Difference between revisions of "Stomach"

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'''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.  Surgeon take-out the organ.  It connects the [[esophagus]] to the [[duodenum]].  An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.
[[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 stomach=
=Normal stomach=
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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.


===Gastric antrum versus gastric body===
===Gastric antrum versus gastric body===
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===Sign out===
===Sign out===
====Short version====
====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>
<pre>
STOMACH, BIOPSY:
STOMACH, BIOPSY:
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====Sleeve gastrectomy====
====Sleeve gastrectomy====
*Indication: morbid [[obesity]].
{{Main|Sleeve gastrectomy}}
<pre>
STOMACH, GREATER CURVE, SLEEVE GASTRECTOMY:
- STOMACH WALL WITHIN NORMAL LIMITS.
</pre>


=Introduction=
=Introduction=
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{{Main|Intestinal metaplasia of the stomach}}
{{Main|Intestinal metaplasia of the stomach}}


==Inflammatory bowel disease & the stomach==
==Inflammatory bowel disease and the stomach==
:See ''[[inflammatory bowel disease]]''.
:See ''[[inflammatory bowel disease]]''.
*Histopathologic findings are usually non-specific.
*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>
*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/gross===
Features - Crohn's:<ref name=Ref_GLP80>{{Ref GLP|80}}</ref>
*+/-Linear fissures, erosions, ulcers, cobblestoning.
*May mimic ''[[linitis plastica]]''.


===Microscopic===
===Microscopic===
Features:<ref>RK. 13 December 2010.</ref>
Features:<ref>Kirsch R. 13 December 2010.</ref>
*Focal inflammation.
*Focal inflammation.
**Common finding - non-specific.
**Common finding - non-specific.
*+/-[[Granulomas]].
*+/-[[Granulomas]].
Note:
*Granulomas in Crohn's gastritis present 7-34% of the time.<ref name=Ref_GLP80>{{Ref GLP|80}}</ref>
====Images====
<gallery>
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>


=Miscellaneous=
=Miscellaneous=
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==Collagenous gastritis==
==Collagenous gastritis==
===General===
{{Main|Collagenous gastritis}}
*Very rare.
*Associated with ''[[collagenous colitis]]''.
 
===Microscopic===
Features:
*Eosinophilic material (collagen) expands lamina propria.
**Band of collagen must be ~thick as RBC diameter.
***Proven by [[trichrome stain]] that highlights collagen.
 
DDx:
*[[Amyloidosis of the stomach]].


==Gastritis cystitis profunda==
==Gastritis cystitis profunda==
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*[[AKA]] ''xanthelasma''.
*[[AKA]] ''xanthelasma''.
*[[AKA]] ''stomach lipidosis''.
*[[AKA]] ''stomach lipidosis''.
===General===
{{Main|Gastric xanthoma}}
*Uncommon.
*Benign.
 
===Gross/endoscopic===
*Yellowish nodule or plaque.<ref name=Ref_GLP111>{{Ref GLP|111}}</ref>
**Classically lesser curvature and antrum.<ref name=pmid6284833/>
 
===Microscopic===
Features:<ref name=Ref_GLP111>{{Ref GLP|111}}</ref>
*Collections of gastric lamina propria with lipid-laden macrophages.
 
DDx:
*[[Signet ring cell carcinoma]].<ref name=pmid6284833>{{Cite journal  | last1 = Drude | first1 = RB. | last2 = Balart | first2 = LA. | last3 = Herrington | first3 = JP. | last4 = Beckman | first4 = EN. | last5 = Burns | first5 = TW. | title = Gastric xanthoma: histologic similarity to signet ring cell carcinoma. | journal = J Clin Gastroenterol | volume = 4 | issue = 3 | pages = 217-21 | month = Jun | year = 1982 | doi =  | PMID = 6284833 }}</ref>
*[[Whipple disease]].
*MAC infection.
 
====Images====
<gallery>
image:Xanthoma_histology.jpg | Xanthoma. (WC)
</gallery>
www:
*[http://www.flickr.com/photos/hemeguy/2911032670/in/photostream/ GX - low mag. (flickr.com)].
*[http://www.flickr.com/photos/hemeguy/2911031464/in/photostream GX - high mag. (flickr.com)].
 
