Clin J Gastroenterol (2013) 6:442–446 DOI 10.1007/s12328-013-0431-9
CASE REPORT
A case of collagenous gastritis resembling nodular gastritis in endoscopic appearance Jun Tanabe • Masakazu Yasumaru • Masahiko Tsujimoto • Hideki Iijima Satoshi Hiyama • Akira Nishio • Yoshiaki Sasayama • Naoki Kawai • Masahide Oshita • Takashi Abe • Sunao Kawano
•
Received: 24 July 2013 / Accepted: 1 October 2013 / Published online: 20 October 2013 Ó Springer Japan 2013
Abstract A 25-year-old Japanese female was referred to our clinic for the investigation of moderate iron-deficiency anemia and epigastralgia. Endoscopic examination showed diffuse mucosal nodules in the gastric body resembling nodular gastritis, but this pattern was not observed in the antrum. Histology of the gastric biopsies taken from the gastric body showed mild atrophic mucosa with chronic active inflammation. Some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen. Four years later, the patient showed no clinical symptoms and signs. A follow-up endoscopic examination showed similar findings, which mimicked pseudopolyposis or a cobblestone-like appearance. The biopsy specimens from the depressed mucosa between the nodules revealed a thickened subepithelial collagen band with no improvement, which led to a diagnosis of collagenous gastritis. Treatment with oral administration of proton-pump inhibitors and histamine-2-receptor antagonists had proved ineffective. To make a correct diagnosis of collagenous
gastritis, we should determine the characteristic endoscopic findings and take biopsies from the depressed mucosa between the nodules.
J. Tanabe (&) Teramoto Memorial Nishitenma Clinic, AS Building 3F, 3-13-20 Nishitenma, Kita-ku, Osaka 530-0043, Japan e-mail: [email protected]
N. Kawai Endoscopy Center, Osaka Police Hospital, Osaka, Japan
M. Yasumaru Sankei Health Insurance Society Clinic, Osaka, Japan M. Tsujimoto Department of Pathology, Osaka Police Hospital, Osaka, Japan H. Iijima S. Hiyama A. Nishio Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan Y. Sasayama Department of Gastroenterology, Teramoto Memorial Hospital, Kawachinagano, Japan
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Keywords Collagenous gastritis Collagen band Pseudopolyposis Nodular gastritis
Introduction Collagenous gastritis is a rare entity of unknown etiology; its pathogenesis is characterized histologically by the presence of a thick subepithelial collagen band associated with an inflammatory infiltrate of gastric mucosa. It was first reported by Colletti and Trainer in 1989 [1], but reports of collagenous gastritis are rare. We present a young female with collagenous gastritis presenting with moderate iron-deficiency anemia.
M. Oshita Department of Internal Medicine, Osaka Police Hospital, Osaka, Japan T. Abe Department of Gastroenterology, Takarazuka Municipal Hospital, Takarazuka, Japan S. Kawano Hankyu Corp. Clinic, Nishinomiya, Japan
Clin J Gastroenterol (2013) 6:442–446
Case report In October 2008, a 25-year-old Japanese female was referred to our clinic for the investigation of moderate irondeficiency anemia and a 5-year history of epigastralgia. She had a history of gastric ulcer bleeding at 17 and 19 years of age. Laboratory data showed moderate iron-deficiency anemia, with measurements of hemoglobin (Hb) of 8.4 g/dl (normal range, 11.5–15.5 g/dl), mean corpuscular volume (MCV) of 65 fl (normal range 83–100 fl), and serum ferritin of 5 ng/ml (normal range 8–180 ng/ml). She had been almost continuously treated with oral proton-pump inhibitors since 2003 and had refused regular nonsteroidal anti-inflammatory drug treatment. A diffuse mucosal nodular pattern was observed in the body of the stomach on esophagogastroduodenoscopy (EGD) and a diagnosis of nodular gastritis was made (Fig. 1). The nodular pattern was not observed in the antral mucosa. The hematoxylin-eosin (HE) sections of the biopsy specimens taken from the gastric body showed mild atrophy and chronic active inflammation. Although we could not determine whether the biopsy specimens were taken from the nodular lesions or the mucosa between the nodules, some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen of less than 10 lm, which was highlighted with Masson trichrome (MT) stain. There were no Helicobacter pylori (Hp) either on the HE stain, Giemsa stain, or on immunohistochemical staining. Serum anti-Hp IgG antibody was negative (3.0 U/ml). The levels of serum pepsinogen I, pepsinogen II, and the pepsinogen I/II ratio were 54.7, 12.3 U/ml, and 4.4, respectively. These results ruled out Hp infection or gastric atrophy. She was admitted to another hospital because of tarry stools and severe anemia in May 2010. Since October
Fig. 1 Endoscopy revealing striking diffuse mucosal nodularity in the body of the stomach. 101 9 76 mm (300 9 300 DPI)
443
2008, she has refused nonsteroidal anti-inflammatory drug treatment. EGD, colonoscopy, and wireless capsule endoscopy did not show the source of the bleeding.
