidence is 1 case per million population. Symptoms include diarrhea, anorexia, and weight loss. Dermatologic changes are alopecia, onychodystrophy, and cutaneous hyperpigmentation. Classic endoscopic features include diffuse polyposis which spares the esophagus. Case: 71 yo M with irritable bowel syndrome, diabetes, atrial fibrillation on warfarin presented with abdominal pain, constipation and diarrhea. Gastroscopy and colonoscopy revealed inactive gastritis and two diminutive adenomatous polyps; no microscopic colitis. Over the course of five months diarrhea worsened, he developed dysgeusia and anorexia with a 25 lb weight loss. Exam: hair loss and dystrophic fingernails (Fig 1). Labs: low ferritin, hemoglobin, protein, and albumin. Stool guaic positive. Repeat EGD showed many antral polyps (Fig 2); histology: foveolar hyperplasia and chronic gastritis. Repeat colonoscopy showed many polyps throughout the colon (Fig 3) and terminal ileum; histology: chronic lamina propria inflammation and cystically dilated crypts and glands. Patient diagnosed with CCS. Weight improving on dietary supplements; symptoms are controlled with loperamide and simethicone. He declines steroids.FigureFigureFigureDiscussion: Hallmark features of CCS include diffuse polyps which are usually inflammatory, hyperplastic or juvenile but can be adenomatous. Histology is often non-specific and includes mixed inflammation, expanded lamina propia, cystic dilation of glands and crypts, and villous atrophy. Our patient had no signs of polyposis on recent EGD or nail changes on prior exams. Over 1 year, he developed non-specific symptoms that were unified by diffuse polyposis seen on repeat endoscopy. His disease onset is similar to the relatively acute onset described in the literature. Complications include malabsorption, gastrointestinal bleeding, small bowel obstruction, congestive heart failure, and sepsis. CCS has an increased risk of colon cancer. It is unclear if this relates to pre-existing polyps or is sporadic. Nutrition supplementation is crucial in therapy. Glucocorticoids are the most effective current therapy. Polyp sampling has been advocated for cancer prevention. It is important to be aware of this constellation of symptoms and to refer for endoscopic evaluation. Early diagnosis is key as this rare disease is progressive and confers significant mortality.

Erratum to: Histopathological Changes in Laparoscopic Sleeve Gastrectomy Specimens: Prevalence, Risk Factors, and Value of Routine Histopathologic Examination.

Laparoscopic sleeve gastrectomy (LSG) is a common surgical therapeutic option for obese patients, with debate about the value of routine histopathologic examination of LSG specimens. We assessed the following: prevalence of different histopathologic changes in LSG specimens, risk factors associated with premalignant and with frequent histopathologic changes, and whether routine histopathologic examination is warranted for LSG patients with nonsignificant clinical history. Retrospective review of records of all LSG patients operated upon at Hamad General Hospital, Qatar (February 2011–July 2014, n = 1555), was conducted. Risk factors (age, BMI, gender, and Helicobacter pylori) were assessed in relation to specific abnormal histopathologic changes. Mean age and BMI of our sample were 35.5 years and 46.8, respectively. Females comprised 69.7% of the sample. Normal histopathologic specimens comprised 52% of the sample. The most common histopathologic changes were chronic inactive gastritis (33%), chronic active gastritis (6.8%), follicular gastritis (2.7%), and lymphoid aggregates (2.2%). We observed rare histopathology in 3.3% of the sample [e.g., intestinal metaplasia and gastrointestinal stromal tumor (GIST)]. Older age was associated with GIST and intestinal metaplasia (P = 0.001 for both). Females were associated with chronic active gastritis (P = 0.003). H. pylori infection was associated with follicular gastritis, lymphoid aggregates, GIST, intestinal metaplasia, and chronic active gastritis (P < 0.001 for each). Older age, H. pylori, and female gender are risk factors for several abnormal histopathologic changes. Histopathologic examination of LSG specimens might harbor significant findings; however, routine histopathologic examination of all LSG specimens, particularly in the absence of suggestive clinical symptoms, is questionable. The association between female gender and chronic active gastritis; and the association between H. pylori infection and GIST are both novel findings that have not been previously reported in the published literature.

