ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Finding in a Man With GERD Garrett M. Harp, Thomas DeRoche, and Brent W. Lacey Departments of Internal Medicine, Pathology, & Gastroenterology, Naval Medical Center San Diego, San Diego, California
Question: A 44-year-old man presented for evaluation of gastroesophageal reflux disease and episodic chest tightness lasting several months. Physical examination revealed a fit, well-appearing man without any abnormal findings. Despite resolution of pyrosis and regurgitation with a trial of omeprazole, he still had a sensation of chest tightness that occurred intermittently with eating and drinking. At that time, he denied dysphagia or odynophagia. He also denied abdominal pain, weight loss, fever, chills, nausea, vomiting, and changes in bowel movements. He noted that the symptoms occurred daily but did not prohibit him from eating a regular diet. Because he continued to have episodic chest pressure despite proton pump inhibitor therapy, we elected to proceed with esophagogastroduodenoscopy (EGD) to rule out a structural etiology. The EGD demonstrated a normal esophagus and duodenum. Survey of the stomach showed a lacy-white pattern of fibrosis with diffuse red nodules that were confluent in several areas and encompassed the entire mucosal surface of the stomach (Figure A–C). The patient’s chest discomfort resolved with dietary modifications and did not recur. We now believe the chest discomfort was likely owing to esophageal spasm related to acid reflux and unrelated to his gastric findings. Initial biopsies of the gastric mucosa were inconclusive for a causal etiology, so we elected to repeat the EGD to further evaluate and better characterize the nature of the abnormality. A repeat EGD 2 weeks later uncovered similar findings. Biopsy specimens from both procedures revealed no dysplasia or metaplasia (Figure D, E). There were no inflammatory processes in the remainder of the gastrointestinal tract on computed tomographic enterography and no perigastric lymphadenopathy was observed.
Gastroenterology 2014;147:e7–e9
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI What is your diagnosis? What medical treatments are available for the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.03.041
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 4: Collagenous Gastritis The biopsies showed a markedly thickened subepithelial collagen layer and a lymphoplasmacytic infiltrate with eosinophils, consistent with collagenous gastritis (Figure D, E). Collagenous gastritis a rare diagnosis diagnosed and characterized histologically. The histopathologic features include an irregularly thickened subepithelial collagen layer accompanied by a mixed inflammatory infiltrate in the lamina propria.1 In adult cases of collagenous gastritis, common presenting symptoms include anemia, diarrhea, and abdominal pain.1 Collagenous gastritis in adults may be an isolated diagnosis, but is frequently associated with microscopic colitis, celiac disease, collagenous sprue, and autoimmune conditions.1 Just as collagenous colitis may be a late manifestation of lymphocytic colitis, collagenous gastritis may be a late stage of a chronic inflammatory gastropathy.1 Currently, there are no consensus recommendations for surveillance and treatment of collagenous gastritis. Several agents have been used to treat collagenous gastritis with marginal results, including corticosteroids, ranitidine, omeprazole, misoprostil, sucralfate, 5-aminosalicylates, and a gluten-free diet.2 Budesonide, which is used to treat collagenous colitis, seems to produce some relief in cases of symptomatic collagenous gastritis.2 We elected not to treat this man because he was asymptomatic. This case demonstrates an unusual presentation of a rare diagnosis. It is the first reported adult case in which collagenous gastritis presented without anemia, localizing symptoms, or systemic illness.
References 1. 2.
Gopal P, McKenna BJ. The collagenous gastroenteritides: similarities and differences. Arch Pathol Lab Med 2010; 134:1485–1489. Leung ST, Chandan VS, Murray JA, et al. Collagenous gastritis: histopathologic features and association with other gastrointestinal diseases. Am J Surg Pathol 2009;33:788–798.
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Question: A 44-year-old man presented for evaluation of gastroesophageal reflux disease and episodic chest tightness lasting several months. Physical examination revealed a fit, well-appearing man without any abnormal findings. Despite resolution of pyrosis and regurgitation with a trial of omeprazole, he still had a sensation of chest tightness that occurred intermittently with eating and drinking. At that time, he denied dysphagia or odynophagia. He also denied abdominal pain, weight loss, fever, chills, nausea, vomiting, and changes in bowel movements. He noted that the symptoms occurred daily but did not prohibit him from eating a regular diet. Because he continued to have episodic chest pressure despite proton pump inhibitor therapy, we elected to proceed with esophagogastroduodenoscopy (EGD) to rule out a structural etiology. The EGD demonstrated a normal esophagus and duodenum. Survey of the stomach showed a lacy-white pattern of fibrosis with diffuse red nodules that were confluent in several areas and encompassed the entire mucosal surface of the stomach (Figure A–C). The patient’s chest discomfort resolved with dietary modifications and did not recur. We now believe the chest discomfort was likely owing to esophageal spasm related to acid reflux and unrelated to his gastric findings. Initial biopsies of the gastric mucosa were inconclusive for a causal etiology, so we elected to repeat the EGD to further evaluate and better characterize the nature of the abnormality. A repeat EGD 2 weeks later uncovered similar findings. Biopsy specimens from both procedures revealed no dysplasia or metaplasia (Figure D, E). There were no inflammatory processes in the remainder of the gastrointestinal tract on computed tomographic enterography and no perigastric lymphadenopathy was observed.
Gastroenterology 2014;147:e7–e9
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI What is your diagnosis? What medical treatments are available for the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.03.041
e8
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 4: Collagenous Gastritis The biopsies showed a markedly thickened subepithelial collagen layer and a lymphoplasmacytic infiltrate with eosinophils, consistent with collagenous gastritis (Figure D, E). Collagenous gastritis a rare diagnosis diagnosed and characterized histologically. The histopathologic features include an irregularly thickened subepithelial collagen layer accompanied by a mixed inflammatory infiltrate in the lamina propria.1 In adult cases of collagenous gastritis, common presenting symptoms include anemia, diarrhea, and abdominal pain.1 Collagenous gastritis in adults may be an isolated diagnosis, but is frequently associated with microscopic colitis, celiac disease, collagenous sprue, and autoimmune conditions.1 Just as collagenous colitis may be a late manifestation of lymphocytic colitis, collagenous gastritis may be a late stage of a chronic inflammatory gastropathy.1 Currently, there are no consensus recommendations for surveillance and treatment of collagenous gastritis. Several agents have been used to treat collagenous gastritis with marginal results, including corticosteroids, ranitidine, omeprazole, misoprostil, sucralfate, 5-aminosalicylates, and a gluten-free diet.2 Budesonide, which is used to treat collagenous colitis, seems to produce some relief in cases of symptomatic collagenous gastritis.2 We elected not to treat this man because he was asymptomatic. This case demonstrates an unusual presentation of a rare diagnosis. It is the first reported adult case in which collagenous gastritis presented without anemia, localizing symptoms, or systemic illness.
References 1. 2.
Gopal P, McKenna BJ. The collagenous gastroenteritides: similarities and differences. Arch Pathol Lab Med 2010; 134:1485–1489. Leung ST, Chandan VS, Murray JA, et al. Collagenous gastritis: histopathologic features and association with other gastrointestinal diseases. Am J Surg Pathol 2009;33:788–798.
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