Fig. 2 a Endoscopy revealing pseudopolyposis, or cobblestone-like mucosal nodularity, in the body of the stomach. 101 9 76 mm (300 9 300 DPI). b Endoscopy revealing pseudopolyposis, or cobblestone-like mucosal nodularity, in the body of the stomach. 101 9 76 mm (300 9 300 DPI). c The mucosa of the gastric antrum is normal. 101 9 76 mm (300 9 300 DPI)
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Clin J Gastroenterol (2013) 6:442–446
Colonoscopy showed normal mucosal appearance and mucosal biopsies were not undertaken. After being treated with oral famotidine and omeprazole supplemented with iron, she was referred to our clinic for a follow-up endoscopic examination in October 2012. She showed no obvious symptoms, no abnormalities by
physical examination, and did not present anemia (Hb 14.2 g/dl, MCV 93.2 fl). EGD showed pseudopolyposis, or cobblestone-like mucosal nodularity, in the body of the stomach (Fig. 2a, b), but the appearance of the antrum was normal (Fig. 2c), similar to the previous EGD in October 2008. No lesions related to bleeding, such as an ulcer or
Fig. 3 a Biopsy specimens from the depressed lesion between the nodules revealing focal superficial epithelial degeneration and moderate infiltration of inflammatory cells in the lamina propria (H&E, 910). A thickened subepithelial collagen band (arrow) and a parietal cell protrusion (asterisk) are seen. 190 9 142 mm (300 9 300 DPI). b Masson trichrome (MT) stain of the biopsy specimens confirming a thickened subepithelial collagen band (arrow) (910). 190 9 142 mm (300 9 300 DPI). c A thickened
subepithelial collagen band measuring 16.5 lm (arrow) (MT, 940) 190 9 142 mm (300 9 300 DPI). d Dilated capillaries entrapped in the subepithelial collagen band (arrow) (H&E, 940). 190 9 142 mm (300 9 300 DPI). e Biopsy specimens of a nodular lesion showing almost normal findings with only mild infiltration of the inflammatory cells (H&E, 910). 903 9 677 mm (600 9 600 DPI). f No subepithelial collagen band is seen (MT, 910). 903 9 677 mm (600 9 600 DPI)
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Clin J Gastroenterol (2013) 6:442–446
cancer, were found. Biopsies were taken from the nodular lesion and the depressed mucosa between the nodules. HE stains of the biopsy specimens from the depressed lesion between the nodules revealed focal superficial epithelial degeneration, numerous intraepithelial lymphocytes, and dense lymphoplasmacytic infiltrates lacking lymphoid follicles with germinal centers in the lamina propria (Fig. 3a). No intestinal metaplasia was observed. All of the biopsy specimens from the depressed lesion showed a thickened subepithelial collagen band of greater than 10 lm that did not extend to deeper portions of the lamina propria, which was highlighted with MT stain (Fig. 3b, c). Some dilated capillaries containing red blood cells were entrapped in the subepithelial collagen band (Fig. 3d). Compared with the pathological findings in 2008, clear improvement was not found. The biopsy specimens of the nodular lesion showed almost normal findings with mild infiltration of the inflammatory cells (Fig. 3e), and no remarkable subepithelial collagen band was seen (Fig. 3f). We concluded the diagnosis was collagenous gastritis.