===IHC===
*CD68 +ve.
*Panker (AE1/AE3) -ve.


==Gastric ischemia==
==Gastric ischemia==
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==Portal hypertensive gastropathy==
==Portal hypertensive gastropathy==
*Abbreviated ''PHG''.
*Abbreviated ''PHG''.
===General===
{{Main|Portal hypertensive gastropathy}}
*Due to [[portal hypertension]].
**Usually secondary to [[liver cirrhosis]] which is typically due to [[alcoholism]].
***Reported in approximately 65% of cirrhotics with portal hypertension in one paper.<ref name=pmid15648238>{{Cite journal  | last1 = Mesihovic | first1 = R. | last2 = Prohic | first2 = D. | last3 = Gribajcevic | first3 = M. | last4 = Vanis | first4 = N. | last5 = Gornjakovic | first5 = S. | last6 = Sarac | first6 = A. | title = Portal hypertensive gastropathy (PHG). | journal = Med Arh | volume = 58 | issue = 6 | pages = 377-9 | month =  | year = 2004 | doi =  | PMID = 15648238 }}
</ref>
 
===Gross===
Features:<ref name=pmid12492178>{{Cite journal  | last1 = Thuluvath | first1 = PJ. | last2 = Yoo | first2 = HY. | title = Portal Hypertensive gastropathy. | journal = Am J Gastroenterol | volume = 97 | issue = 12 | pages = 2973-8 | month = Dec | year = 2002 | doi = 10.1111/j.1572-0241.2002.07094.x | PMID = 12492178 }}</ref>
*Mosaic-like pattern.
**May be referred to as [[Gastric snakeskin appearance|snakeskin-like pattern]].<ref name=pmid22211417/>
**Usu. body of stomach.
*+/-Red spots.
 
Note:
*May mimic eosinophilic gastritis.<ref name=pmid22211417>{{Cite journal  | last1 = Sikanderkhel | first1 = S. | last2 = Luthra | first2 = M. | last3 = Chavalitdhamrong | first3 = D. | title = Snakeskin-like pattern mimicking portal hypertensive gastropathy in patient with eosinophilic gastritis. | journal = Dig Endosc | volume = 24 | issue = 1 | pages = 53 | month = Jan | year = 2012 | doi = 10.1111/j.1443-1661.2011.01155.x | PMID = 22211417 }}</ref>
 
====Images====
<gallery>
Image:PHGastro.jpg | PHG. (WC/Samir)
</gallery>
 
===Microscopic===
Features:<ref name=Ref_GLP120-1>{{Ref GLP|120-1}}</ref>
*Dilated capillaries in the submucosa (prominent) and to a lesser extent in the lamina propria - '''key feature'''.
 
Notes:
*May be associated with [[hyperplastic polyp of the stomach|hyperplastic]]-like polyps.<ref name=pmid22002002>{{Cite journal  | last1 = Lam | first1 = MC. | last2 = Tha | first2 = S. | last3 = Owen | first3 = D. | last4 = Haque | first4 = M. | last5 = Chatur | first5 = N. | last6 = Gray | first6 = JR. | last7 = Yoshida | first7 = EM. | title = Gastric polyps in patients with portal hypertension. | journal = Eur J Gastroenterol Hepatol | volume = 23 | issue = 12 | pages = 1245-9 | month = Nov | year = 2011 | doi = 10.1097/MEG.0b013e32834c15cf | PMID = 22002002 }}</ref>
**Subepithelial [[granulation tissue]] and vascular proliferation.
*Findings in mucosal biopsies are often [[specificity|nonspecific]], i.e. not diagnostic.<ref name=Ref_GLP120-1>{{Ref GLP|120-1}}</ref>
 
DDx:
*[[Gastric antral vascular ectasia]] - have thrombi in the dilated blood vessels.
 
