Fatemeh Nejati-Shahidin

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UNIVERSITY OF MEDICINE AND PHARMACOLOGY IULIU HATIEGANU CLUJ -NAPOCA

GENERAL MEDICINE FACULTY

LICENSE THESIS

Scientific coordination:

Assistant Prof. Dr. Serban Radu

Graduate student:

Fatemeh Nejati-Shahidin

2013


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UNIVERSITY OF MEDICINE AND PHARMACOLOGY IULIU HATIEGANU CLUJ-NAPOCA

GENERAL MEDICINE FACULTY

LICENSE THESIS

CORRELATIONS BETWEEN ENDOSCOPY AND

HISTOLOGY IN CHILDREN'S WITH GASTRITIS

Scientific coordination:

Assistant Prof. Dr. Serban Radu

Graduate student:

Fatemeh Nejati-Shahidin

2013


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CONTENTS

1stPart - Theory

1. Introduction pag.62. Physiopathology of gastritis pag.6

2ndPart - Practical

1. Introduction pag.292. Material and Methods pag.303. Results pag.434. Conclusions pag.645. References pag.65


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License Fatemeh Nejati-Shahidin

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Theoretical Part


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INTRODUCTION

The term gastritis is often used loosely to cover any clinical condition in which upper

central abdominal discomfort or pain, heartburn and nausea or vomiting are conspicuous

symptoms while clinical signs and radiological examinations are negative. There is frequently

poor correlation between symptoms, endoscopic appearance and histology. Thus for accurate

diagnosis of gastric inflammation and of the state of the gastric mucosa, biopsy and subsequent

histological examination is essential.

It is preferable to reserve the term gastritis for appropriate histopathological changes.

With regard to terminology some authors now consider that gastritis should be limited to

mucosal changes associated with inflammation while non-inflammatory conditions should be

designated as gastropathy.

PHISIOPATHOLOGY

Mucosal defense mechanisms

It is usually possible to subdivide gastritis into acute and chronic forms, although the

etiology and pathogenesis of the two may overlap. Inflammation and ulceration of the gastric

mucosa occurs when the balance between aggressive and defense factors break down. The

fact that the stomach secretes hydrochloric acid and pepsinogen, which are implicated as

important final mediators of gastric damage, would render this balance precarious if there were

not a formidable set of defenses against the continuous threat of autodigestion. Thus before

detailed consideration of the various forms of gastritis and their sequel is undertaken it seems

reasonable to briefly consider gastric mucosal defense mechanisms. These can be divided into

several components.


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The sur face mucus layer and gastr ic mucosal barri er

The surface mucus layer constitutes the first line of defence for surface epithelial cells

and is composed of a thin layer of mucus adherent to the mucosal surface. Estimates vary but the

layer is thought to be around 180mm thick [1]. Experimental removal of this layer leads to

mucosal erosion [2]. The structure of the mucus layer is not affected in the short term by

exposure to bile, ethanol and very low pH. It thus limits potential damage due to such agents and

facilitates epithelial repair if damage occurs [3].

The efficacy of the protective surface mucus layer is enhanced by secretion of

bicarbonate by surface cells of the gastric mucosa which results in alkalinization of the overlying

mucus layer with subsequent protection against luminal acid [4].

Bicarbonate secretion is stimulated by a variety of agents including acid in the gastric and

duodenal lumen, cephalic stimulation and E-type prostaglandins [5]. The efficiency of the

protection given by the mucusbicarbonate layer is illustrated by a significant pH gradient across

the layer resulting in almost neutral pH on the mucosal side in contrast to the very acidic levels

on the luminal side [6].

The surface mucus layer is hydrophobic and this water repellent property is thought to

contribute to protection of the mucosa against autodigestion. The hydrophobic property is

conferred by surface-active phospholipid substances within the mucus gel. The protection

afforded by the mucus gel is severely compromised by substances such as luminal aspirin with

resultant damage to underlying surface mucosal cells. Prostaglandins provide some protection

against such damage and maintain a hydrophobic layer of mucus gel over the damaged area and

promote healing [7]. The surface-active phospholipid is produced from the lamellar bodies in

parietal cells and mucous neck cells [8] and the surfactant-like phospholipid forms a

multilayered surface coating which is invisible under electron microscopy using conventional

aldehyde fixation[9].

Davenport proposed the existence of a gastric mucosal barrier with surface cell

membranes and tight junctions between surface epithelial cells as its anatomical basis [10]. This

barrier restricts the back-diffusion of hydrogen ions from acid luminal contents into gastric

mucosa and also provides a transmucosal potential difference of around 50Mv [11].