Discussion Collagenous gastritis is an extremely rare and poorly characterized disease. The diagnosis of collagenous gastritis is made histologically by irregular, focal subepithelial deposition of collagen greater than 10 lm in thickness, entrapping dilated capillaries, and inflammatory cells, similar to collagenous colitis [2]. The patients of collagenous gastritis are divided into two subgroups [3–5]. The first subgroup mainly includes children and young adults with iron-deficiency anemia and upper abdominal pain but no extragastric involvement [6]. The second subgroup mainly includes adults with chronic watery diarrhea and collagenous colitis. Our case is considered to belong to the first subgroup. The cause of anemia seen in patients with collagenous gastritis is unclear, but may be associated with gastric bleeding secondary to damage of dilated capillaries entrapped in the subepithelial fibrous band [7, 8]. The pseudopolyposis-like findings, or cobblestone appearance, in endoscopic images of collagenous gastritis are very typical [9, 10]. In 30 cases reviewed, endoscopy of collagenous gastritis was reported to show nodular appearance of gastric mucosa in 10 out of 17 children or young adults and in 2 out of 13 older adults [11, 12]. Nodularity of the gastric corpus appeared to be characteristic of collagenous gastritis, but cases with nodularity of the gastric antrum were included. In a report by Leung et al. [13], 4 of the 8 older adults showed nodular findings and 3 showed an atrophic pattern endoscopically. The nodular lesions are unaffected gastric mucosa, and
445
the depressed lesion between the nodules is the area damaged by collagenous gastritis. The nodular lesions appear not due to swelling of the mucosa, but are caused by the depression of the inflamed mucosa surrounding the nodules [12]. Collagenous gastritis has a characteristic of female predominance both in pediatric and adult cases [6, 7, 9]. Collagenous gastritis with pseudopolyposis in young females shows nodular appearance endoscopically, but it is not associated with Hp infection and the formation of lymphoid follicles, which are invariably seen in nodular gastritis [14]. Microscopic inflammation and atrophy of the gastric mucosa have been reported to usually occur in collagenous gastritis [1, 7, 12], but the etiology and the natural course of collagenous gastritis, including the cause of microscopic mucosal atrophy, are unknown. Nodular gastritis in young adults is characterized by antral nodularity. In our case, mucosal nodules were prominent in the gastric body, but were not seen in the gastric antrum. The nodules of collagenous gastritis are relatively intact gastric mucosa, but the nodules seen in nodular gastritis are an aggregation of lymphoid follicles with germinal centers. The fact that the depressed mucosa surrounding the nodules, which reflected subepithelial deposition of collagen, was narrow in width and closely gathered together in the gastric corpus might be one of the reasons our case resembled nodular gastritis in endoscopic appearance. Collagenous gastritis has been reported to be associated with massive upper gastrointestinal bleeding, but not accompanied by gastric ulcer or cancer [1, 9]. No specific therapy for collagenous gastritis has been established. Various treatments have been empirically tested, including corticosteroids, ranitidine, omeprazole, misoprostol, sucralfate, 5-aminosalicylates, and hypoallergenic diets, with little benefit [7]. Empirical treatments with proton-pump inhibitors or histamine-2receptor antagonists in patients with collagenous gastritis with upper abdominal pain may lead to a false negative result of Hp infection in the urea breath test or gastric biopsy specimens and parietal cell protrusion of gastric biopsy specimens [15]. Therefore, the status of Hp infection in collagenous gastritis should be assessed by using more than two methods, including anti-Hp IgG antibody. It is important to note that in young patients, such as this case, collagenous gastritis causes frequent gastric bleeding without obvious peptic ulcers and induces iron-deficiency anemia. By knowing the characteristic endoscopic findings of collagenous gastritis and taking biopsies from the depressed mucosa, we were able to make an accurate diagnosis of collagenous gastritis; this will also facilitate diagnosis of collagenous gastritis in future cases.
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446 Disclosures Conflict of Interest: The authors declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Colletti RB, Trainer TD. Collagenous gastritis. Gastroenterology. 1989;97:1552–5. 2. Vesoulis Z, Lozanski G, Ravichandran P, Esber E. Collagenous gastritis: a case report, morphologic evaluation, and review. Mod Pathol. 2000;13:591–6. 3. Lagorce-Pages C, Fabiani B, Bouvier R, Scoazec JY, Durand L, Flejou JF. Collagenous gastritis: a report of six cases. Am J Surg Pathol. 2001;25:1174–9. 4. Jain R, Chetty R. Collagenous gastritis. Int J Surg Pathol. 2010;18:534–6. 5. Suskind D, Wahbeh G, Murray K, Christie D, Kapur RP. Collagenous gastritis, a new spectrum of disease in pediatric patients: two case reports. Cases J. 2009;2:7511.