===Sign out===
<pre>
STOMACH, BIOPSY:
- ANTRAL-TYPE AND BODY-TYPE GASTRIC MUCOSA WITH PROMINENT CAPILLARIES
AND MODERATE CHRONIC INACTIVE INFLAMMATION.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
 
COMMENT:
No fibrin thrombi are seen.  The findings are compatible with portal hypertension.
Clinical correlation is required.
</pre>


==Amyloidosis of the stomach==
==Amyloidosis of the stomach==
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===Stains===
===Stains===
*[[Congo red stain]] +ve.
*[[Congo red stain]] +ve.
==Eosinophilic gastritis==
{{Main|Eosinophilic gastritis}}
==Proton pump inhibitor effect==
*Abbreviated ''PPI effect''.
{{Main|Proton pump inhibitor effect}}


=Gastric polyps=
=Gastric polyps=
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==Hyperplastic polyp of the stomach==
==Hyperplastic polyp of the stomach==
{{Main|Hyperplastic polyp}}
{{Main|Hyperplastic polyp of the stomach}}
*[[AKA]] ''gastric hyperplastic polyp''.
===General===
*Benign.
*Most common gastric polyp.<ref name=pmid19037727/>
 
===Microscopic===
Features:<ref>URL: [http://pathologyoutlines.com/stomach.html#hyperplastic http://pathologyoutlines.com/stomach.html#hyperplastic]. Accessed on: 26 July 2011.</ref>
*Abundant foveolar cells and elongated glands - '''key feature'''.
*+/-Gland dilation.
 
Negatives:
*No atypical nuclei.
*No hyperchromasia.
*No loss of pseudostratification.
 
Notes:
*No serrations - as in the colon.
 
DDx:
*[[Ménétrier's disease]]<ref name=pmid18384215>{{Cite journal  | last1 = Park | first1 = do Y. | last2 = Lauwers | first2 = GY. | title = Gastric polyps: classification and management. | journal = Arch Pathol Lab Med | volume = 132 | issue = 4 | pages = 633-40 | month = Apr | year = 2008 | doi = 10.1043/1543-2165(2008)132[633:GPCAM]2.0.CO;2 | PMID = 18384215 | url=http://www.archivesofpathology.org/doi/full/10.1043/1543-2165(2008)132%5B633:GPCAM%5D2.0.CO;2 }}</ref> (hyperplastic hypersecretory gastropathy).
*[[Juvenile polyp]]<ref name=pmid19037727>{{Cite journal  | last1 = Jain | first1 = R. | last2 = Chetty | first2 = R. | title = Gastric hyperplastic polyps: a review. | journal = Dig Dis Sci | volume = 54 | issue = 9 | pages = 1839-46 | month = Sep | year = 2009 | doi = 10.1007/s10620-008-0572-8 | PMID = 19037727 }}</ref> - abundant lamina propria, dilated glands may have neutrophils.<ref name=Ref_GLP102>{{Ref GLP|102}}</ref>
*[[Peutz-Jeghers polyp]] - thick superficial muscle.
*[[Fundic gland polyp]] - doesn't have foveolar hyperplasia.
 
====Images====
<gallery>
Image: Gastric_hyperplastic_polyp_%281%29_foveolar_type.jpg | Gastric hyperplastic polyp - low mag. (WC/KGH)
Image: Gastric_hyperplastic_polyp_%283%29_foveolar_type.jpg | Gastric hyperplastic polyp - high mag. (WC/KGH)
</gallery>
 
www:
*[http://www.flickr.com/photos/jian-hua_qiao_md/3953137621/ Gastric hyperplastic polyp (flickr.com)].
*[http://www.flickr.com/photos/jian-hua_qiao_md/3953138195/in/photostream/ Gastric hyperplastic polyp (flickr.com)].
 
===Sign out===
<pre>
POLYP, STOMACH (ANTRUM), EXCISION:
- HYPERPLASTIC POLYP.
</pre>
 
====Micro====
The sections show antral-type gastric mucosa with hyperplastic gastric pits.  No gland dilation is apparent. The epithelium matures to the surface. The lamina propria is not expanded.
 
