Difference between revisions of "Stomach"

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'''Stomach''' is an important organ for pathologists.  It is often inflammed and may be a site that cancer arises from.  Gastroenterologists often biopsy the organ.  Surgeon take-out the organ.
[[Image:Gray1051.png|thumb|300px|A drawing of the stomach.]]
'''Stomach''' is an important organ for pathologists.  It is often inflamed and may be a site that cancer arises from.  Gastroenterologists often biopsy the organ.  Surgeons take-out the organ.  It connects the [[esophagus]] to the [[duodenum]].  An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.


=Normal=
=Normal stomach=
==Gross anatomy==
==Gross anatomy==
*Cardia - first part of the stomach; joins with [[esophagus]].
*Cardia - first part of the stomach; joins with [[esophagus]].
Line 9: Line 10:
**[[AKA]] antrum.  
**[[AKA]] antrum.  


Image: [http://en.wikipedia.org/wiki/File:Illu_stomach.jpg Stomach anatomy (wikipedia.org)].
===Image===
<gallery>
Image:Illu_stomach.jpg | Stomach anatomy (WC)
</gallery>


==Microscopic==
==Microscopic==
===Foveolar cells vs. intestinal goblet cells===
===Foveolar cells versus intestinal goblet cells===
*Intestinal goblet cells - clear mucin.
*Intestinal goblet cells - clear mucin.
*Foveolar cells - eosinophilic contents.
*Foveolar cells - eosinophilic contents.


===Stomach vs. intestine<ref>ALS. 4 Feb 2009.</ref> <!-- I think this may be screwed-up -->===
===Stomach versus intestine===
{| class="wikitable"
A tabular comparison:<ref>ALS. 4 Feb 2009.</ref> <!-- I think this part may be screwed-up -->
|
{| class="wikitable sortable"
|'''Intestine'''
! Feature
|'''Stomach'''
! Intestine
! Stomach
|-
|-
|Spacing
|Spacing
Line 36: Line 41:
|PAS-D
|PAS-D
| -ve (???)
| -ve (???)
| +ve (???)
| +ve<ref>{{Cite journal  | last1 = Rubio | first1 = CA. | title = Gastric duodenal metaplasia in duodenal adenomas. | journal = J Clin Pathol | volume = 60 | issue = 6 | pages = 661-3 | month = Jun | year = 2007 | doi = 10.1136/jcp.2006.039388 | PMID = 16837629 | PMC = 1955048 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955048/ }}</ref>
|-
|-
|Villin stain<ref name=pmid2459839>{{cite journal |author=Osborn M, Mazzoleni G, Santini D, Marrano D, Martinelli G, Weber K |title=Villin, intestinal brush border hydrolases and keratin polypeptides in intestinal metaplasia and gastric cancer; an immunohistologic study emphasizing the different degrees of intestinal and gastric differentiation in signet ring cell carcinomas |journal=Virchows Arch A Pathol Anat Histopathol |volume=413 |issue=4 |pages=303–12 |year=1988 |pmid=2459839 |doi= |url=}}</ref>
|Villin stain<ref name=pmid2459839>{{cite journal |author=Osborn M, Mazzoleni G, Santini D, Marrano D, Martinelli G, Weber K |title=Villin, intestinal brush border hydrolases and keratin polypeptides in intestinal metaplasia and gastric cancer; an immunohistologic study emphasizing the different degrees of intestinal and gastric differentiation in signet ring cell carcinomas |journal=Virchows Arch A Pathol Anat Histopathol |volume=413 |issue=4 |pages=303–12 |year=1988 |pmid=2459839 |doi= |url=}}</ref><ref>{{Cite journal  | last1 = Braunstein | first1 = EM. | last2 = Qiao | first2 = XT. | last3 = Madison | first3 = B. | last4 = Pinson | first4 = K. | last5 = Dunbar | first5 = L. | last6 = Gumucio | first6 = DL. | title = Villin: A marker for development of the epithelial pyloric border. | journal = Dev Dyn | volume = 224 | issue = 1 | pages = 90-102 | month = May | year = 2002 | doi = 10.1002/dvdy.10091 | PMID = 11984877 }}</ref>
| +ve
| +ve
| -ve
| -ve
Line 44: Line 49:
|Images
|Images
|[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg Tubular adenoma - goblet<br> cells on right of image (WC)]
|[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg Tubular adenoma - goblet<br> cells on right of image (WC)]
|[http://www.microscopy-uk.org.uk/mag/imgaug01/Fig8.jpg Gastric biopsy (microscopy-uk.org.uk)]
|[http://www.microscopy-uk.org.uk/mag/imgaug01/Fig8.jpg Gastric biopsy (microscopy-uk.org.uk)], <br>[http://commons.wikimedia.org/wiki/File:Gastric_signet_ring_cell_carcinoma_histopatholgy_%282%29_PAS_stain.jpg Stomach with cancer - PAS (WC)], [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg Stomach (WC)]
|}
|}


Notes:
Notes:
*Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.<ref>Sternberg H4P 2nd Ed., P.484</ref>
*Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.<ref>Sternberg H4P 2nd Ed., P.484</ref>
*Memory device: '''F'''olveolar cells have '''f'''riends, i.e. they are close to other foveolar cells.
*Memory device: '''F'''oveolar cells have '''f'''riends, i.e. they are close to other foveolar cells.


Ref.
===Gastric antrum versus gastric body===
*PMID 11984877.
{| class="wikitable sortable"
 
! Cell
===Gastric antrum vs. gastric body===
! Body
{| class="wikitable"
! Antrum
|
! Histology
| '''Body'''
! Image
| '''Antrum'''
| '''Notes'''
| '''Image'''
|-
|-
| '''Parietal cells'''
| '''Parietal cell'''
| abundant
| abundant
| few or none
| few or none
| parietal cells: intensely<br> eosinophilic cytoplasm
| parietal cells: intensely<br> eosinophilic cytoplasm
| [http://commons.wikimedia.org/wiki/File:Parietal_cells.jpg], [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg]
| [[Image:Normal_gastric_mucosa_intermed_mag.jpg|thumb|center|60px|Parietal cells. (WC)]]
|-
|-
| '''Chief cells'''
| '''Chief cell'''
| present
| present
| absent
| absent
| chief cells: basophilic cytoplasm, <br>[[IHC]]: +ve for ''pepsinogen I''
| chief cells: basophilic cytoplasm, <br>[[IHC]]: +ve for ''pepsinogen I''
| [http://commons.wikimedia.org/wiki/File:Chief_cells.JPG]
| [[Image:Chief_cells.JPG|thumb|center|100px|Chief cells. (WC)]]
|-
|-
| '''G cells'''
| '''G cell'''
| absent
| absent
| present
| present
| fried egg appearance <br>(clear cytoplasm); look at high power,<br> IHC: +ve for ''gastrin''.
| fried egg appearance (clear cytoplasm,<br> round nucleus); look at high power - <br>usu. middle 1/3 of gland,<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm]. Accessed on: 3 December 2010.</ref><br> IHC: +ve for ''gastrin''.
| NEED IMAGE
| [[Image:G_cell_hyperplasia_-_very_high_mag.jpg|thumb|center|60px|G cell hyperplasia. (WC)]]
|-
|-
| '''Surface'''
| '''Surface'''
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| blunted villi
| blunted villi
| antrum is somewhat <br>duodenum-like
| antrum is somewhat <br>duodenum-like
| [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg body - flat]
| [[Image:Normal_gastric_mucosa_intermed_mag.jpg |thumb|center|60px|Body - flat. (WC)]]
|-
|-
| '''Gastric glands <br>/ mucosa'''
| '''Gastric glands <br>/ mucosa'''
Line 92: Line 94:
| [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg body - thick], [http://www.wjgnet.com/1007-9327/full/v16/i4/WJG-16-445-g001.htm body & antrum]
| [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg body - thick], [http://www.wjgnet.com/1007-9327/full/v16/i4/WJG-16-445-g001.htm body & antrum]
|}
|}
Notes:
*G cells may superficially resemble intraepithelial lymphocytes.
**G cell nucleus is usu. perfectly round and slightly larger (diameter of 12 micrometers?) than a lymphocyte nucleus (diameter ~ 9-10 micrometers?).
===Sign out===
====Short version====
<pre>
Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
</pre>
<pre>
Stomach, Biopsy:
- Body and antral-type gastric mucosa within normal limits.
</pre>
<pre>
Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
- NEGATIVE for Helicobacter-like organisms.
</pre>
=====Block letters=====
<pre>
STOMACH, BIOPSY:
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
</pre>
<pre>
STOMACH, BIOPSY:
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>
<pre>
STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>
====Long version====
<pre>
STOMACH, BIOPSY:
- BODY/ANTRAL-TYPE GASTRIC MUCOSA.
- INFLAMMATION: ABSENT.
- ATROPHY: ABSENT.
- INTESTINAL METAPLASIA: ABSENT.
- HELICOBACTER-LIKE ORGANISMS: NOT IDENTIFIED WITH ROUTINE STAINS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
====Sleeve gastrectomy====
{{Main|Sleeve gastrectomy}}