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Clin J Gastroenterol (2013) 6:442–446 6. Hijaz NM, Septer SS, Degaetano J, Attard TM. Clinical outcome of pediatric collagenous gastritis: case series and review of literature. World J Gastroenterol. 2013;19:1478–84. 7. Ravikumara M, Ramani P, Spray CH. Collagenous gastritis: a case report and review. Eur J Pediatr. 2007;166:769–73. 8. Coˆte´ JF, Hankard GF, Faure C, Mougenot JF, Holvoet L, Ce´zard JP, et al. Collagenous gastritis revealed by severe anemia in a child. Hum Pathol. 1998;29:883–6. 9. Jin X, Koike T, Chiba T, Kondo Y, Ara N, Uno K, et al. Collagenous gastritis. Dig Endosc. 2013;25:547–9. 10. Kamimura K, Kobayashi M, Narisawa R, Watanabe H, Sato Y, Honma T, et al. Collagenous gastritis: endoscopic and pathologic evaluation of the nodularity of gastric mucosa. Dig Dis Sci. 2007;52:995–1000. 11. Brain O, Rajaguru C, Warren B, Booth J, Travis S. Collagenous gastritis: reports and systematic review. Eur J Gastroenterol Hepatol. 2009;21:1419–24. 12. Stancu M, De Petris G, Palumbo TP, Lev R. Collagenous gastritis associated with lymphocytic gastritis and celiac disease. Arch Pathol Lab Med. 2001;125:1579–84. 13. Leung ST, Chandan VS, Murray JA, Wu TT. Collagenous gastritis: histopathologic features and association with other gastrointestinal diseases. Am J Surg Pathol. 2009;33:788–98. 14. Miyamoto M, Haruma K, Yoshihara M, Hiyama T, Sumioka M, Nishisaka T, et al. Nodular gastritis in adult is caused by Helicobacter pylori infection. Dig Dis Sci. 2003;48:968–75. 15. Stolte N, Meining A, Seifert E, Alexandridis T. Treatment with lansoprazole also induces hypertrophy of the parietal cells of the stomach. Pathol Res Pract. 2000;196:9–13.
CASE REPORT
A case of collagenous gastritis resembling nodular gastritis in endoscopic appearance Jun Tanabe • Masakazu Yasumaru • Masahiko Tsujimoto • Hideki Iijima Satoshi Hiyama • Akira Nishio • Yoshiaki Sasayama • Naoki Kawai • Masahide Oshita • Takashi Abe • Sunao Kawano
•
Received: 24 July 2013 / Accepted: 1 October 2013 / Published online: 20 October 2013 Ó Springer Japan 2013
Abstract A 25-year-old Japanese female was referred to our clinic for the investigation of moderate iron-deficiency anemia and epigastralgia. Endoscopic examination showed diffuse mucosal nodules in the gastric body resembling nodular gastritis, but this pattern was not observed in the antrum. Histology of the gastric biopsies taken from the gastric body showed mild atrophic mucosa with chronic active inflammation. Some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen. Four years later, the patient showed no clinical symptoms and signs. A follow-up endoscopic examination showed similar findings, which mimicked pseudopolyposis or a cobblestone-like appearance. The biopsy specimens from the depressed mucosa between the nodules revealed a thickened subepithelial collagen band with no improvement, which led to a diagnosis of collagenous gastritis. Treatment with oral administration of proton-pump inhibitors and histamine-2-receptor antagonists had proved ineffective. To make a correct diagnosis of collagenous
gastritis, we should determine the characteristic endoscopic findings and take biopsies from the depressed mucosa between the nodules.
J. Tanabe (&) Teramoto Memorial Nishitenma Clinic, AS Building 3F, 3-13-20 Nishitenma, Kita-ku, Osaka 530-0043, Japan e-mail: [email protected]
N. Kawai Endoscopy Center, Osaka Police Hospital, Osaka, Japan
M. Yasumaru Sankei Health Insurance Society Clinic, Osaka, Japan M. Tsujimoto Department of Pathology, Osaka Police Hospital, Osaka, Japan H. Iijima S. Hiyama A. Nishio Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan Y. Sasayama Department of Gastroenterology, Teramoto Memorial Hospital, Kawachinagano, Japan
123
Keywords Collagenous gastritis Collagen band Pseudopolyposis Nodular gastritis
Introduction Collagenous gastritis is a rare entity of unknown etiology; its pathogenesis is characterized histologically by the presence of a thick subepithelial collagen band associated with an inflammatory infiltrate of gastric mucosa. It was first reported by Colletti and Trainer in 1989 [1], but reports of collagenous gastritis are rare. We present a young female with collagenous gastritis presenting with moderate iron-deficiency anemia.
