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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=
=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 (WP)].
===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'''
| '''Histology'''
| '''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 (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''.
| 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''.
| [http://commons.wikimedia.org/wiki/File:G_cell_hyperplasia_-_very_high_mag.jpg]
| [[Image:G_cell_hyperplasia_-_very_high_mag.jpg|thumb|center|60px|G cell hyperplasia. (WC)]]
|-
|-
| '''Surface'''
| '''Surface'''
Line 84: Line 86:
| 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 95: Line 97:
*G cells may superficially resemble intraepithelial lymphocytes.
*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?).
**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 111: Line 163:
*Inflammation + small bacteria = suspect H. pylori gastritis.
*Inflammation + small bacteria = suspect H. pylori gastritis.


=Non-specific disease=
=Some patterns=
==Gastric ulcer==
==Gastric atrophy==
===General===
===General===
*May be benign (e.g. [[peptic ulcer disease]]) or malignant ([[gastric carcinoma]]).
*Has a wide differential diagnosis.
 
Complications:
*Hemorrhage.
*Obstruction.
*Perforation.
 
===Gross===
*Epithelial defect:
**Heaped edges - suggestive of cancer.
**Punched-out edges - suggestive of a benign process.


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


=Non-neoplastic disease=
==Plasma cells in the stomach==
==Gastritis==
DDx of plasmacytosis:
===Etiology===
*[[Plasma cell neoplasm]].
A specific cause is uncommonly identified histologically.
*[[Syphilis]].
*Chronic [[gastritis]].


Gastritis causes:<ref name=Ref_PBoD812-3>{{Ref PBoD|812-3}}</ref>
==Granulomatous gastritis==
*Infectious:
*Usual DDx of granulomatous disease (see ''[[Basics]]'' article):
**H. pylori infection.
**DNF AAII:
**[[Tuberculosis]].
***Drugs, Neoplasms, Foreign body, Autoimmune, Allergic, Infectious, Idiopathic.
**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===
Important ones:
*Erythematous.
*Autoimmune - [[Crohn's disease]].
*Infectious - [[Tuberculosis]].
*Idiopathic - [[Sarcoidosis]].


===Microscopic===
=Non-neoplastic disease=
*Inflammatory cells - see below.
==Peptic ulcer disease==
*Abbreviated ''PUD''.
:For duodenal manifestations see ''[[Peptic duodenitis]]''.
===General===
*Benign.


====Acute gastritis====
Complications:
*[[AKA]] ''active gastritis''.
*Hemorrhage.
*Obstruction.
*Perforation - can be fatal.


Features:
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>
*Neutrophils - especially when intraepithelial.
*[[Helicobacter pylori]].


=====Focal active gastritis=====
===Gross===
DDx:
#Drugs,<ref>{{Cite journal  | last1 = Parfitt | first1 = JR. | last2 = Driman | first2 = DK. | title = Pathological effects of drugs on the gastrointestinal tract: a review. | journal = Hum Pathol | volume = 38 | issue = 4 | pages = 527-36 | month = Apr | year = 2007 | doi = 10.1016/j.humpath.2007.01.014 | PMID = 17367604 }}
</ref> esp. NSAIDs.
#Infectious.
#Inflammatory bowel disease.
 
====Chronic gastritis====
Features:
Features:
*Plasma cells (in lamina propria).
*Typically in the [[duodenum]]; duodenum:stomach = ~4:1.
**Various criteria:
**Epithelial defect with punched-out edges (suggestive of a benign process).
**#Two plasma cells kissing, i.e. two plasma cells touching/overlapping.
**#Three is a crowd, i.e. three plasma cells in close proximity.
 
=====Lymphocytic gastritis=====
The DDx is limited:
#[[Helicobacter gastritis]].
#[[Celiac disease]].
#[[NSAID]]s.
#Idiopathic.
 