Gastric Histopathology of Chronic Gastritis in Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Local Experience

A retrospective review was conducted using the database at King Abdulaziz University Hospital, to determine the most common cause of chronic gastritis among obese individuals. One hundred and thirty-one specimens were examined, obtained from patients who had laparoscopic sleeve gastrectomy and diagnosed with chronic gastritis. Helicobacter pylori was detected in 15 cases only. The most common diagnosis was “Chronic inactive gastritis without Helicobacter pylori infection” in 57 (43.50%) cases, then “Chronic gastritis with lymphoid follicular hyperplasia” in 54 (41.20%) cases, and lastly “Chronic active gastritis” in the remaining 20 (15.20%) Cases. The low incidence of Helicobacter pylori infection even in cases of gastritis with lymphoid follicular hyperplasia support the existence of the new proposed entity (i.e., obesity-related gastritis). Biopsy specimens for cases diagnosed as chronic gastritis were used as control group to confirm the appropriate rate of detecting Helicobacter pylori organisms by morphological examination in the same laboratory. In these biopsies, Helicobacter pylori was present in (50.70%), and reactive follicular hyperplasia was detected in (6%) of total controls.

Demographic and socioeconomic influences on Helicobacter pylori gastritis and its pre-neoplastic lesions amongst US residents.

Gastric infection with Helicobacter pylori (Hp) can lead to chronic inactive gastritis, atrophy and intestinal metaplasia. To investigate in a cross-sectional study these changes among different socioeconomic and ethnic groups within the USA. We used the Miraca Life Sciences database, an electronic depository of clinicopathological records from patients distributed throughout the USA, to extract data from 487 587 patients who underwent oesophago-gastro-duodenoscopy with biopsy between 1/2008 and 12/2014. We then classified patients into ethnic and socioeconomic categories using previously validated algorithms, as well as ZIP code-based information derived from the 2011-2012 US Census. The prevalence of Hp increased significantly until the age-group 40-49, before it leveled off and started a gradual decrease. The prevalence of chronic inactive gastritis, atrophy, and intestinal metaplasia increased significantly with age. The prevalence of Hp, chronic inactive gastritis, intestinal metaplasia, and atrophy decreased significantly with the percentage of Whites per ZIP code. The prevalence of all four diagnoses also decreased significantly with rising levels of income or college education. Hp, chronic inactive gastritis, atrophy and intestinal metaplasia were more common among Hispanics and the influence of income or college education less pronounced than in the entire population. Hp, chronic inactive gastritis, atrophy, and intestinal metaplasia were also more common among East-Asians, Hp and atrophy decreasing with rising income but remaining unaffected by levels of college education. Ethnicity and socioeconomic factors influence the occurrence of Hp gastritis, and its progression to chronic inactive gastritis, atrophy or intestinal metaplasia.

Histopathological Changes in Laparoscopic Sleeve Gastrectomy Specimens: Prevalence, Risk Factors, and Value of Routine Histopathologic Examination

BackgroundLaparoscopic sleeve gastrectomy (LSG) is a common surgical therapeutic option for obese patients, with debate about the value of routine histopathologic examination of LSG specimens. We assessed the following: prevalence of different histopathologic changes in LSG specimens, risk factors associated with premalignant and with frequent histopathologic changes, and whether routine histopathologic examination is warranted for LSG patients with nonsignificant clinical history.MethodsRetrospective review of records of all LSG patients operated upon at Hamad General Hospital, Qatar (February 2011–July 2014, n = 1555), was conducted. Risk factors (age, BMI, gender, and Helicobacter pylori) were assessed in relation to specific abnormal histopathologic changes.ResultsMean age and BMI of our sample were 35.5 years and 46.8, respectively. Females comprised 69.7% of the sample. Normal histopathologic specimens comprised 52% of the sample. The most common histopathologic changes were chronic inactive gastritis (33%), chronic active gastritis (6.8%), follicular gastritis (2.7%), and lymphoid aggregates (2.2%). We observed rare histopathology in 3.3% of the sample [e.g., intestinal metaplasia and gastrointestinal stromal tumor (GIST)]. Older age was associated with GIST and intestinal metaplasia (P = 0.001 for both). Females were associated with chronic active gastritis (P = 0.003). H. pylori infection was associated with follicular gastritis, lymphoid aggregates, GIST, intestinal metaplasia, and chronic active gastritis (P < 0.001 for each).ConclusionOlder age, H. pylori, and female gender are risk factors for several abnormal histopathologic changes. Histopathologic examination of LSG specimens might harbor significant findings; however, routine histopathologic examination of all LSG specimens, particularly in the absence of suggestive clinical symptoms, is questionable. The association between female gender and chronic active gastritis; and the association between H. pylori infection and GIST are both novel findings that have not been previously reported in the published literature.

