Gastritis

Gastritis
Diagnosis in short
Chronic gastritis. H&E stain.
LM	acute: PMNs in the lamina propria or intraepithelial; (usual) chronic: cluster of plasma cells (mild), several clusters (moderate), +/-mucosal erosions (severe); lymphocytic: intraepithelial lymphocytes (25 lymphocytes/100 epithelial cells)
Subtypes	acute gastritis, chronic gastritis, focal acute gastritis (pill gastritis), lymphocytic gastritis
LM DDx	Helicobacter gastritis, collagenous gastritis, Crohn's disease, intestinal metaplasia of the stomach, gastric columnar dysplasia, gastric carcinoma
Stains	Diff-Quik -ve, cresyl violet -ve
IHC	Helicobacter -ve
Site	stomach
Associated Dx	intestinal metaplasia of the stomach - esp. in chronic gastritis
Clinical history	dyspepsia
Symptoms	upper abdominal pain
Prevalence	very common
Blood work	H. pylori -ve or previously +ve
Endoscopy	erythema
Prognosis	good
Other	neg. Helicobacter breath test
Clin. DDx	reactive gastropathy

Gastritis refers to an inflammatory process that affects the stomach.

There are several types of gastritis:

• Chronic gastritis.
• Helicobacter pylori gastritis.
• Acute gastritis.
• "Chemical gastritis" - not really a gastritis; the preferred term is reactive gastropathy.
• Autoimmune gastritis.
• Lymphocytic gastritis.
• Collagenous gastritis.

This article gives an overview of causes of gastritis. It also deals with acute gastritis and the usual chronic gastritis without an apparent histologic cause.

Other forms of gastritis are dealt with in their own articles.

General

• Very common.
• A specific cause is uncommonly identified histologically.

Clinical:

• Dyspepsia - esp. upper abdominal pain.

Etiology

Gastritis causes:

• Infectious:
  • H. pylori infection.
  • Tuberculosis.
  • Salmonellosis.
  • CMV.
  • EBV.
  • Syphilis.
• Endocrine-related:
  • Pernicious anemia.
  • Diabetes mellitus - gastric atony.
• Trauma, e.g. NG tube.
• Vascular, ischemia.
• Autoimmune:
  • Crohn's disease.
• Toxins:
  • Alcohol.
  • Medications, especially NSAIDs.
  • Uremia.
  • Smoking (heavy).
• Radiation.

Endoscopic appearance

• Erythematous.

Microscopic

• Inflammatory cells - see below.

Acute gastritis

• AKA active gastritis.

Features:

• Neutrophils - especially when intraepithelial.

Focal active gastritis

DDx:

1. Drugs, esp. NSAIDs.
2. Infectious.
3. Inflammatory bowel disease.

Chronic gastritis

Features:

• Plasma cells (in lamina propria).
  • Various criteria:
    1. Two plasma cells kissing, i.e. two plasma cells touching/overlapping.
    2. Three is a crowd, i.e. three plasma cells in close proximity.

Note:

• Approximately 20% of cases with an inflamed cardia will have intestinal metaplasia.

Images

• 

  Moderate chronic gastritis - intermed. mag. (WC)

• 

  Moderate chronic gastritis - high mag. (WC)

• 

  Moderate chronic gastritis - very high mag. (WC)

Sydney criteria for gastritis

A bunch of pathologists in Sydney came-up with criteria... and these were revised in Houston.

Classification

Updated Sydney classification:

Feature	Non-atrophic Helicobacter	Atrophic Helicobacter	Autoimmune
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.

Severity

The Sydney group suggests grading severity with the following language:

• Mild.
• Moderate.
• 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.

Parameters & Severity (adapted from Dixon et al.):

Feature	Mild	Moderate	Marked
H. pylori	few touching	many touching	piles
Neutrophils	few	bunches	crowded
Mononuclear cells	not touching	kissing	partying

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Minimal chronic inactive

STOMACH, BIOPSY: 
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITH MINIMAL CHRONIC INACTIVE INFLAMMATION. 
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS. 
- NEGATIVE FOR INTESTINAL METAPLASIA. 
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Mild chronic inactive

Stomach, Antrum, Biopsy:
- Antral-type gastric mucosa with mild chronic inactive inflammation.
- NEGATIVE for Helicobacter-like organisms.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Stomach, Antrum, Biopsy:
- Antral-type gastric mucosa with mild focal chronic inactive inflammation, and mild focal gland tortousity without smooth muscle hyperplasia.
- NEGATIVE for Helicobacter-like organisms.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Block letters

STOMACH, BIOPSY: 
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITH MILD CHRONIC INACTIVE INFLAMMATION. 
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS. 
- NEGATIVE FOR INTESTINAL METAPLASIA. 
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Moderate chronic inactive antrum with mild chronic inactive body

 STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITH MODERATE CHRONIC INACTIVE INFLAMMATION.
- BODY-TYPE GASTRIC MUCOSA WITH MILD CHRONIC INACTIVE INFLAMMATION.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Moderate chronic active

STOMACH, BIOPSY: 
- Body and antral-type gastric mucosa with moderate chronic active inflammation.
- NEGATIVE for Helicobacter-like organisms.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy. 

Block letters

STOMACH, BIOPSY: 
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITH MODERATE CHRONIC ACTIVE INFLAMMATION. 
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS. 
- NEGATIVE FOR INTESTINAL METAPLASIA. 
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Severe active

Stomach, Biopsy: 
- Antral-type gastric mucosa with severe chronic active inflammation 
  with evidence of ulceration (fibrin, necro-inflammatory debris).
- NEGATIVE for Helicobacter-like organisms. 
- NEGATIVE for intestinal metaplasia. 
- NEGATIVE for dysplasia and NEGATIVE for malignancy. 

Comment:
Follow-up is suggested.

Sleeve gastrectomy

Partial Stomach, Sleeve Gastrectomy:
- Stomach wall with focal mild chronic inactive inflammation of the mucosa.
- NEGATIVE for Helicobacter-like organisms.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Alternate

Partial Stomach, Sleeve Gastrectomy:
	- Stomach wall with mild chronic inactive inflammation of the mucosa, otherwise 	  
          within normal limits.

Block letters

STOMACH, GREATER CURVATURE, SLEEVE GASTRECTOMY:
- STOMACH WALL WITH FOCAL MILD CHRONIC ACTIVE INFLAMMATION OF THE MUCOSA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Micro - inactive

The sections show gastric body type mucosa with small clusters of plasma cells. There are no intraepithelial neutrophils. Goblet cells are not identified. The epithelium matures normally to the surface. No Helicobacter organisms are seen.

See also

• Helicobacter pylori gastritis.
• Collagenous gastritis.