Focal neutrophilic inflammation is present. No Helicobacter-like organisms are identified. No intestinal metaplasia is present. No mitotic activity or nuclear atypia is apparent.


==Fundic gland polyp==
==Fundic gland polyp==
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==Gastric dysplasia==
==Gastric dysplasia==
:''Gastric adenoma'' directs here.
{{Main|Stomach adenoma}}
*[[AKA]] ''gastric columnar dysplasia''.
===General===
*Lesions that protrude into the lumen ''and'' are macroscopically apparent are known as: ''adenomas''.<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>
*Polypoid forms are grouped various ways.<ref name=pmid18384215>{{Cite journal  | last1 = Park | first1 = do Y. | last2 = Lauwers | first2 = GY. | title = Gastric polyps: classification and management. | journal = Arch Pathol Lab Med | volume = 132 | issue = 4 | pages = 633-40 | month = Apr | year = 2008 | doi = 10.1043/1543-2165(2008)132[633:GPCAM]2.0.CO;2 | PMID = 18384215 | url=http://www.archivesofpathology.org/doi/full/10.1043/1543-2165(2008)132%5B633:GPCAM%5D2.0.CO;2 }}</ref>
 
====Grading====
Like in the colon - they are divided into:
*Low grade.
*High grade.
 
====Subclassification====
One subclassification:<ref>URL: [http://surgpathcriteria.stanford.edu/gitumors/gastric-adenoma/printable.html http://surgpathcriteria.stanford.edu/gitumors/gastric-adenoma/printable.html]. Accessed on: 18 December 2012.</ref>
*Intestinal: goblet cells or Paneth cells.
**Not associated with FAP.
*Gastric: foveolar epithelium.
**Associated with [[familial adenomatous polyposis]] (FAP).
 
===Microscopic===
*Histologic criteria similar to columnar dysplasia in the [[esophagus]].
**The threshold is much lower than in the colon and rectum.
 
====Foveolar type====
Features:
*Hyperchromasia at the surface - '''key feature'''.
*Cytoplasm with (shortened) champagne flute-like luminal aspect (apical mucin caps).
*Nuclear changes:
**Hyperchromasia.
**Enlargement.
*No intestinal metaplasia.
 
DDx:
*[[Gastric carcinoma]].
*[[Reactive changes]].
 
====Intestinal type====
Features - intestinal:
*[[Intestinal metaplasia of the stomach|Intestinal metaplasia]].
*Hyperchromasia of cytoplasm.
*Nuclear changes:
**Loss of nuclear polarity.
**Increased [[NC ratio]].
**Elongation of nucleus and pseudostratification.
 
DDx:
*[[Gastric carcinoma]].
*[[Reactive changes]].
*[[Intestinal metaplasia of the stomach|Intestinal metaplasia]].
 
=====Images=====
<gallery>
Image:Gastric_adenoma_(1).jpg | Gastric adenoma. (WC/KGH)
Image:Gastric_adenoma_(2).jpg | Gastric adenoma. (WC/KGH)
</gallery>
www:
*[http://www.sciencedirect.com/science/article/pii/S1756231710001878 Gastric polyps - several images (sciencedirect.com)].
*[http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282008%29132%5B633%3AGPCAM%5D2.0.CO%3B2 Gastric polyps - several images (achivesofpathology.org)].
 
====Grading====
=====Low-grade gastric dysplasia=====
Features:
*Nuclear changes:
**Nuclear crowding/pseudostratification with hyperchromasia.
**Elongation of nuclei (cigar-shaped nuclei).
**Nuclear stratification intact; nuclei close to the basement membrane.
*Architecture:
**Focal irregularities in the glandular contours.
 
Negatives:
*No desmoplasia.
*No necrosis.
*No surface maturation.
 
DDx:
*Indefinite for dysplasia.
*High-grade gastric columnar dysplasia - see below.
**The threshold is much lower than in the colon and rectum!
 