===Sydney criteria for gastritis===
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>
 
===Classification===
Updated Sydney classification:<ref name=pmid8827022/>
{| class="wikitable"
| || '''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.<ref>[http://en.wikipedia.org/wiki/Angular_incisure http://en.wikipedia.org/wiki/Angular_incisure]</ref>


===Severity===
Note:
The Sydney group suggests grading severity with the following language:<ref name=pmid8827022/>
*Heaped edges - suggestive of [[stomach cancer|cancer]].
*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.
====Endoscopic image====
 
<gallery>
Parameters & Severity (adapted from Dixon et al.<ref name=pmid8827022/>):
Image:Deep_gastric_ulcer.png | Gastric ulcer. (WC)
{| class="wikitable"
</gallery>
| || '''Mild''' || '''Moderate''' || '''Marked'''
|-
| H. pylori || few touching || many touching  || piles
|-
| Neutrophils || few || bunches  || crowded
|-
| Mononuclear cells || not touching || kissing  || partying
|-
|}
 
==Helicobacter gastritis==
===General===
*Several Helicobacter species can cause gastritis:
**''Helicobacter pylori'' - most common.
**''Helicobacter heilmannii''.
 
Epidemiologic associations - ''Helicobacter'' infections are associated with:<ref>{{Ref PBoD|814}}</ref>
*Gastritis.
*Peptic ulcers.
*Cancer.
**Carcinoma.
**[[MALT lymphoma]].


===Microscopic===
===Microscopic===
Features:
Features:
*Small - smaller than the nucleus of the gastric foveolar cell.
*Loss of epithelium.
**On 400x they are still possible to miss.
*Inflammation.
*Look close to the opening of the gastric glands.
*+/-Helicobacter organisms - ''see [[Helicobacter gastritis]]''.
*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.
*''Helicobacter pylori'':
**Typically have a "v" shape ''or'' a comma-like shape.
*''Helicobacter heilmannii'':
**Corkscrew appearance.


Images:
==Gastritis==
*[http://commons.wikimedia.org/wiki/File:Immunohistochemical_detection_of_Helicobacter_%281%29_histopatholgy.jpg H. pylori - IHC (WC)].
{{Main|Gastritis}}
*Helicobacter gastritis:
{{Main|Chronic gastritis}}
**[http://commons.wikimedia.org/wiki/File:Gastritis_helicobacter_-_high_mag.jpg Gastritis due to HP (WC)].
{{Main|Acute gastritis}}
**[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)].
*[http://gut.bmj.com/content/58/12/1669/F2.large.jpg Helicobacter heilmannii (bmj.com)].<ref>URL: [http://gut.bmj.com/content/58/12/1669.extract http://gut.bmj.com/content/58/12/1669.extract]. Accessed on: 2 March 2012.</ref>


===Stains===
==Helicobacter gastritis==
*[[Cresyl violet stain]] - background and organisms blue.
{{Main|Helicobacter gastritis}}
*[[Warthin-Starry stain]] - background yellow, organisms black.
 
===IHC===
*Helicobacter pylori IHC stain +ve.


==Intestinal metaplasia of the stomach==
==Intestinal metaplasia of the stomach==
*[[AKA]] ''gastric [[intestinal metaplasia]]''.
{{Main|Intestinal metaplasia of the stomach}}
*Abbreviated ''IM''.
===General===
*Often part of surgical pathology report, e.g. "negative for intestinal metaplasia" or "intestinal metaplasia present".
*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.
*May be reversible - some epidemiological evidence.<ref name=pmid12477745>{{Cite journal  | last1 = Walker | first1 = MM. | title = Is intestinal metaplasia of the stomach reversible? | journal = Gut | volume = 52 | issue = 1 | pages = 1-4 | month = Jan | year = 2003 | doi =  | PMID = 12477745 | PMC = 1773527
}}</ref>
 
Significance:
*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>
**Odds ratio for corpus (~5.8x) higher than antrum (2.3x) when compared to individuals without IM.<ref name=pmid21575058>{{Cite journal  | last1 = Sakitani | first1 = K. | last2 = Hirata | first2 = Y. | last3 = Watabe | first3 = H. | last4 = Yamada | first4 = A. | last5 = Sugimoto | first5 = T. | last6 = Yamaji | first6 = Y. | last7 = Yoshida | first7 = H. | last8 = Maeda | first8 = S. | last9 = Omata | first9 = M. | title = Gastric cancer risk according to the distribution of intestinal metaplasia and neutrophil infiltration. | journal = J Gastroenterol Hepatol | volume = 26 | issue = 10 | pages = 1570-5 | month = Oct | year = 2011 | doi = 10.1111/j.1440-1746.2011.06767.x | PMID = 21575058 }}</ref>
 
===Microscopic===
Features:
*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>
**In [[H&E stain|H&E]] the vacuole often stains light grey.
 