=Introduction=
=Introduction=
==Useful stains for stomach==
==Useful stains for stomach==
*Cresyl violet stain<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> - used to find H. pylori.<ref name=pmid10210995>{{cite journal |author=Goggin N, Rowland M, Imrie C, Walsh D, Clyne M, Drumm B |title=Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease |journal=Arch. Dis. Child. |volume=79 |issue=6 |pages=502-5 |year=1998 |month=December |pmid=10210995 |pmc=1717771 |doi= |url=http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=10210995}}</ref>
*[[Cresyl violet stain]]<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> - used to find H. pylori.<ref name=pmid10210995>{{cite journal |author=Goggin N, Rowland M, Imrie C, Walsh D, Clyne M, Drumm B |title=Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease |journal=Arch. Dis. Child. |volume=79 |issue=6 |pages=502-5 |year=1998 |month=December |pmid=10210995 |pmc=1717771 |doi= |url=http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=10210995}}</ref>
*Alcian blue - used to find mucin<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> which is present in intestinal metaplasia
*[[Alcian blue stain]] - used to find mucin<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> which is present in intestinal metaplasia
**Other mucins stains:<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> mucicarmine, PAS, PASD (doesn't stain glycogen)
**Other mucins stains:<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> mucicarmine, [[PAS]], [[PAS-D stain|PASD]] (doesn't stain glycogen)


==Things to look for...==
==Things to look for...==
Line 108: Line 163:
*Inflammation + small bacteria = suspect H. pylori gastritis.
*Inflammation + small bacteria = suspect H. pylori gastritis.


=Non-neoplastic disease=
=Some patterns=
==Gastritis==
==Gastric atrophy==
===Etiology===
===General===
A specific cause is uncommonly identified histologically.
*Has a wide differential diagnosis.
 
Gastritis causes:<ref name=Ref_PBoD812-3>{{Ref PBoD|812-3}}</ref>
*Infectious:
**H. pylori infection.
**Tuberculosis.
**Salmonellosis.
**CMV.
*Endocrine-related:
**Pernicious anemia.
**Diabetes - gastric atony.
*Trauma, e.g. NG tube.
*Vascular, ischemia.
*Autoimmune:
**Crohn's disease.
*Toxins:
**Alcohol.
**Medications (NSAIDS).
**Medications.
**Uremia.
**Smoking (heavy).
*Radiation.
 
===Endoscopic appearance===
*Erythematous.


===Microscopic===
===Microscopic===
*Inflammatory cells - in particular.
Can take three general forms:
**Neutrophils (active gastritis) - especially when intraepithelial, or
#Intestinal metaplasia - see ''intestinal metaplasia'' section.
**Plasma cells (in lamina propria).
#Pseudopyloric metaplasia; gastric body looks like gastric antrum.
***Various criteria:
#*Characterized by ''foveolar hyperplasia''.
***#Two plasma cells kissing, i.e. two plasma cells touching/overlapping.
#Cell loss without replacement.
***#Three is a crowd, i.e. three plasma cells in close proximity.
#*Clue is deep inflammation in the body.


===Sydney criteria for gastritis===
==Plasma cells in the stomach==
A bunch of pathologists in Sydney came-up with criteria... and these were revised in Houston.<ref name=pmid8827022>{{cite journal |author=Dixon MF, Genta RM, Yardley JH, Correa P |title=Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994 |journal=Am. J. Surg. Pathol. |volume=20 |issue=10 |pages=1161-81 |year=1996 |month=October |pmid=8827022 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=20&issue=10&spage=1161}}</ref>
DDx of plasmacytosis:
*[[Plasma cell neoplasm]].
*[[Syphilis]].
*Chronic [[gastritis]].


===Classification<ref name=pmid8827022/>===
==Granulomatous gastritis==
{| class="wikitable"
*Usual DDx of granulomatous disease (see ''[[Basics]]'' article):
| || '''Non-atrophic Helicobacter''' || '''Atrophic Helicobacter''' || '''Autoimmune'''
**DNF AAII:
|-
***Drugs, Neoplasms, Foreign body, Autoimmune, Allergic, Infectious, Idiopathic.
| Inflammation pattern || antral or diffuse || antrum & corpus, mild inflammation || corpus only
|-
| Atrophy & metaplasia || nil || atrophy present, metaplasia at incisura || corpus only
|-
|}
Notes:  
*''Corpus'' = gastric body.
*''Incisura'' = angular incisure, incisura angularis (Latin) - notched transition point on lesser curvature of the stomach between pylorus and body.<ref>[http://en.wikipedia.org/wiki/Angular_incisure http://en.wikipedia.org/wiki/Angular_incisure]</ref>


===Severity===
Important ones:
The Sydney group suggests grading severity with the following language:<ref name=pmid8827022/>
*Autoimmune - [[Crohn's disease]].
*Mild.
*Infectious - [[Tuberculosis]].
*Moderate.
*Idiopathic - [[Sarcoidosis]].
*Marked.


These terms are applied to the parameters described in a biopsy.  The Sydney criteria lists ''H. pylori'', ''neutrophils'', ''mononuclear cells'', ''antrum (atrophy)'', ''corpus (atrophy)'' and ''intestinal metaplasia''. The paper that discusses this also give a visual analogue scale.
=Non-neoplastic disease=
==Peptic ulcer disease==
*Abbreviated ''PUD''.
:For duodenal manifestations see ''[[Peptic duodenitis]]''.
===General===
*Benign.


Parameters & Severity (adapted from Dixon et al.<ref name=pmid8827022/>):
Complications:
{| class="wikitable"
*Hemorrhage.
| || '''Mild''' || '''Moderate''' || '''Marked'''
*Obstruction.
|-
*Perforation - can be fatal.
| H. pylori || few touching || many touching  || piles
|-
| Neutrophils || few || bunches  || crowded
|-
| Mononuclear cells || not touching || kissing  || partying
|-
|}


==Helicobacter gastritis==
Etiology - typically:<ref name=pmid19683340>{{Cite journal  | last1 = Malfertheiner | first1 = P. | last2 = Chan | first2 = FK. | last3 = McColl | first3 = KE. | title = Peptic ulcer disease. | journal = Lancet | volume = 374 | issue = 9699 | pages = 1449-61 | month = Oct | year = 2009 | doi = 10.1016/S0140-6736(09)60938-7 | PMID = 19683340 }}</ref>
===General===
*[[Helicobacter pylori]].
*Several Helicobacter species can cause gastritis; H. pylori most common


===Finding Helicobacter===
===Gross===
*Small - smaller than the nucleus of the gastric foveolar cell.
Features:
**On 400x they are still possible to miss.
*Typically in the [[duodenum]]; duodenum:stomach = ~4:1.
*Commonly have a "v" shape.
**Epithelial defect with punched-out edges (suggestive of a benign process).
*Look close to the opening of the gastric glands.
*Are often are found in groups.
*Location - can be antrum and/or body.<ref>{{cite journal |author=Maaroos HI, Kekki M, Villako K, Sipponen P, Tamm A, Sadeniemi L |title=The occurrence and extent of Helicobacter pylori colonization and antral and body gastritis profiles in an Estonian population sample |journal=Scand. J. Gastroenterol. |volume=25 |issue=10 |pages=1010-7 |year=1990 |month=October |pmid=2263873 |doi= |url=}}</ref>
*Helicobacter don't like the intestinal mucosa or mucosa that has undergone intestinal metaplasia -- you're unlikely to find 'em there.


Images:  
Note:
*[http://commons.wikimedia.org/wiki/File:Immunohistochemical_detection_of_Helicobacter_%281%29_histopatholgy.jpg H. pylori - IHC (WC)].
*Heaped edges - suggestive of [[stomach cancer|cancer]].
*Helicobacter gastritis:
**[http://commons.wikimedia.org/wiki/File:Gastritis_helicobacter_-_high_mag.jpg Gastritis due to HP (WC)].
**[http://commons.wikimedia.org/wiki/File:Gastritis_helicobacter_-_very_high_mag_cropped.jpg HP visible (WC)].
*[http://commons.wikimedia.org/wiki/Category:Helicobacter_gastritis Set of images - HP gastritis (WC)].