Images:
*[http://path.upmc.edu/cases/case431.html Low-grade gastric columnar dysplasia - several images (upmc.edu)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F4/ Gastric low-grade dysplasia (nih.gov)].<ref name=pmid22076218>{{Cite journal  | last1 = Kushima | first1 = R. | last2 = Kim | first2 = KM. | title = Interobserver Variation in the Diagnosis of Gastric Epithelial Dysplasia and Carcinoma between Two Pathologists in Japan and Korea. | journal = J Gastric Cancer | volume = 11 | issue = 3 | pages = 141-5 | month = Sep | year = 2011 | doi = 10.5230/jgc.2011.11.3.141 | PMID = 22076218 }}</ref>
=====High-grade gastric dysplasia=====
Features:
*Nuclear changes:
**Round hyperchromatic nuclei.
**Loss of normal nuclear stratification.
*Architecture:
**Irregularities in the glandular contours.
**Back-to-back glands.
**Cribriforming of the glands.
**+/-Necrosis.
 
Negatives:
*No [[desmoplasia]].
 
DDx:
*Low-grade gastric columnar dysplasia.
*[[Gastric adenocarcinoma]].
 
=====Images=====
<gallery>
Image:High_grade_gastric_dysplasia_-_low_mag.jpg | High grade gastric dysplasia - low mag. (WC/Nephron)
Image:High_grade_gastric_dysplasia_-_very_high_mag.jpg | High grade gastric dysplasia - very high mag. (WC/Nephron)
</gallery>
www:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404600/figure/F8/ Gastric high-grade dysplasia - probably (nih.gov)].<ref name=pmid22188910>{{Cite journal  | last1 = Correa | first1 = P. | last2 = Piazuelo | first2 = MB. | title = The gastric precancerous cascade. | journal = J Dig Dis | volume = 13 | issue = 1 | pages = 2-9 | month = Jan | year = 2012 | doi = 10.1111/j.1751-2980.2011.00550.x | PMID = 22188910 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F7/ Gastric high-grade dysplasia - probably (nih.gov)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F6/ Gastric high-grade dysplasia (nih.gov)].<ref name=pmid22076218/>
 
===Sign out===
====Indefinite for dypslasia====
<pre>
STOMACH, ANTRUM, BIOPSIES:
- ANTRAL-TYPE MUCOSA INDEFINITE FOR DYSPLASIA WITH MODERATE CHRONIC INFLAMMATION.
- EXTENSIVE INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANSIMS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Intestinal type====
<pre>
STOMACH, ANTRUM, BIOPSIES:
- ANTRAL-TYPE MUCOSA WITH FOCUS OF LOW-GRADE DYSPLASIA (INTESTINAL TYPE).
- EXTENSIVE INTESTINAL METAPLASIA.
- MODERATE CHRONIC INFLAMMATION.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANSIMS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Foveolar type====
<pre>
STOMACH POLYP, BIOPSY:
- ADENOMATOUS POLYP, FOVEOLAR TYPE.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>


==Gastric neuroendocrine tumour==
==Gastric neuroendocrine tumour==
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Features:
Features:
*Sheets of lymphoid cells.
*Sheets of lymphoid cells.
*"Lymphoepithelial lesion" - gastric crypts invaded by a monomorphous population of lymphocytes.<ref>Bailey, D. 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'''.
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Others:
Others:
*CD3 (T cells) - scatter positivity.
*CD3 (T cells) - scatter positivity.
*CD20 (B cells) +ve.
*[[CD20]] (B cells) +ve.
*CD138 (plasma cells).
*CD138 (plasma cells).
*kappa, lambda -- often one is predominant, suggesting clonality.
*kappa, lambda -- often one is predominant, suggesting clonality.
Line 721: Line 496:
! Other
! Other
|-
|-
| Hereditary diffuse gastric cancer (HDGC) syndrome  
| [[Hereditary diffuse gastric cancer syndrome|Hereditary diffuse gastric cancer (HDGC) syndrome]]
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
| diffuse - more specifically [[signet ring cell carcinoma]]
| diffuse - more specifically [[signet ring cell carcinoma]]
Line 747: Line 522:
|-
|-
| Familial breast and ovarian cancer 2<ref name=omim600185>{{OMIM|600185}}</ref>
| Familial breast and ovarian cancer 2<ref name=omim600185>{{OMIM|600185}}</ref>
| BRCA2
| [[BRCA2]]
| ?
| ?
| ?
| ?
|}
|}


==Gastric adenocarcinoma==
==Gastric carcinoma==
===General===
:Includes ''gastric adenocarcinoma''.
Epidemiology:
{{Main|Gastric carcinoma}}
*Prognosis is often poor as it is discovered at a late stage.
*Higher prevalence in countries in the far east (e.g. Japan) - thought to be environmental, e.g. diet.
 
