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Stomach is an important organ for pathologists. It is often inflammed and may be a site that cancer arises from. Gastroenterologists often biopsy the organ. Surgeon take-out the organ.

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).

Image: Stomach anatomy (


Foveolar cells vs. intestinal goblet cells

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

Stomach vs. intestine

  • Villin (+ve in small intestine).
  • PAS-D (+ve in foveolar epithelium).

Stomach vs. intestine[1]

Intestine Stomach
Spacing Goblets cell - spaced Folveolar 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 (???)
Villin stain +ve (???) -ve (???)
Images Tubular adenoma - goblet cells on right of image (WC) Gastric biopsy (


  • Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.[2]
  • Memory device: Folveolar cells have friends, i.e. they are close to other folveolar cells.


  • PMID 11984877.

Useful stains for stomach

  • Cresyl violet stain[3] - used to find H. pylori.[4]
  • Alcian blue - used to find mucin[5] which is present in intestinal metaplasia
    • Other mucins stains:[6] mucicarmine, PAS, PASD (doesn't stain glycogen)

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.



A specific cause is uncommonly identified histologically.

Gastritis causes:[7]

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

Endoscopic appearance

  • Erythematous.


  • Inflammatory cells - in particular.
    • Neutrophils (active gastritis) - especially when intraepithelial, or
    • Plasma cells (in lamina propria).
      • Various criteria:
        1. Two plasma cells kissing, i.e. two plasma cells touching/overlapping.
        2. Three is a crowd, i.e. three plasma cells in close proximity.

Sydney criteria for gastritis

A bunch of pathologists in Sydney came-up with criteria... and these were revised in Houston.[8]


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


  • Corpus = gastric body.
  • Incisura = angular incisure, incisura angularis (Latin) - notched transition point on lesser curvature of the stomach between pylorus and body.[9]


The Sydney group suggests grading severity with the following language:[8]

  • Mild.
  • Moderate.
  • Marked.

These terms are applied to the parameters described in a biopsy. The Sydney criteria lists H. pylori, neutrophils, mononuclear cells, antrum (atrophy), corpus (atrophy) and intestinal metaplasia. The paper that discusses this also give a visual analogue scale.

Parameters & Severity (adapted from Dixon et al.[8]):

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

Helicobacter spp gastritis

  • Several Helicobacter species can cause gastritis; H. pylori most common

Finding Helicobacter

  • Small - smaller than the nucleus of the gastric foveolar cell.
    • On 400x they are still possible to miss.
  • Commonly have a "v" shape.
  • Look close to the opening of the gastric glands.
  • Are often are found in groups.
  • Location - can be antrum and/or body.[10]
  • Helicobacter don't like the intestinal mucosa or mucosa that has undergone intestinal metaplasia -- you're unlikely to find 'em there.

Image: H pylori IHC -

Epidemiologic associations

Helicobacter infections are associated with:[11]

  • Gastritis.
  • Peptic ulcers.
  • Cancer.
    • Carcinoma.
    • MALT lymphoma.

Intestinal metaplasia


  • Goblet cells are present in the stomach.[12]
    • With cresyl violet vacuole stains blue.
    • With H&E vacuole may stain greyish.


  • Thought to be signifant risk to carcinoma.[13]
  • 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.

Gastric dysplasia


  • Criteria similar to those in adenomatous colonic polyps - see Microscopic.
  • Divided into:
    • Low grade.
    • High grade.
      • Nuclei no longer stratified.


  • Nuclear changes.
    • Nuclear crowding/pseudostratification.
    • Elongation of nuclei (cigar-shaped nuclei).
  • Cytoplasm - hyperchromatic.
  • Mitosis - particularily above the basement membrane.

Image: Gastric adenoma (

Gastric polyps

Similar to colonic polyps - see intestinal polyps.

DDx polyp (similar to colon & rectum):

  • Hyperplastic - most common, characterised by abundant elongated foveola + glands.
  • Hamartomatous - weriod stuff.
  • Inflammatory fibroid polyp - inflammation, myxoid stroma.
  • Fundic gland polyp - cystic dilation, flat epithelium.
  • Adenomatous polyp.

Hyperplastic polyp



  • Abundant foveolar cells and elongated glands


  • No atypical nuclei.
  • No hyperchromasia.
  • No loss of pseudostratification.


Adenomatous polyps

Divided into 'gastric' and 'intestinal type'[15]


  • Type.
    • Intestinal: goblet cells or Paneth cells.
    • Gastric: foveolar epithelium. (???)
  • Architectural crowding of glands.
  • Hyperchromasia of cytoplasm.
  • Nuclear changes:
    • Loss of nuclear polarity.
    • Incr. NC ratio.
    • Elongation of nucleus.