===Epidemiologic associations===
====Endoscopic image====
Helicobacter infections are associated with:<ref>{{Ref PBoD|814}}</ref>
<gallery>
*Gastritis.
Image:Deep_gastric_ulcer.png | Gastric ulcer. (WC)
*Peptic ulcers.
</gallery>
*Cancer.
**Carcinoma.
**[[MALT lymphoma]].


==Intestinal metaplasia==
===Microscopic===
===General===
Features:
*Often part of surgical pathology report, e.g. "negative for intestinal metaplasia" or "intestinal metaplasia present".
*Loss of epithelium.
*May be associated with Helicobacter spp. infection -- though Helicobacter don't like intestinal type mucosa, i.e. H. pylori are not typically found in regions with intestinal metaplasia.
*Inflammation.
*+/-Helicobacter organisms - ''see [[Helicobacter gastritis]]''.


====Significance====
==Gastritis==
*Moderate risk increase for carcinoma; risk less than for Barrett's esophagus.<ref name=pmid20203636>{{cite journal |author=Correa P, Piazuelo MB, Wilson KT |title=Pathology of gastric intestinal metaplasia: clinical implications |journal=Am. J. Gastroenterol. |volume=105 |issue=3 |pages=493–8 |year=2010 |month=March |pmid=20203636 |pmc=2895407 |doi=10.1038/ajg.2009.728 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2895407/?tool=pubmed}}</ref>
{{Main|Gastritis}}
{{Main|Chronic gastritis}}
{{Main|Acute gastritis}}


===Microscopy===
==Helicobacter gastritis==
Features:
{{Main|Helicobacter gastritis}}
*Goblet cells are present in the stomach.<ref>URL: [http://esynopsis.uchc.edu/eAtlas/GI/1280.htm http://esynopsis.uchc.edu/eAtlas/GI/1280.htm]. Accessed on: 16 August 2010.</ref>
**With cresyl violet vacuole [[stains]] blue.
**With H&E vacuole may stain greyish.


=Miscellaneous=
==Intestinal metaplasia of the stomach==
This is a grab bag of stuff seen in the stomach.  Some of it is quite rare.
{{Main|Intestinal metaplasia of the stomach}}
==Gastric antral vascular ectasia==
===General===
*Abbreviated ''GAVE''.
*Antrum lesion - due dilated capillaries.
*AKA ''watermelon stomach'' - due to characteristic endoscopic appearance.<ref name=pmid18625989>{{cite journal |author=Chatterjee S |title=Watermelon stomach |journal=CMAJ |volume=179 |issue=2 |pages=162 |year=2008 |month=July |pmid=18625989 |pmc=2443230 |doi=10.1503/cmaj.080461 |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=18625989}}</ref>


===Gross/endoscopic appearance===
==Inflammatory bowel disease and the stomach==
* Linear red streaks in antrum - oriented toward the pyloric valve... vaguely resembles a watermelon.
:See ''[[inflammatory bowel disease]]''.
*Histopathologic findings are usually non-specific.
*Conventional thinking ''was'' upper GI involvement = [[Crohn's disease]]; this is changing.<ref name=pmid20962621>{{cite journal |author=Lin J, McKenna BJ, Appelman HD |title=Morphologic findings in upper gastrointestinal biopsies of patients with ulcerative colitis: a controlled study |journal=Am. J. Surg. Pathol. |volume=34 |issue=11 |pages=1672–7 |year=2010 |month=November |pmid=20962621 |doi=10.1097/PAS.0b013e3181f3de93 |url=}}</ref>


Endoscopic images:  
===Endoscopic/gross===
*[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2443230&rendertype=figure&id=f1-19 Watermelon stomach (pubmedcentral.nih.gov)].
Features - Crohn's:<ref name=Ref_GLP80>{{Ref GLP|80}}</ref>
*[http://en.wikipedia.org/wiki/File:Gave.png GAVE (WP)].
*+/-Linear fissures, erosions, ulcers, cobblestoning.
*May mimic ''[[linitis plastica]]''.


===Microscopic===
===Microscopic===
Features:<ref>{{Ref GLP|118}}</ref>
Features:<ref>Kirsch R. 13 December 2010.</ref>
*Fibrin thrombi - '''characteristic feature'''.
*Focal inflammation.
*Dilated capillaries in lamina propria.
**Common finding - non-specific.
*+/-[[Granulomas]].


Images:
Note:
*[http://commons.wikimedia.org/wiki/File:Gastric_antral_vascular_ectasia_-_2_-_intermed_mag.jpg GAVE - intermed. mag. (WC)].
*Granulomas in Crohn's gastritis present 7-34% of the time.<ref name=Ref_GLP80>{{Ref GLP|80}}</ref>
*[http://commons.wikimedia.org/wiki/File:Gastric_antral_vascular_ectasia_-_2_-_very_high_mag.jpg GAVE - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Gastric_antral_vascular_ectasia_-_very_high_mag.jpg GAVE - two thrombi - very high mag. (WC)].


==Reactive gastropathy==
====Images====
===General===
<gallery>
*May be seen in the context of a previous resection/surgical reconstruction, e.g. Billroth II.
Image: Crohn's gastritis -- low mag.jpg | CG - low mag. (WC)
Image: Crohn's gastritis -- intermed mag.jpg | CG - intermed. mag. (WC)
Image: Crohn's gastritis -- high mag.jpg | CG - high mag. (WC)
Image: Crohn's gastritis -- very high mag.jpg | CG - very high mag. (WC)
</gallery>


====Epidemiology====
=Miscellaneous=
*Associated with...<ref>ALS. 5 February 2009.</ref>
This is a grab bag of stuff seen in the stomach.  Some of it is quite rare.
**Excess acid.
==Gastric antral vascular ectasia==
**EtOH.
{{Main|Gastric antral vascular ectasia}}
**Bile.
**H. pylori.
**Drug:
***Iron (brown pigment on histology).
***NSAIDs.


===Microscopic===
==Reactive gastropathy==
Features -triad:<ref>El-Zimaity. 18 October 2010.</ref>
{{Main|Reactive gastropathy}}
#Foveolar hyperplasia.
#*Tortuosity of glands in the "neck" region of the gastric glands.
#*Associated with "mucin depletion" - cytoplasm not clear -- as is usual.
#Smooth muscle fibre hyperplasia.
#*Abundant eosinophilic lamina propria.
#Scant acute & chronic inflammatory cells.


Notes:
==Autoimmune metaplastic atrophic gastritis==
*Triad rarely present.
*[[AKA]] ''autoimmune gastritis''.
{{Main|Autoimmune metaplastic atrophic gastritis}}


DDx:
==Collagenous gastritis==
*Amyloidosis.
{{Main|Collagenous gastritis}}
*Collagenous gastritis.


==Gastric atrophy==
==Gastritis cystitis profunda==
*[[AKA]] ''Gastritic cystica profunda''.{{fact}}
===General===
===General===
*Has a wide differential diagnosis.
*May be associated with glandular proliferation as well.<ref>URL: [http://www.springerlink.com/content/u2v2525241754557/ http://www.springerlink.com/content/u2v2525241754557/] Accessed on: 19 November 2010.</ref> (???)
*Super rare.
*Similar to ''[[cystitis cystica]]''.


===Microscopic===
===Microscopic===
Can take three general forms:
Features:
#Intestinal metaplasia - see ''intestinal metaplasia'' section.
*Cystic spaces lined by foveolar epithelium.
#Pseudopyloric metaplasia; gastric body looks like gastric antrum.
#*Characterized by ''foveolar hyperplasia''.
#Cell loss without replacement.
#*Clue is deep inflammation in the body.


==Lymphocytic gastritis==
==Ménétrier's disease==
===General===
{{Main|Ménétrier's disease}}
DDx:
*Celiac disease.
**Check [[duodenum]].
*H. pylori.
*HIV/AIDS.