Image:
*[http://en.wikipedia.org/wiki/File:Gastric_adenocarcinoma.jpg Intestinal metaplasia in the stomach - crappy quality (WC)].


==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=
This is a grab bag of stuff seen in the stomach.  Some of it is quite rare.
This is a grab bag of stuff seen in the stomach.  Some of it is quite rare.
==Gastric antral vascular ectasia==
==Gastric antral vascular ectasia==
===General===
{{Main|Gastric antral vascular ectasia}}
*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===
* Linear red streaks in antrum - oriented toward the pyloric valve... vaguely resembles a watermelon.
 
Endoscopic images:
*[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2443230&rendertype=figure&id=f1-19 Watermelon stomach (pubmedcentral.nih.gov)].
*[http://en.wikipedia.org/wiki/File:Gave.png GAVE (WP)].
 
===Microscopic===
Features:<ref>{{Ref GLP|118}}</ref>
*Fibrin thrombi - '''characteristic feature'''.
*Dilated capillaries in lamina propria.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Gastric_antral_vascular_ectasia_-_2_-_intermed_mag.jpg GAVE - intermed. mag. (WC)].
*[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==
==Reactive gastropathy==
===General===
{{Main|Reactive gastropathy}}
*[[AKA]] ''chemical gastropathy'',<ref name=pmid16939055>{{Cite journal  | last1 = Genta | first1 = RM. | title = Differential diagnosis of reactive gastropathy. | journal = Semin Diagn Pathol | volume = 22 | issue = 4 | pages = 273-83 | month = Nov | year = 2005 | doi =  | PMID = 16939055 }}</ref> incorrectly referred to as ''chemical gastritis'' (see below).
*May be seen in the context of a previous resection/surgical reconstruction, e.g. Billroth II.
 
====Epidemiology====
Associated with:<ref>ALS. 5 February 2009.</ref>
*Excess acid.
*EtOH.
*Bile.
*H. pylori.
*Drugs:<ref name=pmid16939055>{{Cite journal  | last1 = Genta | first1 = RM. | title = Differential diagnosis of reactive gastropathy. | journal = Semin Diagn Pathol | volume = 22 | issue = 4 | pages = 273-83 | month = Nov | year = 2005 | doi =  | PMID = 16939055 }}</ref>
**Iron (brown pigment on histology).
**NSAIDs - synergistic effect with corticosteroids.


Drugs that cause erosions and/or ulcers -- adapted from ''Genta'':<ref name=pmid16939055>{{Cite journal  | last1 = Genta | first1 = RM. | title = Differential diagnosis of reactive gastropathy. | journal = Semin Diagn Pathol | volume = 22 | issue = 4 | pages = 273-83 | month = Nov | year = 2005 | doi =  | PMID = 16939055 }}</ref>
==Autoimmune metaplastic atrophic gastritis==
 
*[[AKA]] ''autoimmune gastritis''.
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
{{Main|Autoimmune metaplastic atrophic gastritis}}
! Drug
! Comment
! Indication for Rx
|-
| NSAIDs
| common cause
| pain, reduce cardiovascular risk
|-
| Corticosteroids
| synergistic effect with NSAIDs
| rheumatologic diseases + others
|-
| Potassium (KCl)
| common cause
| renal failure
|-
| Bisphophonates
| uncommon cause
| osteoporosis
|-
| Ferrous sulfate
| very common if symptomatic
| iron deficiency anemia
|-
| Chloroquine
| uncommon
| only in the context of [[malaria]]
|-
| Sodium polystyrene sulfonate (Kayexalate)
| rare
| renal failure patients
|}
 
====Relation to gastritis====
*May mimic a (true) gastritis symptomatically and visually in an endoscopic examination.
*"Chemical gastritis" is misnomer. Etymologically, the ''-itis'' in ''gastritis'', implies an inflammatory process.  Chemical gastropathy is not (predominantly) an inflammatory process.
**This type of confusion is not uncommon. [[Steatohepatitis]] is another example of this; it is not a process with significant inflammation yet, confusingly, carries the ''-itis'' ending.
 