M. Oshita Department of Internal Medicine, Osaka Police Hospital, Osaka, Japan T. Abe Department of Gastroenterology, Takarazuka Municipal Hospital, Takarazuka, Japan S. Kawano Hankyu Corp. Clinic, Nishinomiya, Japan
Clin J Gastroenterol (2013) 6:442–446
Case report In October 2008, a 25-year-old Japanese female was referred to our clinic for the investigation of moderate irondeficiency anemia and a 5-year history of epigastralgia. She had a history of gastric ulcer bleeding at 17 and 19 years of age. Laboratory data showed moderate iron-deficiency anemia, with measurements of hemoglobin (Hb) of 8.4 g/dl (normal range, 11.5–15.5 g/dl), mean corpuscular volume (MCV) of 65 fl (normal range 83–100 fl), and serum ferritin of 5 ng/ml (normal range 8–180 ng/ml). She had been almost continuously treated with oral proton-pump inhibitors since 2003 and had refused regular nonsteroidal anti-inflammatory drug treatment. A diffuse mucosal nodular pattern was observed in the body of the stomach on esophagogastroduodenoscopy (EGD) and a diagnosis of nodular gastritis was made (Fig. 1). The nodular pattern was not observed in the antral mucosa. The hematoxylin-eosin (HE) sections of the biopsy specimens taken from the gastric body showed mild atrophy and chronic active inflammation. Although we could not determine whether the biopsy specimens were taken from the nodular lesions or the mucosa between the nodules, some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen of less than 10 lm, which was highlighted with Masson trichrome (MT) stain. There were no Helicobacter pylori (Hp) either on the HE stain, Giemsa stain, or on immunohistochemical staining. Serum anti-Hp IgG antibody was negative (3.0 U/ml). The levels of serum pepsinogen I, pepsinogen II, and the pepsinogen I/II ratio were 54.7, 12.3 U/ml, and 4.4, respectively. These results ruled out Hp infection or gastric atrophy. She was admitted to another hospital because of tarry stools and severe anemia in May 2010. Since October
Fig. 1 Endoscopy revealing striking diffuse mucosal nodularity in the body of the stomach. 101 9 76 mm (300 9 300 DPI)
443
2008, she has refused nonsteroidal anti-inflammatory drug treatment. EGD, colonoscopy, and wireless capsule endoscopy did not show the source of the bleeding.
Fig. 2 a Endoscopy revealing pseudopolyposis, or cobblestone-like mucosal nodularity, in the body of the stomach. 101 9 76 mm (300 9 300 DPI). b Endoscopy revealing pseudopolyposis, or cobblestone-like mucosal nodularity, in the body of the stomach. 101 9 76 mm (300 9 300 DPI). c The mucosa of the gastric antrum is normal. 101 9 76 mm (300 9 300 DPI)
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Clin J Gastroenterol (2013) 6:442–446
Colonoscopy showed normal mucosal appearance and mucosal biopsies were not undertaken. After being treated with oral famotidine and omeprazole supplemented with iron, she was referred to our clinic for a follow-up endoscopic examination in October 2012. She showed no obvious symptoms, no abnormalities by
physical examination, and did not present anemia (Hb 14.2 g/dl, MCV 93.2 fl). EGD showed pseudopolyposis, or cobblestone-like mucosal nodularity, in the body of the stomach (Fig. 2a, b), but the appearance of the antrum was normal (Fig. 2c), similar to the previous EGD in October 2008. No lesions related to bleeding, such as an ulcer or
Fig. 3 a Biopsy specimens from the depressed lesion between the nodules revealing focal superficial epithelial degeneration and moderate infiltration of inflammatory cells in the lamina propria (H&E, 910). A thickened subepithelial collagen band (arrow) and a parietal cell protrusion (asterisk) are seen. 190 9 142 mm (300 9 300 DPI). b Masson trichrome (MT) stain of the biopsy specimens confirming a thickened subepithelial collagen band (arrow) (910). 190 9 142 mm (300 9 300 DPI). c A thickened
subepithelial collagen band measuring 16.5 lm (arrow) (MT, 940) 190 9 142 mm (300 9 300 DPI). d Dilated capillaries entrapped in the subepithelial collagen band (arrow) (H&E, 940). 190 9 142 mm (300 9 300 DPI). e Biopsy specimens of a nodular lesion showing almost normal findings with only mild infiltration of the inflammatory cells (H&E, 910). 903 9 677 mm (600 9 600 DPI). f No subepithelial collagen band is seen (MT, 910). 903 9 677 mm (600 9 600 DPI)