Fundic gland polyps


  • Fundic location - duh!



  • Polypoid shape (may not be appreciated on microscopy).
  • Dilated gastric glands.
    • Flatted epithelial lining - key feature.


  • Weak association with FAP (Familial Adenomatous Polyposis).[17]
  • Associated with chronic proton pump inhibitors (PPI) use -- approximately 4x risk.[18]


Gastric antral vascular ectasia


  • Abbreviated GAVE.
  • Antrum lesion - due dilated capillaries.
  • AKA watermelon stomach - due to characteristic endoscopic appearance.[20]

Gross/endoscopic appearance

  • Linear red streaks in antrum - oriented toward the pyloric valve... vaguely resembles a watermelon.

Endoscopic images:


  • Fibrin thrombi - characteristic feature.
  • Dilated capillaries in lamina propria.

Reactive gastropathy


  • May be seen in the context of a previous resection/surgical reconstruction, e.g. Billroth II.


  • Associated with...[22]
    • Excess acid.
    • EtOH.
    • Bile.
    • H. pylori.

Gastric cancer

Gastric lymphoma

  • MALT lymphoma = mucosa-associated lymphoid tissue lymphoma.
  • Associated with helicobacter infection.[23]


  • "Lymphoepithelial lesion" - gastric crypts invaded by a monomorphous population of lymphocytes.

IHC - work-up

  • Panker -- most useful.


  • CD3, CD20, CD138, kappa, lambda, Bcl-2.


  • Triple therapy (two antibiotics, proton pump inhibitor (PPI)).[24]
  • Surgery - if triple therapy fails.

Gastric adenocarcinoma


  • Two different classification schemes.
    • Lauren[25] - two types:
      • Intestinal type (mass forming).
      • Diffuse type (infiltrative).
    • WHO classification - 6 subtypes for adenocarcinoma (papillary, tubular, mucinous, signet-rign, undifferentiated, adenosquamous).[26]


  • Associated with helicobacter infections.
  • 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.


  • Adenocarcinoma - gland-forming lesion.
  • Signet ring carcinoma.


  • Surgical excision.
    • Proximal tumours may require a complete gastrectomy as the stomach is innervated from its proximal part.

See also


  1. ALS. 4 Feb 2009.
  2. Sternberg H4P 2nd Ed., P.484
  4. 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.
  7. PBoD PP.812-3.
  8. 8.0 8.1 8.2 8.3 Dixon MF, Genta RM, Yardley JH, Correa P (October 1996). "Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994". Am. J. Surg. Pathol. 20 (10): 1161-81. PMID 8827022.
  10. Maaroos HI, Kekki M, Villako K, Sipponen P, Tamm A, Sadeniemi L (October 1990). "The occurrence and extent of Helicobacter pylori colonization and antral and body gastritis profiles in an Estonian population sample". Scand. J. Gastroenterol. 25 (10): 1010-7. PMID 2263873.
  11. PBoD P.814.
  13. need one
  15. NEED ONE
  16. NEED REF.
  17. Freeman HJ (March 2008). "Proton pump inhibitors and an emerging epidemic of gastric fundic gland polyposis". World J. Gastroenterol. 14 (9): 1318-20. PMID 18322941.
  18. Jalving M, Koornstra JJ, Wesseling J, Boezen HM, DE Jong S, Kleibeuker JH (November 2006). "Increased risk of fundic gland polyps during long-term proton pump inhibitor therapy". Aliment. Pharmacol. Ther. 24 (9): 1341-8. doi:10.1111/j.1365-2036.2006.03127.x. PMID 17059515.
  19. Masaoka T, Suzuki H, Hibi T (May 2008). "Gastric epithelial cell modality and proton pump inhibitor". J Clin Biochem Nutr 42 (3): 191-6. doi:10.3164/jcbn.2008028. PMC 2386521. PMID 18545640. //
  20. Chatterjee S (July 2008). "Watermelon stomach". CMAJ 179 (2): 162. doi:10.1503/cmaj.080461. PMC 2443230. PMID 18625989.
  21. GILP P.118
  22. ALS 5 Feb 2009.
  23. Mbulaiteye, SM.; Hisada, M.; El-Omar, EM. (2009). "Helicobacter Pylori associated global gastric cancer burden.". Front Biosci 14: 1490-504. PMID 19273142.
  24. 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.
  25. PMID 14320675.
  26. PBoD P.823.