===Microscopic===
Features - triad:<ref>El-Zimaity. 18 October 2010.</ref><ref name=pmid16939055/>
#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.
Additional features.
*+/-Edema.
*+/-Erosions.
 
Notes:
*Triad rarely present; mild inflammation common.
 
DDx:
*[[Amyloidosis]].
*[[Collagenous gastritis]].
 
Images:
*[http://commons.wikimedia.org/wiki/File:Reactive_gastropathy_-_low_mag.jpg RG - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Reactive_gastropathy_-_high_mag.jpg RG - high mag. (WC)].
 
==Gastric atrophy==
===General===
*Has a wide differential diagnosis.
 
===Microscopic===
Can take three general forms:
#Intestinal metaplasia - see ''intestinal metaplasia'' section.
#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==
===General===
DDx:
*Celiac disease.
**Check [[duodenum]].
*H. pylori.
*HIV/AIDS.
 
===Microscopic===
Features:<ref>El-Zimaity. 18 October 2010.</ref>
*25 lymphocytes / 100 epithelial cells.
 
==Pernicious anemia==
===General===
*Gastric atrophy.
*Loss of parietal cells.
*Intrinsic factor antibodies present in serum.
**Intrinsic factor -- absorbs vitamin B12.
*Macrocytic [[anemia]].
 
===Microscopic===
Features:
*Corpus predominant inflammation.
*Increased G cells in the antrum.
***Increased gastrin level to try and stimulate (missing) parietal cells.
 
*See ''gastric atrophy'' section.


==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.
 
==Granulomatous gastritis==
*Usual DDx of granulomatous disease (see ''[[Basics]]'' article):
**DNF AAII:
***Drugs, Neoplasms, Foreign body, Autoimmune, Allergic, Infectious, Idiopathic.
 
Important ones:
*Autoimmune - [[Crohn's disease]].
*Infectious - Tuberculosis.
*Idiopathic - Sarcoidosis.
 
==Plasma cells in the stomach==
DDx of plasmacytosis:
*[[Plasma cell neoplasm]].
*[[Syphilis]].
*Chronic [[gastritis]].


==Gastritis cystitis profunda==
==Gastritis cystitis profunda==
*[[AKA]] ''Gastritic cystica profunda''.{{fact}}
===General===
===General===
*[[AKA]] ''Gastritic cystica profunda''. (???)
*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> (???)
*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.
*Super rare.
*Similar to ''[[cystitis cystica]]''.
*Similar to ''[[cystitis cystica]]''.
Line 482: Line 291:


==Ménétrier's disease==
==Ménétrier's disease==
*[[AKA]] ''diffuse foveolar cell hyperplasia''.<ref name=Ref_PCPBoD8_410>{{Ref PCPBoD8|410}}</ref>
{{Main|Ménétrier's disease}}
===General===
*Super rare.
*Increased risk of gastric adenocarcinoma.<ref name=Ref_PCPBoD8_410>{{Ref PCPBoD8|410}}</ref>


Clinical:<ref>{{Cite journal  | last1 = Rich | first1 = A. | last2 = Toro | first2 = TZ. | last3 = Tanksley | first3 = J. | last4 = Fiske | first4 = WH. | last5 = Lind | first5 = CD. | last6 = Ayers | first6 = GD. | last7 = Piessevaux | first7 = H. | last8 = Washington | first8 = MK. | last9 = Coffey | first9 = RJ. | title = Distinguishing Ménétrier's disease from its mimics. | journal = Gut | volume = 59 | issue = 12 | pages = 1617-24 | month = Dec | year = 2010 | doi = 10.1136/gut.2010.220061 | PMID = 20926644 }}</ref>
==Gastric xanthoma==
*Classic: nausea, emesis, abdominal pain and peripheral edema.
*Abbreviated ''GX''.
*[[AKA]] ''xanthelasma''.
*[[AKA]] ''stomach lipidosis''.
{{Main|Gastric xanthoma}}


Other:
==Gastric ischemia==
*Gastric mass (may mimic cancer).
:''Gastric necrosis'' redirects here.
*Hypochlorhydria.
===General===
*Protein loss - leads to peripheral edema.
*Rare.
*May arise due to:
**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>
**Therapeutic embolization.<ref name=pmid22020717/>


===Microscopic===
===Microscopic===
Features:<ref name=Ref_PCPBoD8_410>{{Ref PCPBoD8|410}}</ref>
Features:
*Foveolar cell hyperplasia - '''key feature'''.
*+/-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>
*[[Necrosis]] of the epithelium lining the gastric pits.