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It thus provides mucosal protection against low luminal pH levels. The surface-active

phospholipid layer has similar properties to the barrier proposed by Davenport and is susceptible

to similar barrier breakers.

This layer may thus be a component of the gastric mucosal barrier [9]. In addition to

providing

protection, phospholipid acts as a lubricant and enhances mixing of gastric contents while

minimizing mechanical damage to the mucosa [8].

Epitheli al r enewal

The gastric mucosa has the ability to proliferate and replace damaged surface epithelial

cells very rapidly. The proliferative zone from which cells are replaced lies at the junction of the

base of the surface pits and the tip of the glands [12].

Experimental studies in the rat indicate that following ethanol-induced damage to the

gastric mucosa, complete restitution of mucosal integrity can occur within 15 min [4]. In other

species such as the frog, restoration of normal functional activity takes approximately 6 hours

[13]. Locally produced growth factors such as epidermal growth factor (EGF) synthesized in

salivary glands, Brunners glands and in small amounts in gastric mucosa, transforming growth

factor alpha (TGF-a) synthesized in gastrointestinal mucosa, and gastrin are thought to facilitate

mucosal repair [4,14] Mucosal injury is rapidly followed by a highly complex local sequence

designed to repair injury and restore the epithelial surface. This involves up-regulation of

numerous genes and expression of peptides and growth factors [15].

Mucosal blood flow

Fundamental to the protective components mentioned above is an adequate gastric

mucosal blood flow. Adequate blood flow enables the mucosa to dispose of hydrogen ions

diffusing in from the gastric lumen [16]. Experimental studies indicate that increased hydrogen

ion concentration in the lumen causes increased gastric mucosal blood flow, which, within limits,

maintains physiological levels of intramucosal pH [17]. Interruption of blood flow causes a rapid

fall in intramucosal pH and subsequent ulceration. Hypovolaemic shock results in focal

ulceration similar to that seen in acute erosive gastritis [18].


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Duodenal mucosa appears more sensitive to minor degrees of ischaemia while gastric

lesions appear only after a significant drop in mucosal blood flow [19].

Cytoprotection

Endogenous prostaglandins synthesized in the gastric mucosa from the precursor

arachidonic acid provide mucosal protection against noxious agents [20]. Prostaglandins have

many protective actions including stimulation of mucus secretion [21] and increase in gastric

mucosal blood flow [22]. Bicarbonate production by gastric and duodenal mucosa is also

stimulated [2325] and the protective layer of hydrophobic surface-active phospholipid is

maintained [24]. Adaptive cytoprotection whereby repeated exposure of the mucosa to mild

irritants confers protection is also thought to be associated with prostaglandins [25].

Prostaglandins also modulate the gastric mucosal inflammatory response by inhibiting

release of tumour necrosis factor (TNF) from macrophages [26] and TNF and other potentially

ulcerogenic inflammatory mediators from mast cells [27,28]. There is evidence that non-steroidal

anti-inflammatory drug (NSAID)-induced gastric mucosal damage is related to a reduction in

endogenous prostaglandin secretion [29,30].

Exogenous prostaglandin also attenuates experimentally induced aspirin damage and

maintains a hydrophobic mucus gel layer over damaged epithelium, thus aiding the healing

process [7].

Nitric oxide appears to have a similar role to that of prostaglandins in cytoprotection.

Suppression of endogenous nitric oxide increases susceptibility of the gastric mucosa to

experimental injury [31]. The exceedingly complex effects of various cytokines in cytoprotection

and wound healing are slowly becoming clarified. Both epidermal growth factor EGF and TGF-a

inhibit acid secretion and protect the gastric mucosa against experimentally induced damage

[14]. Removal of submandibular salivary glands, an important source of EGF which reaches the

stomach via saliva, results in an increased incidence and extent of experimentally induced

ulceration in rats [32]. TGF-a binds to the same receptor as EGF and is synthesized in gastric

mucosa. Production is markedly increased following mucosal injury, indicating a possible role

for the polypeptide in subsequent repair [33]. Lowering the concentration of TGF-a, which is

principally derived from macrophages and activated platelets, accelerates healing of

experimentally induced ulcers in rats but in contrast high concentrations of the cytokine are


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associated with excessive formation of extracellular matrix and scarring, a feature which may

predispose to ulcer relapse [34].