Risk factors:
*Associated with helicobacter infections, i.e. [[Helicobacter gastritis]].
*[[Alcohol]] - heavy use.<ref name=pmid21993435>{{Cite journal  | last1 = Duell | first1 = EJ. | last2 = Travier | first2 = N. | last3 = Lujan-Barroso | first3 = L. | last4 = Clavel-Chapelon | first4 = F. | last5 = Boutron-Ruault | first5 = MC. | last6 = Morois | first6 = S. | last7 = Palli | first7 = D. | last8 = Krogh | first8 = V. | last9 = Panico | first9 = S. | title = Alcohol consumption and gastric cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. | journal = Am J Clin Nutr | volume = 94 | issue = 5 | pages = 1266-75 | month = Nov | year = 2011 | doi = 10.3945/ajcn.111.012351 | PMID = 21993435 }}</ref>
*Genetic syndromes - see [[hereditary gastric cancer]].
 
Note:
*Possible association with tobacco use - dependent on the study.<ref>{{Cite journal  | last1 = Nomura | first1 = A. | last2 = Grove | first2 = JS. | last3 = Stemmermann | first3 = GN. | last4 = Severson | first4 = RK. | title = Cigarette smoking and stomach cancer. | journal = Cancer Res | volume = 50 | issue = 21 | pages = 7084 | month = Nov | year = 1990 | doi =  | PMID = 2208177 | URL = http://cancerres.aacrjournals.org/cgi/pmidlookup?view=long&pmid=2208177}}</ref>
 
Treatment:
*Surgical excision. 
**Proximal tumours may require a complete gastrectomy as the stomach is innervated from its proximal part.
 
====Classification====
*Two different classification schemes.
**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:
***Intestinal type (mass forming).
***Diffuse type (infiltrative).
**WHO classification - 6 subtypes for adenocarcinoma:<ref name=Ref_PBoD823>{{Ref PBoD |823}}</ref>
**#Papillary carcinoma.
**#Tubular carcinoma.
**#Mucinous carcinoma.
**#Signet-ring carcinoma.
**#Undifferentiated carcinoma.
**#[[Adenosquamous carcinoma]].
 
Lame memory device ''STOMACH'':
*'''S'''ignet ring, '''T'''ubular, '''O'''h papillary, '''M'''ucinous, '''A'''denosquamouas, '''C'''rappy '''H'''igh grade (Undifferentiated).
 
===Gross===
Location:
*Large carcinomas preferentially involve the lesser curvature.<ref name=pmid2550682>{{Cite journal  | last1 = Yamagawa | first1 = H. | last2 = Onishi | first2 = T. | title = [A clinicopathological study of early gastric cancers with a diameter larger than five centimeters]. | journal = Gan No Rinsho | volume = 35 | issue = 10 | pages = 1114-8 | month = Sep | year = 1989 | doi =  | PMID = 2550682 }}</ref>
*Ulceration with heaped (raised) edges.
**Appearance of the typical intestinal type tumour.
*Diffuse wall thickening with loss of the rugae - called ''linitis plastica''.
**Typically due to diffuse carcinoma.
 
Main DDx of ulcer:
*[[Peptic ulcer disease]] - have a "punched-out" appearance: sharp edge, no granularity of surrounding mucosa.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Linitis_plastica.jpg Linitis plastica - endoscopic image (WC)].
*[http://commons.wikimedia.org/wiki/File:Adenocarcinoma_of_the_stomach.jpg Ulcerating gastric carcinoma (WC)].
*[http://commons.wikimedia.org/wiki/File:Adenocarcinoma,_stomach,_gross_pathology_IMG0037a_lores.jpg Ulcerating gastric carcinoma (WC)].
 