Telepathology a Useful Method in the Diagnosis Digestive Biopsies with Rare Entities. Case Presentation of a Collagenous Gastritis.

Introduction/ Background Collagenous gastritis is a rare entity in current surgical pathology practice. Since the introduction of the term until present, only small series and isolated cases have been reported, generally by high-specialized centers in gastrointestinal pathology. In current practice, the diagnosis of this unusual affection is based on clinical data corroborated with endoscopic and pathological findings. Due to the small number of cases the diagnostic criteria are partly taken from microscopic colitis diagnosis. Thus, it is considered that the association of the appropriate clinical context (stomach pain, watery diarrhea, endoscopic nodular appearance) and histological gastritis changes with collagen deposition of dense material with a 10um minimum variable thickness that comprises capillaries and inflammatory elements. The technical advantage of a digital slide scanner is allowing access to an experienced pathologist in digestive pathology’s opinion and conducting precision measurement. Aims Our presentation brings to attention of pathologist community a rarely diagnosed entity and the advantages of tele-pathology in timely accessing an expert opinion and performing accurate measurements. Methods We received gastric biopsy samples endoscopically taken from a 56-year female who complained of transit disorders, vomiting, epigastric pain that did not improve after IPP treatment. On endoscopy exam a nonspecific aspect with discrete erythema and vaguely nodular appearance of the gastric mucosae was noted. The specimens were paraffin embedded, and serial sections were stained HE, AB-PAS and MGG. The obtained slides were fully scanned and a gastrointestinal pathology expert advice was requested. Subsequently, a Mason’s Trichrome stain and tenascin immunohistochemistry test were performed. The examined section showed gastric mucosal epithelium with scarce intraepithelial lymphocytes (5-6 lymphocytes/100 cells). The surface epithelium had the tendency to roll away from the variable thickened stroma. The glandular architecture and chorion were modified by a nonspecific inflammatory infiltrate. A diagnose of chronic inactive gastritis with intestinal metaplasia areas was propose, and an expert opinion was requested. Digitally scanned sections using the Leica II Aperio slide scanner were taken. Examination of slides was made using the Imagescope12.2 Leica. Micrometeric measurements of the hyaline material varied between 9.5-51um. The review of glass slides on traditional optical microscope was made confirming the diagnosis. Results Collagenous gastritis remains an underestimated condition due to its low incidence and lack of expertise in the field. Hence telepathology becomes a useful tool for requesting a second opinion and precisions measurements.

Ketamine-Induced Crystalline Gastritis

Ketamine is an anesthetic agent commonly used for various pain syndromes. It is also a recreational drug. It is rarely prescribed orally because of its poor oral bioavailability. Oral dosages range from 0.5 mg/kg/day to 21 mg/kg/day based on the indication. A recent retrospective analysis reported gastropathy and gastritis in 80% of oral and inhalational ketamine users. A 27-year-old man with Mollaret's meningitis was admitted for intractable neuropathic pain; only parenteral ketamine provided symptomatic relief. He was later transitioned to oral ketamine, and prescribed up to 28 mg/kg/day for symptom control. One week later, he developed acute burning mid-epigastric pain and nausea. EGD revealed multiple “Band-Aid®”- like superficial plaques in the gastric cardia (Figure 1). Biopsy specimens showed active inflammation and deposits of clear refractile crystals in the gastric mucosa (Figure 2). Our clinical impression was ketamine-induced gastritis. Ketamine was discontinued and then reintroduced at 4 mg/kg/day. The patient's epigastric symptoms resolved. Three weeks later, a repeat EGD confirmed mucosal healing and absence of plaque. Biopsy specimens revealed inactive gastritis without crystalline deposition.Figure 1Figure 2This report is the first description in the literature of a crystalline-associated reactive gastritis in a patient on oral ketamine. The clinical features that support causality with ketamine include abrupt symptom onset with initiation of ketamine, lack of clinical or endoscopic features to suggest an alternative diagnosis, and prompt histologic and clinical resolution with cessation of ketamine. We speculate that crystalline-associated reactive gastritis is a dose-dependent phenomenon, as our patient was on a higher total dosage of oral ketamine than described in the literature. There were no excipients in the ketamine capsules that may have crystallized in vivo, suggesting ketamine crystallization was responsible for the patient's reactive gastritis. To investigate this hypothesis, we suspended a 5% solution of ketamine in normal saline. The specimen was examined under white light and polarizing light microscopy. Clear refractile crystals (Figure 3), similar to our patient's gastric biopsy specimen, were noted.Figure 3Our analysis strongly supports a case of ketamine-induced crystalline gastritis. Practitioners should be aware of this previously undescribed complication of oral ketamine.

