Gastritis

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Gastritis
Diagnosis in short

Chronic gastritis. H&E stain.

LM acute: PMNs in the lamina propria or intraepithelial; (usual) chronic: cluster of plasma cells (mild), several clusters (moderate), +/-mucosal erosions (severe); lymphocytic: intraepithelial lymphocytes (25 lymphocytes/100 epithelial cells)
Subtypes acute gastritis, chronic gastritis, focal acute gastritis (pill gastritis), lymphocytic gastritis
LM DDx Helicobacter gastritis, collagenous gastritis, Crohn's disease, intestinal metaplasia of the stomach, gastric columnar dysplasia, gastric carcinoma
Stains Diff-Quik -ve, cresyl violet -ve
IHC Helicobacter -ve
Site stomach

Associated Dx intestinal metaplasia of the stomach - esp. in chronic gastritis
Clinical history dyspepsia
Symptoms upper abdominal pain
Prevalence very common
Blood work H. pylori -ve or previously +ve
Endoscopy erythema
Prognosis good
Other neg. Helicobacter breath test
Clin. DDx reactive gastropathy

Gastritis refers to an inflammatory process that affects the stomach.

There are several types of gastritis:

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

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

General

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

Clinical:

  • Dyspepsia - esp. upper abdominal pain.

Etiology

Gastritis causes:[1]

Endoscopic appearance

  • Erythematous.

Microscopic

  • Inflammatory cells - see below.

Acute gastritis

  • AKA active gastritis.

Features:

  • Neutrophils - especially when intraepithelial.

Focal active gastritis

DDx:

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

Chronic gastritis

Features:

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

Note:

Images

Sydney criteria for gastritis

A bunch of pathologists in Sydney came-up with criteria... and these were revised in Houston.[4]

Classification

Updated Sydney classification:[4]

Feature Non-atrophic Helicobacter Atrophic Helicobacter Autoimmune
Inflammation pattern antral or diffuse antrum & corpus, mild inflammation corpus only
Atrophy & metaplasia nil atrophy present, metaplasia at incisura corpus only

Notes:

  • Corpus = gastric body.
  • Incisura = angular incisure, incisura angularis (Latin) - notched transition point on lesser curvature of the stomach between pylorus and body.[5]

Severity

The Sydney group suggests grading severity with the following language:[4]

  • 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.[4]):

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

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Minimal chronic inactive

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

Mild chronic inactive

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

Block letters

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

Moderate chronic inactive antrum with mild chronic inactive body

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

Moderate chronic active

STOMACH, BIOPSY: 
- Body and antral-type gastric mucosa with moderate chronic active inflammation.
- NEGATIVE for Helicobacter-like organisms.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy. 
Block letters
STOMACH, BIOPSY: 
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITH MODERATE CHRONIC ACTIVE INFLAMMATION. 
- NEGATIVE FOR HELICOBACTOR-LIKE ORGANISMS. 
- NEGATIVE FOR INTESTINAL METAPLASIA. 
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Severe active

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

Comment:
Follow-up is suggested.

Sleeve gastrectomy

Partial Stomach, Sleeve Gastrectomy:
- Stomach wall with focal mild chronic inactive inflammation of the mucosa.
- NEGATIVE for Helicobactor-like organisms.
- NEGATIVE for intestinal metaplasia.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
Alternate
Partial Stomach, Sleeve Gastrectomy:
	- Stomach wall with mild chronic inactive inflammation of the mucosa, otherwise 	  
          within normal limits.
Block letters
STOMACH, GREATER CURVATURE, SLEEVE GASTRECTOMY:
- STOMACH WALL WITH FOCAL MILD CHRONIC ACTIVE INFLAMMATION OF THE MUCOSA.
- NEGATIVE FOR HELICOBACTOR-LIKE ORGANISMS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Micro - inactive

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

See also

References

  1. Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 812-3. ISBN 0-7216-0187-1.
  2. Parfitt, JR.; Driman, DK. (Apr 2007). "Pathological effects of drugs on the gastrointestinal tract: a review.". Hum Pathol 38 (4): 527-36. doi:10.1016/j.humpath.2007.01.014. PMID 17367604.
  3. Voutilainen, M.; Färkkilä, M.; Mecklin, JP.; Juhola, M.; Sipponen, P. (Nov 1999). "Chronic inflammation at the gastroesophageal junction (carditis) appears to be a specific finding related to Helicobacter pylori infection and gastroesophageal reflux disease. The Central Finland Endoscopy Study Group.". Am J Gastroenterol 94 (11): 3175-80. doi:10.1111/j.1572-0241.1999.01513.x. PMID 10566710.
  4. 4.0 4.1 4.2 4.3 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. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=20&issue=10&spage=1161.
  5. http://en.wikipedia.org/wiki/Angular_incisure