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Clin J Gastroenterol (2013) 6:442–446
cancer, were found. Biopsies were taken from the nodular lesion and the depressed mucosa between the nodules. HE stains of the biopsy specimens from the depressed lesion between the nodules revealed focal superficial epithelial degeneration, numerous intraepithelial lymphocytes, and dense lymphoplasmacytic infiltrates lacking lymphoid follicles with germinal centers in the lamina propria (Fig. 3a). No intestinal metaplasia was observed. All of the biopsy specimens from the depressed lesion showed a thickened subepithelial collagen band of greater than 10 lm that did not extend to deeper portions of the lamina propria, which was highlighted with MT stain (Fig. 3b, c). Some dilated capillaries containing red blood cells were entrapped in the subepithelial collagen band (Fig. 3d). Compared with the pathological findings in 2008, clear improvement was not found. The biopsy specimens of the nodular lesion showed almost normal findings with mild infiltration of the inflammatory cells (Fig. 3e), and no remarkable subepithelial collagen band was seen (Fig. 3f). We concluded the diagnosis was collagenous gastritis.
Discussion Collagenous gastritis is an extremely rare and poorly characterized disease. The diagnosis of collagenous gastritis is made histologically by irregular, focal subepithelial deposition of collagen greater than 10 lm in thickness, entrapping dilated capillaries, and inflammatory cells, similar to collagenous colitis [2]. The patients of collagenous gastritis are divided into two subgroups [3–5]. The first subgroup mainly includes children and young adults with iron-deficiency anemia and upper abdominal pain but no extragastric involvement [6]. The second subgroup mainly includes adults with chronic watery diarrhea and collagenous colitis. Our case is considered to belong to the first subgroup. The cause of anemia seen in patients with collagenous gastritis is unclear, but may be associated with gastric bleeding secondary to damage of dilated capillaries entrapped in the subepithelial fibrous band [7, 8]. The pseudopolyposis-like findings, or cobblestone appearance, in endoscopic images of collagenous gastritis are very typical [9, 10]. In 30 cases reviewed, endoscopy of collagenous gastritis was reported to show nodular appearance of gastric mucosa in 10 out of 17 children or young adults and in 2 out of 13 older adults [11, 12]. Nodularity of the gastric corpus appeared to be characteristic of collagenous gastritis, but cases with nodularity of the gastric antrum were included. In a report by Leung et al. [13], 4 of the 8 older adults showed nodular findings and 3 showed an atrophic pattern endoscopically. The nodular lesions are unaffected gastric mucosa, and
445
the depressed lesion between the nodules is the area damaged by collagenous gastritis. The nodular lesions appear not due to swelling of the mucosa, but are caused by the depression of the inflamed mucosa surrounding the nodules [12]. Collagenous gastritis has a characteristic of female predominance both in pediatric and adult cases [6, 7, 9]. Collagenous gastritis with pseudopolyposis in young females shows nodular appearance endoscopically, but it is not associated with Hp infection and the formation of lymphoid follicles, which are invariably seen in nodular gastritis [14]. Microscopic inflammation and atrophy of the gastric mucosa have been reported to usually occur in collagenous gastritis [1, 7, 12], but the etiology and the natural course of collagenous gastritis, including the cause of microscopic mucosal atrophy, are unknown. Nodular gastritis in young adults is characterized by antral nodularity. In our case, mucosal nodules were prominent in the gastric body, but were not seen in the gastric antrum. The nodules of collagenous gastritis are relatively intact gastric mucosa, but the