Laboratory Diagnosis of Celiac Disease in Patients with Selective IgA Deficiency.

A 49-year-old woman presented to the emergency department complaining of nausea, vomiting, and epigastric pain for 3 days. The initial workup was consistent with acute pancreatitis (with increased serum amylase and lipase), for which she was treated with fluids, morphine, and supportive care. Past medical history was marked by gastroesophageal reflux disease and hypertension. She also admitted to heavy alcohol consumption. Her hemoglobin on admission was 8.7 g/dL (reference, 11.5–15.5 g/dL), which dropped to 6.3 g/dL during her stay, and she was transfused with 2 units of packed red blood cells. Review of the peripheral blood smear revealed mild hypochromia and microcytosis, but was otherwise unremarkable. The mean corpuscular volume was 73 fl (reference, 80–96 fl). The ferritin concentration was 5 ng/mL (reference, 10–150 ng/mL). The patient had been seen 2 years earlier for a routine visit, at which time her hemoglobin was 11.0 g/dL. An upper gastrointestinal endoscopy was performed 2 weeks after her discharge from the emergency department to rule out a potential source of bleeding. It revealed diffuse erythema and granularity in the stomach and a reduction of duodenal folds. Biopsies of the stomach revealed chronic inflammation consistent with inactive gastritis. Staining for Helicobacter pylori was negative. Biopsies of the duodenum revealed patchy areas of villus blunting with crypt …

Effect of Helicobacter pylori on NFKB1, p38α and TNF-α mRNA expression levels in human gastric mucosa.

Helicobacter pylori infects ~50% of the world population, causing chronic gastritis and other forms of cellular damage. The present study assessed the influence of H. pylori on the mRNA expression levels of nuclear factor-κB1 (NFKB1), p38α and tumor necrosis factor-α (TNF-α) in human gastric mucosa in a southern Brazilian population. Human gastric tissue was collected by upper endoscopy and H. pylori diagnosis was performed using a rapid urease test and histological analysis. Total RNA was extracted and purified for subsequent cDNA synthesis and analysis by quantitative polymerase chain reaction (qPCR). The gastric tissue samples were divided into four groups as follows: Normal, inactive chronic gastritis, active chronic gastritis and intestinal metaplasia. The SDHA gene was classified as the most stable when compared with ACTB, GAPDH, B2M and HPRT1 genes, and was therefore selected as the reference gene for qPCR data normalization. TNF-α mRNA expression was significantly higher in samples that were positive for H. pylori and with active chronic gastritis. However, no difference was detected in the mRNA expression levels of NFKB1 and p38α between the groups. The present study concluded that the presence of H. pylori is associated with TNF-α upregulation in human gastric mucosa, but had no effect on NFKB1 and p38α mRNA expression levels.

Tactile Corpuscle-like Bodies in Gastrointestinal-type Mucosa

Tactile corpuscle-like bodies (TCLB) are microscopic Schwannian structures that simulate the superficial mechanoreceptors of the peripheral nervous system (Wagner-Meissner corpuscles). They have been described nearly exclusively in peripheral nerve sheath tumors, namely diffuse neurofibromas, and schwannomas but also in cellular nevi. There are rare reports of these structures in the gastrointestinal tract (predominantly the lower tract), with the presumption that they are incidental reactive neural proliferations. We compiled 9 cases showing this rare phenomenon in gastrointestinal-type mucosa in nonsyndromic patients to further characterize its features. There were 6 men and 3 women (age range, 39 to 79 y, mean 56 y) with lesions involving esophagus/gastro-esophageal junction (n=7), sigmoid colon (n=1), and gastric heterotopia of the cricopharynx (n=1). Endoscopic examination was abnormal in 6 of the 7 cases (including changes consistent with Barrett esophagus and polypoid/nodular mucosa) and normal in 1 of 7 cases for which this information was available. The histologic features were similar in all cases, with unencapsulated clusters of lamellated and concentrically arranged spindle cells in the lamina propria. The foci of TCLB ranged in size from <0.1 to 1.5 mm in the greatest dimension. Abnormal histopathologic findings were identified in the background mucosa in 6 of 9 cases (including Barrett esophagus, active and inactive chronic gastritis, enterochromaffin-like cell hyperplasia, and gastric intestinal metaplasia). None of the patients showed signs of neurofibromatosis type 1, multiple endocrine neoplasia type 2B, Cowden syndrome, or other inherited syndrome. No morbidity related to TCLB was reported for the patients with available follow-up.