===Microscopic===
==Gastric xanthoma==
Features:<ref>El-Zimaity. 18 October 2010.</ref>
*Abbreviated ''GX''.
*25 lymphocytes / 100 epithelial cells.
*[[AKA]] ''xanthelasma''.
*[[AKA]] ''stomach lipidosis''.
{{Main|Gastric xanthoma}}


==Pernicious anemia==
==Gastric ischemia==
:''Gastric necrosis'' redirects here.
===General===
===General===
*Gastric atrophy.
*Rare.
*Loss of parietal cells.
*May arise due to:
*Intrinsic factor antibodies present in serum.
**Small bowel obstruction.<ref name=pmid18209748>{{Cite journal  | last1 = Steen | first1 = S. | last2 = Lamont | first2 = J. | last3 = Petrey | first3 = L. | title = Acute gastric dilation and ischemia secondary to small bowel obstruction. | journal = Proc (Bayl Univ Med Cent) | volume = 21 | issue = 1 | pages = 15-7 | month = Jan | year = 2008 | doi =  | PMID = 18209748 | PMC = 2190544}}</ref>
**Intrinsic factor -- absorbs vitamin B12.
**Therapeutic embolization.<ref name=pmid22020717/>


===Microscopic===
===Microscopic===
Features:
Features:
*Corpus predominant inflammation.
*+/-Pseudomembrane formation.<ref name=pmid21360426>{{Cite journal  | last1 = Herman | first1 = J. | last2 = Chavalitdhamrong | first2 = D. | last3 = Jensen | first3 = DM. | last4 = Cortina | first4 = G. | last5 = Manuyakorn | first5 = A. | last6 = Jutabha | first6 = R. | title = The significance of gastric and duodenal histological ischemia reported on endoscopic biopsy. | journal = Endoscopy | volume = 43 | issue = 4 | pages = 365-8 | month = Apr | year = 2011 | doi = 10.1055/s-0030-1256040 | PMID = 21360426 }}</ref>
*Increased G cells in the antrum.
*[[Necrosis]] of the epithelium lining the gastric pits.
***Increased gastrin level to try and stimulate (missing) parietal cells.
 
Image:
*[https://www.thieme-connect.com/media/endoscopy/2011S02/097cl2.jpg Gastric necrosis (thieme-connect.com)].<ref name=pmid22020717>{{Cite journal  | last1 = Papanikolaou | first1 = IS. | last2 = Foukas | first2 = PG. | last3 = Sioulas | first3 = A. | last4 = Beintaris | first4 = I. | last5 = Panagopoulos | first5 = P. | last6 = Karamanolis | first6 = G. | last7 = Panayiotides | first7 = IG. | last8 = Dimitriadis | first8 = G. | last9 = Triantafyllou | first9 = K. | title = A case of gastric ischemic necrosis. | journal = Endoscopy | volume = 43 Suppl 2 UCTN | issue =  | pages = E342 | month =  | year = 2011 | doi = 10.1055/s-0030-1256795 | PMID = 22020717 }}</ref>


*See ''gastric atrophy'' section.
==Portal hypertensive gastropathy==
*Abbreviated ''PHG''.
{{Main|Portal hypertensive gastropathy}}


==Collagenous gastritis==
==Amyloidosis of the stomach==
*[[AKA]] ''gastric amyloidosis''.
{{Main|Amyloidosis}}
===General===
===General===
*Very rare.
*Very rare.
*Associated ''[[collagenous colitis]]''.
*Etiologies: various - see [[amyloidosis]].
 
===Gross/endoscopy===
*Red/swollen gastric folds.<ref name=pmid22863214>{{Cite journal  | last1 = Kamata | first1 = T. | last2 = Suzuki | first2 = H. | last3 = Yoshinaga | first3 = S. | last4 = Nonaka | first4 = S. | last5 = Fukagawa | first5 = T. | last6 = Katai | first6 = H. | last7 = Taniguchi | first7 = H. | last8 = Kushima | first8 = R. | last9 = Oda | first9 = I. | title = Localized gastric amyloidosis differentiated histologically from scirrhous gastric cancer using endoscopic mucosal resection: a case report. | journal = J Med Case Rep | volume = 6 | issue = 1 | pages = 231 | month =  | year = 2012 | doi = 10.1186/1752-1947-6-231 | PMID = 22863214 | PMC = 3438062 | URL = http://www.jmedicalcasereports.com/content/6/1/231 }} </ref>
 
Endoscopic DDx:
*[[Stomach cancer]].<ref name=pmid14606114>{{Cite journal  | last1 = Wu | first1 = D. | last2 = Lou | first2 = JY. | last3 = Chen | first3 = J. | last4 = Fei | first4 = L. | last5 = Liu | first5 = GJ. | last6 = Shi | first6 = XY. | last7 = Lin | first7 = HT. | title = A case report of localized gastric amyloidosis. | journal = World J Gastroenterol | volume = 9 | issue = 11 | pages = 2632-4 | month = Nov | year = 2003 | doi =  | PMID = 14606114 }}</ref><ref name=pmid22814919>{{Cite journal  | last1 = Sawada | first1 = T. | last2 = Adachi | first2 = Y. | last3 = Akino | first3 = K. | last4 = Arimura | first4 = Y. | last5 = Ishida | first5 = T. | last6 = Ishii | first6 = Y. | last7 = Endo | first7 = T. | title = Endoscopic features of primary amyloidosis of the stomach. | journal = Endoscopy | volume = 44 Suppl 2 UCTN | issue =  | pages = E275-6 | month =  | year = 2012 | doi = 10.1055/s-0032-1309750 | PMID = 22814919 | URL = https://www.thieme-connect.com/DOI/DOI?10.1055/s-0032-1309750 }}</ref>


===Microscopic===
===Microscopic===
Features:
Features:
*Eosinophilic material (collagen) expands lamina propria.
*Lamina propria expanded by amorphous paucicellular material.
**Band of collagen must be ~thick as RBC diameter.
***Proven by trichrome stain that highlights collagen.
 
==Granulomatous gastritis==
*Usual DDx of granulomatous disease (see ''[[Basics]]'' article):
**DNF AAII:
***Drugs, Neoplasms, Foreign body, Autoimmune, Allergic, Infectious, Idiopathic.


Important ones:
Image:
*Autoimmune - [[Crohn's disease]].
*[http://www.jmedicalcasereports.com/content/6/1/231/figure/F5 Stomach amyloidosis (jmedicalcasereports.com)].<ref name=pmid22863214/>
*Infectious - Tuberculosis.
*Idiopathic - Sarcoidosis.


==Miscellaneous==
===Stains===
*DDx of Plasmacytosis:
*[[Congo red stain]] +ve.
**[[Plasma cell dyscrasia]].
**[[Syphilis]].


==Gastritis cystitis profunda==
==Eosinophilic gastritis==
===General===
{{Main|Eosinophilic gastritis}}
*[[AKA]] ''Gastritic cystica profunda''. (???)
*May be assoc. with glandular proliferation as well.<ref>URL: [http://www.springerlink.com/content/u2v2525241754557/ http://www.springerlink.com/content/u2v2525241754557/] Accessed on: 19 November 2010.</ref> (???)
*Super rare.
*Similar to ''[[cystitis cystica]]''.


===Microscopic===
==Proton pump inhibitor effect==
Features:
*Abbreviated ''PPI effect''.
*Cystic spaces lined by foveolar epithelium.
{{Main|Proton pump inhibitor effect}}


=Gastric polyps=
=Gastric polyps=
Line 359: Line 354:
DDx polyp (similar to colon & rectum):
DDx polyp (similar to colon & rectum):
*Hyperplastic - most common, characterised by abundant elongated foveola + glands.
*Hyperplastic - most common, characterised by abundant elongated foveola + glands.
*Hamartomatous - weriod stuff.
*[[Hamartomatous polyps|Hamartomatous]] - weriod stuff.
*Inflammatory fibroid polyp - inflammation, myxoid stroma.
*[[Inflammatory fibroid polyp]] - inflammation, [[myxoid stroma]].
*Fundic gland polyp - cystic dilation, flat epithelium.
*[[Fundic gland polyp]] - cystic dilation, flat epithelium.
*Adenomatous polyp.
*[[Gastric adenoma]] - polypoid [[gastric dysplasia]].


==Hyperplastic polyp==
==Inflammatory fibroid polyp==
===Histology===
{{Main|Inflammatory fibroid polyp}}
Features:<ref>[http://pathologyoutlines.com/stomach.html#hyperplastic http://pathologyoutlines.com/stomach.html#hyperplastic]</ref>
*Abundant foveolar cells and elongated glands


Negatives:
==Hyperplastic polyp of the stomach==
*No atypical nuclei.
{{Main|Hyperplastic polyp of the stomach}}
*No hyperchromasia.
*No loss of pseudostratification.