DDx:
Image:
*[[Cronkhite-Canada syndrome]].<ref name="pmid11428328">{{cite journal |author=Junnarkar SP, Sloan JM, Johnston BT, Laird JD, Irwin ST |title=Cronkhite-Canada syndrome |journal=The Ulster medical journal |volume=70 |issue=1 |pages=56–8 |year=2001 |month=May |pmid=11428328 |pmc=2449205 |doi= |url=}}</ref>
*[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>


Images:
==Portal hypertensive gastropathy==
*[http://path.upmc.edu/cases/case36.html Ménétrier's disease - crappy images (upmc.edu)].
*Abbreviated ''PHG''.
{{Main|Portal hypertensive gastropathy}}


==Gastric xanthoma==
==Amyloidosis of the stomach==
*Abbreviated ''GX''.
*[[AKA]] ''gastric amyloidosis''.
*[[AKA]] ''xanthelasma''.
{{Main|Amyloidosis}}
*[[AKA]] ''stomach lipidosis''.
===General===
===General===
*Uncommon.
*Very rare.
*Benign.
*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>


===Gross/endoscopic===
Endoscopic DDx:
*Yellowish nodule or plaque.<ref name=Ref_GLP111>{{Ref GLP|111}}</ref>
*[[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>
**Classically lesser curvature and antrum.<ref name=pmid6284833/>


===Microscopic===
===Microscopic===
Features:<ref name=Ref_GLP111>{{Ref GLP|111}}</ref>
Features:
*Collections of gastric lamina propria with lipid-laden macrophages.
*Lamina propria expanded by amorphous paucicellular material.
 
Image:
*[http://www.jmedicalcasereports.com/content/6/1/231/figure/F5 Stomach amyloidosis (jmedicalcasereports.com)].<ref name=pmid22863214/>


DDx:
===Stains===
*[[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>
*[[Congo red stain]] +ve.
*[[Whipple disease]].
*MAC infection.


Images:
==Eosinophilic gastritis==
*[http://www.flickr.com/photos/hemeguy/2911032670/in/photostream/ GX - low mag. (flickr.com)].
{{Main|Eosinophilic gastritis}}
*[http://www.flickr.com/photos/hemeguy/2911031464/in/photostream GX - high mag. (flickr.com)].


===IHC===
==Proton pump inhibitor effect==
*CD68 +ve.
*Abbreviated ''PPI effect''.
*Panker (AE1/AE3) -ve.
{{Main|Proton pump inhibitor effect}}


=Gastric polyps=
=Gastric polyps=
Line 542: Line 357:
*[[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]].


==Inflammatory fibroid polyp==
==Inflammatory fibroid polyp==
===General===
{{Main|Inflammatory fibroid polyp}}
*Benign.
*Through-out GI tract.
*Can be thought of as granulation tissue-like.<ref name=Ref_DCHH138/>
===Microscopic===
Features:<ref name=pmid20393746>{{Cite journal  | last1 = Daum | first1 = O. | last2 = Hatlova | first2 = J. | last3 = Mandys | first3 = V. | last4 = Grossmann | first4 = P. | last5 = Mukensnabl | first5 = P. | last6 = Benes | first6 = Z. | last7 = Michal | first7 = M. | title = Comparison of morphological, immunohistochemical, and molecular genetic features of inflammatory fibroid polyps (Vanek's tumors). | journal = Virchows Arch | volume = 456 | issue = 5 | pages = 491-7 | month = May | year = 2010 | doi = 10.1007/s00428-010-0914-8 | PMID = 20393746 }}</ref>
*Proliferating spindle cells (fibroid) - '''key feature'''.
**Loosely arranged, concentrically, around blood vessels.<ref name=Ref_GLP115>{{Ref GLP|115}}</ref>
**Perivascular hypocellular zones.<ref name=Ref_DCHH138>{{Ref DCHH|138}}</ref>
*Inflammation:
**Eosinophils - often prominent.
*+/-Leiomyoma/schwannoma-like areas - with nuclear palisading.<ref name=Ref_DCHH138>{{Ref DCHH|138}}</ref>
*+/-Vascular for fibrous tissue.
*Poorly circumscribed/infiltrates into the lamina propria.
 