===Microscopic===
Features - variable, either of the two following:
#"Typical adenocarcinoma":
#*Gland-forming lesion that infiltrates into the lamina propria or beyond.
#*Nuclear pleomorphism - common.
#+/-Signet ring carcinoma.
#*Scattered single cells in the lamina propria or beyond with:
#**Abundant cytoplasm containing one large (mucin-filled) vacuole.
#**A peripheral nucleus (displaced by the vacuole).
 
DDx:
*[[Gastric xanthoma]] - may mimic signet ring cell carcinoma.
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Gastric_adenocarcinoma.jpg Gastric adenocarcinoma (WC)].
**[http://commons.wikimedia.org/wiki/File:Signet_ring_cells_5.jpg SRC - breast (WC)].
**[http://en.wikipedia.org/wiki/File:Gastric_signet_ring_cell_carcinoma_histopatholgy_%282%29_PAS_stain.jpg Gastric SRC - PAS stain (WC)].
*www:
**[http://path.upmc.edu/cases/case196.html Gastric adenocarcinoma - several images (upmc.edu)].
 
===Stains===
*Mucicarmine +ve.
 
===IHC===
*CK7 +ve.
*CK20 -ve, occasionally +ve.
 
Others:
*p53 +ve in upto 75% of cases.<ref name=pmid21772890>{{Cite journal  | last1 = Zali | first1 = MR. | last2 = Moaven | first2 = O. | last3 = Asadzadeh Aghdaee | first3 = H. | last4 = Ghafarzadegan | first4 = K. | last5 = Ahmadi | first5 = KJ. | last6 = Farzadnia | first6 = M. | last7 = Arabi | first7 = A. | last8 = Abbaszadegan | first8 = MR. | title = Clinicopathological significance of E-cadherin, β-catenin and p53 expression in gastric adenocarinoma. | journal = J Res Med Sci | volume = 14 | issue = 4 | pages = 239-47 | month = Jul | year = 2009 | doi =  | PMID = 21772890 }}</ref>
 
===Molecular===
*May have HER2 over expression - more common in intestinal-type tumours.<ref name=pmid22213295>{{Cite journal  | last1 = Romiti | first1 = A. | last2 = Di Rocco | first2 = R. | last3 = Milione | first3 = M. | last4 = Ruco | first4 = L. | last5 = Ziparo | first5 = V. | last6 = Zullo | first6 = A. | last7 = Duranti | first7 = E. | last8 = Sarcina | first8 = I. | last9 = Barucca | first9 = V. | title = Somatostatin receptor subtype 2 A (SSTR2A) and HER2 expression in gastric adenocarcinoma. | journal = Anticancer Res | volume = 32 | issue = 1 | pages = 115-9 | month = Jan | year = 2012 | doi =  | PMID = 22213295 }}</ref>
**Poor prognosis - like in breast cancer.
**Scoring system different than in breast cancer - complete membrane staining is not required.
 
===Sign out===
====Biopsy====
=====Intestinal type=====
<pre>
STOMACH, BIOPSY:
- INVASIVE ADENOCARCINOMA, INTESTINAL TYPE, MODERATELY DIFFERENTIATED.
- Gastric mucosa with moderate chronic active inflammation and extensive
  intestinal metaplasia.
- Benign small bowel mucosa with erosions.
</pre>
 
=====Diffuse type=====
<pre>
STOMACH, BIOPSY:
- INVASIVE ADENOCARCINOMA, DIFFUSE TYPE.
 
COMMENT:
A pankeratin immunostain demonstrates single (infiltrating) epithelial cells in the
lamina propria.
</pre>
 
=====Micro=====
The tumour consists of single cells with abundant foamy-appearing cytoplasm and eccentric
nuclei with mild nuclear atypia.


=See also=
=See also=

Revision as of 18:37, 28 May 2019

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.

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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