===Links===
==Fundic gland polyp==
*[http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675(06)70277-7 Hyperplastic polyp image (pathconsultddx.com)].
{{Main|Fundic gland polyp}}


==Adenomatous polyps==
=Neoplastic=
Divided into 'gastric' and 'intestinal type'<ref>NEED ONE</ref>
The spectrum from benign to malignant is divided into five:<ref name=pmid10680883>{{Cite journal  | last1 = Rugge | first1 = M. | last2 = Correa | first2 = P. | last3 = Dixon | first3 = MF. | last4 = Hattori | first4 = T. | last5 = Leandro | first5 = G. | last6 = Lewin | first6 = K. | last7 = Riddell | first7 = RH. | last8 = Sipponen | first8 = P. | last9 = Watanabe | first9 = H. | title = Gastric dysplasia: the Padova international classification. | journal = Am J Surg Pathol | volume = 24 | issue = 2 | pages = 167-76 | month = Feb | year = 2000 | doi =  | PMID = 10680883 }}</ref>
#Benign.
#Indefinite for gastric epithelial dysplasia.
#Low-grade gastric epithelial dysplasia.
#High-grade gastric epithelial dysplasia.
#Gastric carcinoma.


===Histology===
==Gastric dysplasia==
*Type.
{{Main|Stomach adenoma}}
**Intestinal: goblet cells or Paneth cells.
**Gastric: foveolar epithelium. (???)
*Architectural crowding of glands.
*Hyperchromasia of cytoplasm.
*Nuclear changes:
**Loss of nuclear polarity.
**Incr. NC ratio.
**Elongation of nucleus.


==Fundic gland polyps==
==Gastric neuroendocrine tumour==
*[[AKA]] ''neuroendocrine tumour of the stomach'' and ''gastric NET''.
===General===
===General===
*''Fundic'' location - duh!
*Behaviour dependent on the subtype.
 
*Uncommon.
====Clinical significance====
*Weak association with [[FAP]] (Familial Adenomatous Polyposis).<ref>{{cite journal |author=Freeman HJ |title=Proton pump inhibitors and an emerging epidemic of gastric fundic gland polyposis |journal=World J. Gastroenterol. |volume=14 |issue=9 |pages=1318-20 |year=2008 |month=March |pmid=18322941 |doi= |url=http://www.wjgnet.com/1007-9327/14/1318.asp}}</ref>
*Associated with chronic proton pump inhibitors (PPI) use -- approximately 4x risk.<ref>{{cite journal |author=Jalving M, Koornstra JJ, Wesseling J, Boezen HM, DE Jong S, Kleibeuker JH |title=Increased risk of fundic gland polyps during long-term proton pump inhibitor therapy |journal=Aliment. Pharmacol. Ther. |volume=24 |issue=9 |pages=1341-8 |year=2006 |month=November |pmid=17059515 |doi=10.1111/j.1365-2036.2006.03127.x |url=}}</ref>
 
Notes:
*Animal studies suggested PPIs cause [[neuroendocrine tumour]]s -- but this has not been found in humans.<ref>{{cite journal |author=Masaoka T, Suzuki H, Hibi T |title=Gastric epithelial cell modality and proton pump inhibitor |journal=J Clin Biochem Nutr |volume=42 |issue=3 |pages=191-6 |year=2008 |month=May |pmid=18545640 |pmc=2386521 |doi=10.3164/jcbn.2008028 |url=}}</ref>
 
===Microscopic===
Features:<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A2B001-PQ01-M.htm http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A2B001-PQ01-M.htm]. Accessed on: 19 October 2010.</ref>
*Polypoid shape (may not be appreciated on microscopy).
*Dilated gastric glands.
**Flatted epithelial lining (consisting of normal foveolar epithelium) - '''key feature'''.
 
Image:
*[http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/A2B001-PQ01-M.htm Fundic gland polyp (ouhsc.edu)].


====Overview of subtypes====
Divided into four types:<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/StomachNET_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/StomachNET_11protocol.pdf]. Accessed on: 29 March 2012.</ref>
{| class="wikitable sortable"
!Tumour type
!Relative prevalence
!Multifocality
!Tumour size
!Typical location
!Clinical
!Other
!Histology
|-
|Type 1
| ~75%
| yes
| small (5-10 mm)
| body
| benign typically, female:male ~ 4:1, 50-60 years
| chronic atrophic gastritis - usu. autoimmune
| WDNET, WDNEC
|-
|Type 2
| rare
| yes
| small ~15 mm
| body
| aggressive, ~50 years old
| assoc. [[MEN I]], hyperchlorhydia
| WDNEC, WDNET
|-
|Type 3
| 10-15%
| no
| small and large
| variable location
| aggressive if >2.0 cm, males > females
| normal gastrin levels
| WDNET
|-
|Type 4
| extremely rare
| no
| large
| variable location
| aggressive (mets usu. at time of Dx), males > females
| elevated gastrin d/t parietal cell dysfunction
| PDNEC
|-
|}
Notes:
Notes:
*The presence of dysplastic changes should prompt consideration of ''FAP''.
*WDNET = well-differentiated neuroendocrine tumour.
 
*WDNEC = well-differentiated neuroendocrine carcinoma.
=Neoplastic=
*PDNEC = poorly-differentiated neuroendocrine carinoma.
==Gastric dysplasia==
===General===
*Criteria similar to those in adenomatous colonic polyps - see ''Microscopic''.
*Divided into:
**Low grade.  
**High grade.
***Nuclei no longer stratified.  


===Microscopic===
===Microscopic===
*Nuclear changes.
:''See [[neuroendocrine tumours]]''
**Nuclear crowding/pseudostratification.
**Elongation of nuclei (cigar-shaped nuclei).
*Cytoplasm - hyperchromatic.
*Mitosis - particularily above the basement membrane.
 
Image: [http://commons.wikimedia.org/wiki/File:Gastric_adenoma_(2).jpg Gastric adenoma (WC)].


=Neoplastic rare=
=Neoplastic rare=
==Gastric calcifying fibrous tumour==
==Gastric calcifying fibrous tumour==
===General===
{{Main|Calcifying fibrous tumour}}
*Rare.
*Benign.
 
===Microscopic===
Features:<ref name=pmid16858502>{{cite journal |author=Attila T, Chen D, Gardiner GW, Ptak TW, Marcon NE |title=Gastric calcifying fibrous tumor |journal=Can. J. Gastroenterol. |volume=20 |issue=7 |pages=487–9 |year=2006 |month=July |pmid=16858502 |pmc=2659917 |doi= |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659917/}}</ref>
*Submucosal circumscribed fibrocollagenous nodule.
*Psammomatous calcifications.
*Focal plasma cells at the periphery.


=Gastric cancer=
=Gastric cancer=
*GIST (see ''[[gastrointestinal stromal tumour]]'').
*[[Gastrointestinal stromal tumour]] (GIST).
*Adenocarcinoma.
*[[Gastric adenocarcinoma]].
*MALT lymphoma.
*[[MALT lymphoma]].


==Gastric lymphoma==
==Gastric lymphoma==
Line 459: Line 461:
Features:
Features:
*Sheets of lymphoid cells.
*Sheets of lymphoid cells.
*"Lymphoepithelial lesion" - gastric crypts invaded by a monomorphous population of lymphocytes.<ref>DB. 6 August 2010.</ref>
*"[[Lymphoepithelial lesion]]" - gastric crypts invaded by a monomorphous population of lymphocytes.<ref>Bailey, D. 6 August 2010.</ref>
**Features:
**Features:
**# Cluster of lymphocytes - three cells or more - '''key feature'''.
**# Cluster of lymphocytes - three cells or more - '''key feature'''.
Line 466: Line 468:
**Associated with MALT lymphoma;<ref name=pmid1452124>{{Cite journal  | last1 = Papadaki | first1 = L. | last2 = Wotherspoon | first2 = AC. | last3 = Isaacson | first3 = PG. | title = The lymphoepithelial lesion of gastric low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT): an ultrastructural study. | journal = Histopathology | volume = 21 | issue = 5 | pages = 415-21 | month = Nov | year = 1992 | doi =  | PMID = 1452124 }}</ref> however, not specific.
**Associated with MALT lymphoma;<ref name=pmid1452124>{{Cite journal  | last1 = Papadaki | first1 = L. | last2 = Wotherspoon | first2 = AC. | last3 = Isaacson | first3 = PG. | title = The lymphoepithelial lesion of gastric low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT): an ultrastructural study. | journal = Histopathology | volume = 21 | issue = 5 | pages = 415-21 | month = Nov | year = 1992 | doi =  | PMID = 1452124 }}</ref> however, not specific.