DDx:
*[[Inflammatory myofibroblastic tumour]].
*[[GIST]] - usually sharply demarcated border.
 
Notes:
*Concentric = share the same centre.<ref>URL: [http://dictionary.reference.com/browse/concentric http://dictionary.reference.com/browse/concentric]. Accessed on: 29 November 2011.</ref>
 
Images:
*[http://commons.wikimedia.org/wiki/File:Inflammatory_fibroid_polyp_-_low_mag.jpg IFP - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Inflammatory_fibroid_polyp_-_high_mag.jpg IFP - high mag. (WC)].
 
===IHC===
Features:<ref name=pmid20393746/>
*CD34 +ve.
**There is a CD34 -ve variant.
*Vimentin +ve -- diffuse.<ref>{{Cite journal  | last1 = Kolodziejczyk | first1 = P. | last2 = Yao | first2 = T. | last3 = Tsuneyoshi | first3 = M. | title = Inflammatory fibroid polyp of the stomach. A special reference to an immunohistochemical profile of 42 cases. | journal = Am J Surg Pathol | volume = 17 | issue = 11 | pages = 1159-68 | month = Nov | year = 1993 | doi =  | PMID = 8214261 }}</ref>
 
Others:
*CD117 -ve.<ref name=pmid15163021>{{Cite journal  | last1 = Ozolek | first1 = JA. | last2 = Sasatomi | first2 = E. | last3 = Swalsky | first3 = PA. | last4 = Rao | first4 = U. | last5 = Krasinskas | first5 = A. | last6 = Finkelstein | first6 = SD. | title = Inflammatory fibroid polyps of the gastrointestinal tract: clinical, pathologic, and molecular characteristics. | journal = Appl Immunohistochem Mol Morphol | volume = 12 | issue = 1 | pages = 59-66 | month = Mar | year = 2004 | doi =  | PMID = 15163021 }}
</ref>
*S100 -ve.
 
===Molecular===
*A subset have mutations in PDGFRA.<ref name=pmid20393746>{{Cite journal  | last1 = Daum | first1 = O. | last2 = Hatlova | first2 = J. | last3 = Mandys | first3 = V. | last4 = Grossmann | first4 = P. | last5 = Mukensnabl | first5 = P. | last6 = Benes | first6 = Z. | last7 = Michal | first7 = M. | title = Comparison of morphological, immunohistochemical, and molecular genetic features of inflammatory fibroid polyps (Vanek's tumors). | journal = Virchows Arch | volume = 456 | issue = 5 | pages = 491-7 | month = May | year = 2010 | doi = 10.1007/s00428-010-0914-8 | PMID = 20393746 }}</ref>


==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'''.
 
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>
*[[Peutz-Jeghers polyp]].
 
Images:
*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)].
*[[WC]]:
**[http://en.wikipedia.org/wiki/File:Gastric_hyperplastic_polyp_%281%29_foveolar_type.jpg Gastric hyperplasia - low mag. (WC)].
**[http://en.wikipedia.org/wiki/File:Gastric_hyperplastic_polyp_%283%29_foveolar_type.jpg Gastric hyperplasia - high mag. (WC)].
 
==Adenomatous polyps==
===General===
*Divided into "gastric" and "intestinal type". (???)
 
*Can be 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> (???)
 
===Microscopic===
*Type.
**Intestinal: goblet cells or Paneth cells.
**Gastric: foveolar epithelium. (???)
*Architectural crowding of glands.
*Hyperchromasia of cytoplasm.
*Nuclear changes:
**Loss of nuclear polarity.
**Increased [[NC ratio]].
**Elongation of nucleus.