Autoimmune Metaplastic Atrophic Gastritis

Autoimmune metaplastic atrophic gastritis (AMAG) is a significant risk factor for pernicious anemia and gastric neoplasia. Still, the histologic features of AMAG are frequently overlooked, especially in the early stages of the disease. The purpose of our study, therefore, was to catalogue the progression of histologic changes that precede the development of AMAG in affected individuals. Over a 2-year period (2012 to 2014), the diagnosis of AMAG was rendered on material from 113 patients seen at Johns Hopkins Hospital (∼1.8% of "in house" gastric biopsies). Prior gastric body biopsies had been performed on 54 (48%) patients in the cohort, and the majority of these specimens had also shown AMAG. Eighteen of the previous biopsies, however, carried a diagnosis other than AMAG: 13 inactive chronic gastritis, 2 acute Helicobacter pylori gastritis, and 1 each of eosinophilic gastritis, iron pill gastritis, and proton-pump inhibitor-like effect. Upon review of these 18 biopsies, the most common histologic findings were heavy full-thickness or deep lamina propria chronic inflammation (12), inflammatory destruction of oxyntic glands (12), metaplasia (intestinal, pyloric, or pancreatic acinar) (10), prominent lamina propria eosinophils (8), and parietal cell pseudohypertrophy (4). At least 2 of these features were present in the majority (13, 72%) of the biopsies. In addition, 7 (58%) of these patients were also found to have another autoimmune or inflammatory disorder before the diagnosis of AMAG. Although subtle, histologic features of developing AMAG are identifiable in routine gastric body biopsies. When metaplasia, full-thickness chronic inflammation, and/or oxyntic destruction are seen, a note suggesting laboratory testing and/or close clinical follow-up in this subset of patients may be warranted.

Emphysematous Gastritis: A More Recognized Complication in Diabetic Patients

Emphysematous gastritis is a condition involving invasion of the gastric wall by gas-producing organisms. Previous relevant articles include case reports and a case review of 41 patients. Computed Tomography (CT) findings reveal a streaky and linear band of air with thickening of gastric wall in the setting of poorly controlled diabetes. Mortality can be as high as 62%, and early recognition with prompt delivery of broad-spectrum antibiotics is key in management. 24 year old white female presents with multiple admissions for abdominal pain. Medical history includes uncontrolled diabetes type 1, hypothyroidism, kidney disease, and prior peptic ulcer. CT Abdomen reveals extraluminal free intraperitoneal air in the left upper abdomen concerning for perforated ulcer. An EGD is performed, revealing an erythematous patch along the greater curvature. Biopsies show chronic inactive gastritis with mucosal hemorrhage without H. pylori. After 4 additional admissions within 60 days, a repeat CT Abdomen for abdominal pain reveals air in an edematous gastric wall with extensive intrahepatic portal venous gas. Meropenem is added, but there is persistence of abdominal pain and poor oral intake 18 days into admission. Repeat CT shows distended gastric lumen without wall thickening or definite pneumatosis. Repeat EGD shows a non-bleeding, 7x2cm necrotic ulcer in lesser curvature of stomach. Patient was taken to surgery for Roux-en-Y. Current knowledge of emphysematous gastritis is limited to case reports, with only one published textbook found. Predisposing factors include: diabetes, malignancy, alcohol, NSAID use, post-abdominal or pelvic surgery, and corrosive ingestion. Subsequent ischemia or necrosis permits gas-forming organisms to enter the gastric wall. CT findings include air presenting as streaky and linear consistency, which can be differentiated from gastric emphysema as the latter presents with round air bubbles. Management is geared by early recognition, broad spectrum antibiotics, and supportive care. Consider surgery when there is gastric perforation, or uncontrolled sepsis. The overall mortality is as high as 62%, and it is associated with gas-producing bacteria and fungi Emphysematous gastritis is a rare, but deadly complication in poorly controlled diabetic patients. Consider this condition when there is gastric thickening, linear or streaky air in wall on CT imaging. Management includes broad spectrum antibiotic and supportive care.