===IHC - work-up===
DDx:
*Reactive lymphoid hyperplasia.
*[[Syphilis]].<ref name=pmid20021615>{{Cite journal  | last1 = Kim | first1 = K. | last2 = Kim | first2 = EJ. | last3 = Kim | first3 = MJ. | last4 = Song | first4 = HJ. | last5 = Lee | first5 = YS. | last6 = Jung | first6 = KW. | last7 = Yu | first7 = E. | title = Clinicopathological features of syphilitic gastritis in Korean patients. | journal = Pathol Int | volume = 59 | issue = 12 | pages = 884-9 | month = Dec | year = 2009 | doi = 10.1111/j.1440-1827.2009.02462.x | PMID = 20021615 }}</ref><ref name=pmid7661178>{{Cite journal  | last1 = Long | first1 = BW. | last2 = Johnston | first2 = JH. | last3 = Wetzel | first3 = W. | last4 = Flowers | first4 = RH. | last5 = Haick | first5 = A. | title = Gastric syphilis: endoscopic and histological features mimicking lymphoma. | journal = Am J Gastroenterol | volume = 90 | issue = 9 | pages = 1504-7 | month = Sep | year = 1995 | doi =  | PMID = 7661178 }}</ref>
 
===IHC===
*Panker -- most useful.
*Panker -- most useful.


Others:
Others:
*CD3, CD20, CD138, kappa, lambda, BCL2.
*CD3 (T cells) - scatter positivity.
*[[CD20]] (B cells) +ve.
*CD138 (plasma cells).
*kappa, lambda -- often one is predominant, suggesting clonality.
*BCL2 +ve.


===Treatment===
===Treatment===
Line 478: Line 488:
Review paper: PMID 16950858.
Review paper: PMID 16950858.


==Gastric adenocarcinoma==
==Hereditary gastric cancer==
===General===
Several syndromes are associated with gastric cancer:<ref>{{Cite journal  | last1 = Sereno | first1 = M. | last2 = Aguayo | first2 = C. | last3 = Guillén Ponce | first3 = C. | last4 = Gómez-Raposo | first4 = C. | last5 = Zambrana | first5 = F. | last6 = Gómez-López | first6 = M. | last7 = Casado | first7 = E. | title = Gastric tumours in hereditary cancer syndromes: clinical features, molecular biology and strategies for prevention. | journal = Clin Transl Oncol | volume = 13 | issue = 9 | pages = 599-610 | month = Sep | year = 2011 | doi = | PMID = 21865131 }}</ref>
*Two different classification schemes.
{| class="wikitable sortable"
**Lauren<ref name=pmid14320675>{{cite journal |author=LAUREN P |title=THE TWO HISTOLOGICAL MAIN TYPES OF GASTRIC CARCINOMA: DIFFUSE AND  SO-CALLED INTESTINAL-TYPE CARCINOMA. AN ATTEMPT AT A HISTO-CLINICAL CLASSIFICATION |journal=Acta Pathol Microbiol Scand |volume=64 |issue= |pages=31–49 |year=1965 |pmid=14320675 |doi= |url=}}</ref> - two types:
! Disease
***Intestinal type (mass forming).
! Gene
***Diffuse type (infiltrative).
! Histology
**WHO classification - 6 subtypes for adenocarcinoma (papillary, tubular, mucinous, signet-rign, undifferentiated, adenosquamous).<ref name=Ref_PBoD823>{{Ref PBoD |823}}</ref>
! Other
 
|-
===Epidemiology===
| [[Hereditary diffuse gastric cancer syndrome|Hereditary diffuse gastric cancer (HDGC) syndrome]]
*Associated with helicobacter infections.
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
*Prognosis is often poor as it is discovered at a late stage.
| diffuse - more specifically [[signet ring cell carcinoma]]
*Higher prevalence in countries in the far east (e.g. Japan) - thought to be environmental, e.g. diet.
| most important; assoc. [[invasive lobular carcinoma]]<ref name=pmid9537325>{{Cite journal  | last1 = Guilford | first1 = P. | last2 = Hopkins | first2 = J. | last3 = Harraway | first3 = J. | last4 = McLeod | first4 = M. | last5 = McLeod | first5 = N. | last6 = Harawira | first6 = P. | last7 = Taite | first7 = H. | last8 = Scoular | first8 = R. | last9 = Miller | first9 = A. | title = E-cadherin germline mutations in familial gastric cancer. | journal = Nature | volume = 392 | issue = 6674 | pages = 402-5 | month = Mar | year = 1998 | doi = 10.1038/32918 | PMID = 9537325 }}</ref>
 
|-
===Microscopy===
| [[Lynch syndrome]]
*Adenocarcinoma - gland-forming lesion.
| MSH2, MLH1, others
*Signet ring carcinoma.
| ?
| colorectal carcinoma, endometrial carcinoma
|-
| [[Familial adenomatous polyposis]]
| APC
| ?
| adenomatous polyps
|-
| [[Peutz-Jeghers syndrome]]
| STK11
| ?
| stomach hamartomas - not precursor
|-
| [[Li-Fraumeni syndrome]]
| TP53 (p53)
| ?
| [[AKA]] SBLA syndrome = sarcomas, breast, brain, leukemia, laryngeal, lung, adrenocortical carcinoma
|-
| Familial breast and ovarian cancer 2<ref name=omim600185>{{OMIM|600185}}</ref>
| [[BRCA2]]
| ?
| ?
|}


===Treatment===
==Gastric carcinoma==
*Surgical excision.
:Includes ''gastric adenocarcinoma''.
**Proximal tumours may require a complete gastrectomy as the stomach is innervated from its proximal part.
{{Main|Gastric carcinoma}}


=See also=
=See also=
*[[Esophagus]].
*[[Esophagus]].
*[[Duodenum]].
*[[Granulation tissue]].
*[[Intestinal polyps]].
*[[Intestinal polyps]].
*[[Duodenum]].


=References=
=References=

Latest revision as of 15:51, 26 January 2022

A drawing of the stomach.

Stomach is an important organ for pathologists. It is often inflamed and may be a site that cancer arises from. Gastroenterologists often biopsy the organ. Surgeons take-out the organ. It connects the esophagus to the duodenum. An introduction to gastrointestinal pathology is in the gastrointestinal pathology article.

Normal stomach

Gross anatomy

  • Cardia - first part of the stomach; joins with esophagus.
  • Fundus - superior portion - not attached directly to the esophagus.
  • Body - contains parietal cells.
  • Pylorus - distal (think pyloric stenosis); it joins with the duodenum.

Image

  • Stomach anatomy (WC)

Microscopic

Foveolar cells versus intestinal goblet cells

  • Intestinal goblet cells - clear mucin.
  • Foveolar cells - eosinophilic contents.

Stomach versus intestine

A tabular comparison:[1]

Feature Intestine Stomach
Spacing Goblets cell - spaced Foveolar cells - beside one another
Morphology of epithelial cells columnar tall columnar (Champagne flute)
Vesicle at luminal surface touching/small opening wide open
PAS-D -ve (???) +ve[2]
Villin stain[3][4] +ve -ve
Images Tubular adenoma - goblet
cells on right of image (WC) 		Gastric biopsy (microscopy-uk.org.uk),
Stomach with cancer - PAS (WC), Stomach (WC)

Notes:

  • Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.[5]
  • Memory device: Foveolar cells have friends, i.e. they are close to other foveolar cells.

Gastric antrum versus gastric body

Cell Body Antrum Histology Image
Parietal cell abundant few or none parietal cells: intensely
eosinophilic cytoplasm
Parietal cells. (WC)
Chief cell present absent chief cells: basophilic cytoplasm,
IHC: +ve for pepsinogen I
Chief cells. (WC)
G cell absent present fried egg appearance (clear cytoplasm,
round nucleus); look at high power -
usu. middle 1/3 of gland,[6]
IHC: +ve for gastrin.
G cell hyperplasia. (WC)
Surface flat blunted villi antrum is somewhat
duodenum-like
Body - flat. (WC)
Gastric glands
/ mucosa 		thick thin not so useful for
discrimination 		body - thick, body & antrum

Notes:

  • G cells may superficially resemble intraepithelial lymphocytes.
    • G cell nucleus is usu. perfectly round and slightly larger (diameter of 12 micrometers?) than a lymphocyte nucleus (diameter ~ 9-10 micrometers?).