nodules seen in nodular gastritis are an aggregation of lymphoid follicles with germinal centers. The fact that the depressed mucosa surrounding the nodules, which reflected subepithelial deposition of collagen, was narrow in width and closely gathered together in the gastric corpus might be one of the reasons our case resembled nodular gastritis in endoscopic appearance. Collagenous gastritis has been reported to be associated with massive upper gastrointestinal bleeding, but not accompanied by gastric ulcer or cancer [1, 9]. No specific therapy for collagenous gastritis has been established. Various treatments have been empirically tested, including corticosteroids, ranitidine, omeprazole, misoprostol, sucralfate, 5-aminosalicylates, and hypoallergenic diets, with little benefit [7]. Empirical treatments with proton-pump inhibitors or histamine-2receptor antagonists in patients with collagenous gastritis with upper abdominal pain may lead to a false negative result of Hp infection in the urea breath test or gastric biopsy specimens and parietal cell protrusion of gastric biopsy specimens [15]. Therefore, the status of Hp infection in collagenous gastritis should be assessed by using more than two methods, including anti-Hp IgG antibody. It is important to note that in young patients, such as this case, collagenous gastritis causes frequent gastric bleeding without obvious peptic ulcers and induces iron-deficiency anemia. By knowing the characteristic endoscopic findings of collagenous gastritis and taking biopsies from the depressed mucosa, we were able to make an accurate diagnosis of collagenous gastritis; this will also facilitate diagnosis of collagenous gastritis in future cases.
123
446 Disclosures Conflict of Interest: The authors declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Colletti RB, Trainer TD. Collagenous gastritis. Gastroenterology. 1989;97:1552–5. 2. Vesoulis Z, Lozanski G, Ravichandran P, Esber E. Collagenous gastritis: a case report, morphologic evaluation, and review. Mod Pathol. 2000;13:591–6. 3. Lagorce-Pages C, Fabiani B, Bouvier R, Scoazec JY, Durand L, Flejou JF. Collagenous gastritis: a report of six cases. Am J Surg Pathol. 2001;25:1174–9. 4. Jain R, Chetty R. Collagenous gastritis. Int J Surg Pathol. 2010;18:534–6. 5. Suskind D, Wahbeh G, Murray K, Christie D, Kapur RP. Collagenous gastritis, a new spectrum of disease in pediatric patients: two case reports. Cases J. 2009;2:7511.
123
Clin J Gastroenterol (2013) 6:442–446 6. Hijaz NM, Septer SS, Degaetano J, Attard TM. Clinical outcome of pediatric collagenous gastritis: case series and review of literature. World J Gastroenterol. 2013;19:1478–84. 7. Ravikumara M, Ramani P, Spray CH. Collagenous gastritis: a case report and review. Eur J Pediatr. 2007;166:769–73. 8. Coˆte´ JF, Hankard GF, Faure C, Mougenot JF, Holvoet L, Ce´zard JP, et al. Collagenous gastritis revealed by severe anemia in a child. Hum Pathol. 1998;29:883–6. 9. Jin X, Koike T, Chiba T, Kondo Y, Ara N, Uno K, et al. Collagenous gastritis. Dig Endosc. 2013;25:547–9. 10. Kamimura K, Kobayashi M, Narisawa R, Watanabe H, Sato Y, Honma T, et al. Collagenous gastritis: endoscopic and pathologic evaluation of the nodularity of gastric mucosa. Dig Dis Sci. 2007;52:995–1000. 11. Brain O, Rajaguru C, Warren B, Booth J, Travis S. Collagenous gastritis: reports and systematic review. Eur J Gastroenterol Hepatol. 2009;21:1419–24. 12. Stancu M, De Petris G, Palumbo TP, Lev R. Collagenous gastritis associated with lymphocytic gastritis and celiac disease. Arch Pathol Lab Med. 2001;125:1579–84. 13. Leung ST, Chandan VS, Murray JA, Wu TT. Collagenous gastritis: histopathologic features and association with other gastrointestinal diseases. Am J Surg Pathol. 2009;33:788–98. 14. Miyamoto M, Haruma K, Yoshihara M, Hiyama T, Sumioka M, Nishisaka T, et al. Nodular gastritis in adult is caused by Helicobacter pylori infection. Dig Dis Sci. 2003;48:968–75. 15. Stolte N, Meining A, Seifert E, Alexandridis T. Treatment with lansoprazole also induces hypertrophy of the parietal cells of the stomach. Pathol Res Pract. 2000;196:9–13.