==Fundic gland polyp==
==Fundic gland polyp==
===General===
{{Main|Fundic gland polyp}}
*Most common stomach polyp.<ref name=pmid20567540/>
*''Fundic'' location - duh!
**May be in the body.<ref name=pmid20567540>{{Cite journal  | last1 = Spiegel | first1 = A. | last2 = Stein | first2 = P. | last3 = Patel | first3 = M. | last4 = Patel | first4 = R. | last5 = Lebovics | first5 = E. | title = A report of gastric fundic gland polyps. | journal = Gastroenterol Hepatol  (N Y) | volume = 6 | issue = 1 | pages = 45-8 | month = Jan | year = 2010 | doi =  | PMID = 20567540 }}</ref>
 
====Clinical significance====
*Weak association with FAP ([[familial adenomatous polyposis]]).<ref name=pmid20567540/><ref name=pmid18322941>{{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)].
 
Notes:
*The presence of dysplastic changes should prompt consideration of ''FAP''.


=Neoplastic=
=Neoplastic=
Line 667: Line 376:
#Gastric carcinoma.
#Gastric carcinoma.


==Gastric columnar dysplasia==
==Gastric dysplasia==
*[[AKA]] ''gastric dysplasia''.
{{Main|Stomach adenoma}}
 
==Gastric neuroendocrine tumour==
*[[AKA]] ''neuroendocrine tumour of the stomach'' and ''gastric NET''.
===General===
===General===
*Criteria similar to columnar dysplasia in the [[esophagus]].
*Behaviour dependent on the subtype.
*Uncommon.


Divided into:
====Overview of subtypes====
*Low grade.  
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>
*High grade.  
{| 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:
*WDNET = well-differentiated neuroendocrine tumour.
*WDNEC = well-differentiated neuroendocrine carcinoma.
*PDNEC = poorly-differentiated neuroendocrine carinoma.


===Microscopic===
===Microscopic===
 
:''See [[neuroendocrine tumours]]''
====Low-grade gastric columnar 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.
 
Images:
*[http://path.upmc.edu/cases/case431.html Low-grade gastric columnar dysplasia - several images (upmc.edu)].
 
====High-grade gastric columnar 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.
 
Images:
*[http://commons.wikimedia.org/w/index.php?title=File:High_grade_gastric_dysplasia_-_low_mag.jpg High grade gastric dysplasia - low mag. (WC)].
*[http://commons.wikimedia.org/w/index.php?title=File:High_grade_gastric_dysplasia_-_very_high_mag.jpg High grade gastric dysplasia - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Gastric_adenoma_(2).jpg Gastric adenoma (WC)].


=Neoplastic rare=
=Neoplastic rare=
Line 733: 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 749: Line 477:
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 760: Line 488:
Review paper: PMID 16950858.
Review paper: PMID 16950858.


==Familial gastric carcinoma==
==Hereditary gastric cancer==
*Signet ring carcinoma - associated with E-cadherin (CDH1<ref>{{OMIM|192090}}</ref>) mutation.<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>
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>
 
{| class="wikitable sortable"
==Gastric adenocarcinoma==
! Disease
===General===
! Gene
Epidemiology:
! Histology
*Associated with helicobacter infections, i.e. [[helicobacter gastritis]].
! Other
*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.
| [[Hereditary diffuse gastric cancer syndrome|Hereditary diffuse gastric cancer (HDGC) syndrome]]
 
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
Treatment:
| diffuse - more specifically [[signet ring cell carcinoma]]
*Surgical excision. 
| 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>
**Proximal tumours may require a complete gastrectomy as the stomach is innervated from its proximal part.
|-
| [[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<ref name=omim600185>{{OMIM|600185}}</ref>
| [[BRCA2]]
| ?
| ?
|}


====Classification====
==Gastric carcinoma==
*Two different classification schemes.
:Includes ''gastric adenocarcinoma''.
**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:
{{Main|Gastric carcinoma}}
***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).
 
===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)].
 
===IHC===
CK7 +ve.
CK20 -ve, occasionally +ve.


=See also=
=See also=
Michael
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