Sign out

Short version

Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.

Stomach, Biopsy:
- Body and antral-type gastric mucosa within normal limits.

Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
- NEGATIVE for Helicobacter-like organisms.
Block letters
STOMACH, BIOPSY:
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.

STOMACH, BIOPSY:
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.

STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.

Long version

STOMACH, BIOPSY:
- BODY/ANTRAL-TYPE GASTRIC MUCOSA.
- INFLAMMATION: ABSENT.
- ATROPHY: ABSENT.
- INTESTINAL METAPLASIA: ABSENT.
- HELICOBACTER-LIKE ORGANISMS: NOT IDENTIFIED WITH ROUTINE STAINS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Sleeve gastrectomy

Main article: Sleeve gastrectomy

Introduction

Useful stains for stomach

Things to look for...

  • Parietal cells (indicate you're in the body of the stomach) - pink (eosinophilic) cytoplasm.
    • Lack of parietal cells -- DDx: Bx of antrum (pylorus), Bx of cardia, pernicious anemia.
  • Goblet cells = intestinal metaplasia.
  • Architectural distortion of gastric glands - suspect cancer.
  • Signet ring cells = (usually) gastric carcinoma.
    • Can be very easy to miss in some biopsies.
  • Inflammation + small bacteria = suspect H. pylori gastritis.

Some patterns

Gastric atrophy

General

  • Has a wide differential diagnosis.

Microscopic

Can take three general forms:

  1. Intestinal metaplasia - see intestinal metaplasia section.
  2. Pseudopyloric metaplasia; gastric body looks like gastric antrum.
    • Characterized by foveolar hyperplasia.
  3. Cell loss without replacement.
    • Clue is deep inflammation in the body.

Plasma cells in the stomach

DDx of plasmacytosis:

Granulomatous gastritis

  • Usual DDx of granulomatous disease (see Basics article):
    • DNF AAII:
      • Drugs, Neoplasms, Foreign body, Autoimmune, Allergic, Infectious, Idiopathic.

Important ones:

Non-neoplastic disease

Peptic ulcer disease

  • Abbreviated PUD.
For duodenal manifestations see Peptic duodenitis.

General

  • Benign.

Complications:

  • Hemorrhage.
  • Obstruction.
  • Perforation - can be fatal.

Etiology - typically:[11]

Gross

Features:

  • Typically in the duodenum; duodenum:stomach = ~4:1.
    • Epithelial defect with punched-out edges (suggestive of a benign process).

Note:

  • Heaped edges - suggestive of cancer.

Endoscopic image

  • Gastric ulcer. (WC)

Microscopic

Features:

Gastritis

Main article: Gastritis
Main article: Chronic gastritis
Main article: Acute gastritis

Helicobacter gastritis

Main article: Helicobacter gastritis

Intestinal metaplasia of the stomach

Main article: Intestinal metaplasia of the stomach

Inflammatory bowel disease and the stomach

See inflammatory bowel disease.
  • Histopathologic findings are usually non-specific.
  • Conventional thinking was upper GI involvement = Crohn's disease; this is changing.[12]

Endoscopic/gross

Features - Crohn's:[13]

  • +/-Linear fissures, erosions, ulcers, cobblestoning.
  • May mimic linitis plastica.

Microscopic

Features:[14]

  • Focal inflammation.
    • Common finding - non-specific.
  • +/-Granulomas.

Note:

  • Granulomas in Crohn's gastritis present 7-34% of the time.[13]

Images

  • CG - low mag. (WC)

  • CG - intermed. mag. (WC)

  • CG - high mag. (WC)

  • CG - very high mag. (WC)

Miscellaneous

This is a grab bag of stuff seen in the stomach. Some of it is quite rare.

Gastric antral vascular ectasia

Main article: Gastric antral vascular ectasia

Reactive gastropathy

Main article: Reactive gastropathy

Autoimmune metaplastic atrophic gastritis

  • AKA autoimmune gastritis.
Main article: Autoimmune metaplastic atrophic gastritis

Collagenous gastritis

Main article: Collagenous gastritis

Gastritis cystitis profunda

General

  • May be associated with glandular proliferation as well.[15] (???)
  • Super rare.
  • Similar to cystitis cystica.

Microscopic

Features:

  • Cystic spaces lined by foveolar epithelium.

Ménétrier's disease

Main article: Ménétrier's disease

Gastric xanthoma

  • Abbreviated GX.
  • AKA xanthelasma.
  • AKA stomach lipidosis.
Main article: Gastric xanthoma

Gastric ischemia

Gastric necrosis redirects here.

General

  • Rare.
  • May arise due to:
    • Small bowel obstruction.[16]
    • Therapeutic embolization.[17]

Microscopic

Features:

  • +/-Pseudomembrane formation.[18]
  • Necrosis of the epithelium lining the gastric pits.

Image:

Portal hypertensive gastropathy

  • Abbreviated PHG.
Main article: Portal hypertensive gastropathy

Amyloidosis of the stomach

  • AKA gastric amyloidosis.
Main article: Amyloidosis

General

Gross/endoscopy

  • Red/swollen gastric folds.[19]

Endoscopic DDx:

Microscopic

Features:

  • Lamina propria expanded by amorphous paucicellular material.

Image:

Stains

Eosinophilic gastritis

Main article: Eosinophilic gastritis

Proton pump inhibitor effect

  • Abbreviated PPI effect.
Main article: Proton pump inhibitor effect

Gastric polyps

Similar to colonic polyps - see intestinal polyps.

DDx polyp (similar to colon & rectum):

Inflammatory fibroid polyp

Main article: Inflammatory fibroid polyp

Hyperplastic polyp of the stomach

Main article: Hyperplastic polyp of the stomach

Fundic gland polyp

Main article: Fundic gland polyp

Neoplastic

The spectrum from benign to malignant is divided into five:[22]

  1. Benign.
  2. Indefinite for gastric epithelial dysplasia.
  3. Low-grade gastric epithelial dysplasia.
  4. High-grade gastric epithelial dysplasia.
  5. Gastric carcinoma.

Gastric dysplasia

Main article: Stomach adenoma

Gastric neuroendocrine tumour

  • AKA neuroendocrine tumour of the stomach and gastric NET.

General

  • Behaviour dependent on the subtype.
  • Uncommon.

Overview of subtypes

Divided into four types:[23]

Tumour type Relative prevalence Multifocality Tumour size Typical location Clinical Other Histology
Type 1 ~75% yes small (5-10 mm) body benign typically, female:male ~ 4:1, 50-60 years chronic atrophic gastritis - usu. autoimmune WDNET, WDNEC
Type 2 rare yes small ~15 mm body aggressive, ~50 years old assoc. MEN I, hyperchlorhydia WDNEC, WDNET
Type 3 10-15% no small and large variable location aggressive if >2.0 cm, males > females normal gastrin levels WDNET
Type 4 extremely rare no large variable location aggressive (mets usu. at time of Dx), males > females elevated gastrin d/t parietal cell dysfunction PDNEC

Notes:

  • WDNET = well-differentiated neuroendocrine tumour.
  • WDNEC = well-differentiated neuroendocrine carcinoma.
  • PDNEC = poorly-differentiated neuroendocrine carinoma.

Microscopic

See neuroendocrine tumours

Neoplastic rare

Gastric calcifying fibrous tumour

Main article: Calcifying fibrous tumour

Gastric cancer

Gastric lymphoma

Main article: MALT lymphoma

General

  • Associated with helicobacter infection.[24]
  • Usually MALT lymphoma (mucosa-associated lymphoid tissue lymphoma).

Microscopic

Features:

  • Sheets of lymphoid cells.
  • "Lymphoepithelial lesion" - gastric crypts invaded by a monomorphous population of lymphocytes.[25]
    • Features:
      1. Cluster of lymphocytes - three cells or more - key feature.
        • Single lymphocytes don't count.
      2. Clearing around the lymphocyte cluster.
    • Associated with MALT lymphoma;[26] however, not specific.

DDx:

IHC

  • Panker -- most useful.

Others:

  • CD3 (T cells) - scatter positivity.
  • CD20 (B cells) +ve.
  • CD138 (plasma cells).
  • kappa, lambda -- often one is predominant, suggesting clonality.
  • BCL2 +ve.

Treatment

  • Triple therapy (two antibiotics, proton pump inhibitor (PPI)).[29]
  • Surgery - if triple therapy fails.

Review paper: PMID 16950858.

Hereditary gastric cancer

Several syndromes are associated with gastric cancer:[30]

Disease Gene Histology Other
Hereditary diffuse gastric cancer (HDGC) syndrome CDH1 (E-cadherin)[31] diffuse - more specifically signet ring cell carcinoma most important; assoc. invasive lobular carcinoma[32]
Lynch syndrome MSH2, MLH1, others ? colorectal carcinoma, endometrial carcinoma
Familial adenomatous polyposis APC ? adenomatous polyps
Peutz-Jeghers syndrome STK11 ? stomach hamartomas - not precursor
Li-Fraumeni syndrome TP53 (p53) ? AKA SBLA syndrome = sarcomas, breast, brain, leukemia, laryngeal, lung, adrenocortical carcinoma
Familial breast and ovarian cancer 2[33] BRCA2 ? ?

Gastric carcinoma

Includes gastric adenocarcinoma.
Main article: Gastric carcinoma

See also

References

  1. ↑ ALS. 4 Feb 2009.
  2. ↑ Rubio, CA. (Jun 2007). "Gastric duodenal metaplasia in duodenal adenomas.". J Clin Pathol 60 (6): 661-3. doi:10.1136/jcp.2006.039388. PMC 1955048. PMID 16837629. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955048/.
  3. ↑ Osborn M, Mazzoleni G, Santini D, Marrano D, Martinelli G, Weber K (1988). "Villin, intestinal brush border hydrolases and keratin polypeptides in intestinal metaplasia and gastric cancer; an immunohistologic study emphasizing the different degrees of intestinal and gastric differentiation in signet ring cell carcinomas". Virchows Arch A Pathol Anat Histopathol 413 (4): 303–12. PMID 2459839.
  4. ↑ Braunstein, EM.; Qiao, XT.; Madison, B.; Pinson, K.; Dunbar, L.; Gumucio, DL. (May 2002). "Villin: A marker for development of the epithelial pyloric border.". Dev Dyn 224 (1): 90-102. doi:10.1002/dvdy.10091. PMID 11984877.
  5. ↑ Sternberg H4P 2nd Ed., P.484
  6. ↑ URL: http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm. Accessed on: 3 December 2010.
  7. ↑ http://www.histology-world.com/stains/stains.htm
  8. ↑ Goggin N, Rowland M, Imrie C, Walsh D, Clyne M, Drumm B (December 1998). "Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease". Arch. Dis. Child. 79 (6): 502-5. PMC 1717771. PMID 10210995. http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=10210995.
  9. ↑ http://www.histology-world.com/stains/stains.htm
  10. ↑ http://www.histology-world.com/stains/stains.htm
  11. ↑ Malfertheiner, P.; Chan, FK.; McColl, KE. (Oct 2009). "Peptic ulcer disease.". Lancet 374 (9699): 1449-61. doi:10.1016/S0140-6736(09)60938-7. PMID 19683340.
  12. ↑ Lin J, McKenna BJ, Appelman HD (November 2010). "Morphologic findings in upper gastrointestinal biopsies of patients with ulcerative colitis: a controlled study". Am. J. Surg. Pathol. 34 (11): 1672–7. doi:10.1097/PAS.0b013e3181f3de93. PMID 20962621.
  13. ↑ 13.0 13.1 Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 80. ISBN 978-0443066573.
  14. ↑ Kirsch R. 13 December 2010.
  15. ↑ URL: http://www.springerlink.com/content/u2v2525241754557/ Accessed on: 19 November 2010.
  16. ↑ Steen, S.; Lamont, J.; Petrey, L. (Jan 2008). "Acute gastric dilation and ischemia secondary to small bowel obstruction.". Proc (Bayl Univ Med Cent) 21 (1): 15-7. PMC 2190544. PMID 18209748. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190544/.
  17. ↑ 17.0 17.1 Papanikolaou, IS.; Foukas, PG.; Sioulas, A.; Beintaris, I.; Panagopoulos, P.; Karamanolis, G.; Panayiotides, IG.; Dimitriadis, G. et al. (2011). "A case of gastric ischemic necrosis.". Endoscopy 43 Suppl 2 UCTN: E342. doi:10.1055/s-0030-1256795. PMID 22020717.
  18. ↑ Herman, J.; Chavalitdhamrong, D.; Jensen, DM.; Cortina, G.; Manuyakorn, A.; Jutabha, R. (Apr 2011). "The significance of gastric and duodenal histological ischemia reported on endoscopic biopsy.". Endoscopy 43 (4): 365-8. doi:10.1055/s-0030-1256040. PMID 21360426.
  19. ↑ 19.0 19.1 Kamata, T.; Suzuki, H.; Yoshinaga, S.; Nonaka, S.; Fukagawa, T.; Katai, H.; Taniguchi, H.; Kushima, R. et al. (2012). "Localized gastric amyloidosis differentiated histologically from scirrhous gastric cancer using endoscopic mucosal resection: a case report.". J Med Case Rep 6 (1): 231. doi:10.1186/1752-1947-6-231. PMC 3438062. PMID 22863214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3438062/.
  20. ↑ Wu, D.; Lou, JY.; Chen, J.; Fei, L.; Liu, GJ.; Shi, XY.; Lin, HT. (Nov 2003). "A case report of localized gastric amyloidosis.". World J Gastroenterol 9 (11): 2632-4. PMID 14606114.
  21. ↑ Sawada, T.; Adachi, Y.; Akino, K.; Arimura, Y.; Ishida, T.; Ishii, Y.; Endo, T. (2012). "Endoscopic features of primary amyloidosis of the stomach.". Endoscopy 44 Suppl 2 UCTN: E275-6. doi:10.1055/s-0032-1309750. PMID 22814919.
  22. ↑ Rugge, M.; Correa, P.; Dixon, MF.; Hattori, T.; Leandro, G.; Lewin, K.; Riddell, RH.; Sipponen, P. et al. (Feb 2000). "Gastric dysplasia: the Padova international classification.". Am J Surg Pathol 24 (2): 167-76. PMID 10680883.
  23. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/StomachNET_11protocol.pdf. Accessed on: 29 March 2012.
  24. ↑ Mbulaiteye, SM.; Hisada, M.; El-Omar, EM. (2009). "Helicobacter Pylori associated global gastric cancer burden.". Front Biosci 14: 1490-504. PMID 19273142.
  25. ↑ Bailey, D. 6 August 2010.
  26. ↑ Papadaki, L.; Wotherspoon, AC.; Isaacson, PG. (Nov 1992). "The lymphoepithelial lesion of gastric low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT): an ultrastructural study.". Histopathology 21 (5): 415-21. PMID 1452124.
  27. ↑ Kim, K.; Kim, EJ.; Kim, MJ.; Song, HJ.; Lee, YS.; Jung, KW.; Yu, E. (Dec 2009). "Clinicopathological features of syphilitic gastritis in Korean patients.". Pathol Int 59 (12): 884-9. doi:10.1111/j.1440-1827.2009.02462.x. PMID 20021615.
  28. ↑ Long, BW.; Johnston, JH.; Wetzel, W.; Flowers, RH.; Haick, A. (Sep 1995). "Gastric syphilis: endoscopic and histological features mimicking lymphoma.". Am J Gastroenterol 90 (9): 1504-7. PMID 7661178.
  29. ↑ Zullo, A.; Hassan, C.; Andriani, A.; Cristofari, F.; De Francesco, V.; Ierardi, E.; Tomao, S.; Morini, S. et al. (Aug 2009). "Eradication therapy for Helicobacter pylori in patients with gastric MALT lymphoma: a pooled data analysis.". Am J Gastroenterol 104 (8): 1932-7; quiz 1938. doi:10.1038/ajg.2009.314. PMID 19532131.
  30. ↑ Sereno, M.; Aguayo, C.; Guillén Ponce, C.; Gómez-Raposo, C.; Zambrana, F.; Gómez-López, M.; Casado, E. (Sep 2011). "Gastric tumours in hereditary cancer syndromes: clinical features, molecular biology and strategies for prevention.". Clin Transl Oncol 13 (9): 599-610. PMID 21865131.
  31. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 192090
  32. ↑ Guilford, P.; Hopkins, J.; Harraway, J.; McLeod, M.; McLeod, N.; Harawira, P.; Taite, H.; Scoular, R. et al. (Mar 1998). "E-cadherin germline mutations in familial gastric cancer.". Nature 392 (6674): 402-5. doi:10.1038/32918. PMID 9537325.
  33. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 600185
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