Following ulceration in the stomach and elsewhere in the gut, development of a novel

cell line is frequently induced from stem cells. This appears adjacent to the ulcer and grows in

proliferating buds into the lamina propria and eventually reaches the mucosal surface. This ulcer-

associated cell lineage (UACL) is capable of secreting EGF which may promote healing of the

ulcerated mucosa [35]. The UACL also secretes trefoil peptides. These peptides, so named

because of their cloverleaf-like molecular structure occur in three forms throughout the stomach

and intestine: TFF1/pS2, TFF2/pSP and TFF3/ITF [15]. TFF1 is expressed by surface cells of

UACL in the stomach while TFF2 is found in deeper glandular structures [36]. Some appear to

promote epithelial repair following ulceration [37] while targeted gene experiments indicate that

TFF1/pS2, which occurs in gastric mucosa, may promote differentiation of mucosal cells [38].

The UACL also induces TFF1/pS2 expression in adjacent goblet and neuroendocrine cells [39].

ACUTE EROSIVE/HEMORRHAGIC GASTRITIS (STRESS GASTRITIS) [40-47]

Acute erosive/hemorrhagic gastritis is characterized by an acute gastric injury with an

abrupt onset of abdominal pain and bleeding, usually associated with intake of alcohol,

nonsteroidal anti-inflammatory drugs (NSAIDs), or low hemodynamic state following major

trauma, presenting with multiple superficial erosions in the gastric mucosa and histologically

characterized by hemorrhage, mucosal defect, and superficial necrosis.

Clinical features

Patients present with abrupt onset of abdominal pain (burning epigastric pain), nausea,

vomiting, and gastrointestinal (GI) bleeding with melena, hematemesis, or occult bleeding.

Bleeding can be minimal and self-resolving or life threatening. Patients with aspirin- or alcohol-

induced injury usually make a quick recovery, whereas hypoperfusion-related gastritis (stress

ulcers) is associated with greater morbidity and mortality. Studies have found acute erosive

gastropathy as the cause of upper GI bleeding in 6% to 34% of cases; the other important causes


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of bleeding are peptic ulcer disease, esophageal varices, and Mallory-Weiss tear. Although more

often affecting older patients, the reported age range is 29 to 87 years.

The pathogenesis of acute hemorrhagic gastritis reflects an imbalance between mucosal

irritants such as acid, pepsin, bile salts, NSAIDs, and other chemicals versus mucoprotective

factors such as mucin, bicarbonates, prostaglandins, epidermal growth factors, mucosal blood

flow, and the remarkable ability of gastric mucosa to re-epithelialize.

1. Direct irritant action of chemical agents such as NSAIDs and alcohol resulting in mucosal

erosion, necrosis, and hemorrhage.

2. Additional injury by acid, pepsin, and bile salts that gain entry resulting from the disrupted

mucosal barrier.

3. NSAIDs with their cyclo-oxygenaseinhibiting action inhibit prostaglandins, which in turn

reduces bicarbonate and mucin secretions that have protective roles on the mucosal surface.

4. In cases of hypoperfusion-related stress ulcers, the pathogenesis is related to reduced gastric

mucosal blood flow, vasoconstriction, and reperfusion injury with release of free oxygen

radicals.

Pathologic features

Gross and endoscopic findings

Endoscopic examination has superseded radiologic tests in diagnosis and management.

Stress-related ulcers are mostly distributed in the fundus and body, whereas NSAID-related

erosive gastropathy is present in the antrum. The gastric erosions are multiple, 2 to 5 mm in

diameter, superficial, round, and dark. The intervening mucosa is edematous and hyperemic with

petechial hemorrhage.

Microscopic findings

Histologic findings may or may not be impressive owing mostly to the remarkable

capacity of stomach mucosa to re-epithelialize. Hence, depending on the interval of the gastritis

with the endoscopic biopsy, histologic changes range from subepithelial hemorrhage/superficial


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lamina propria hemorrhage, mucosal sloughing and necrosis, to neutrophil infiltration. Gastric

erosions are limited to the mucosa and do not extend beyond the muscularis mucosae. Gastric

ulcers, on the other hand, are deep, with extension beyond the submucosa. The healing phase is

associated with regenerative epithelium with increased mitotic activity, dark enlarged nuclei with

prominent nucleoli, amphophilic cytoplasm (a feature of active RNA synthesis), and syncytial

glandular architecture. These changes can be alarming and should not be mistaken for

malignancy. The presence of superimposed ulcer or erosion with active neutrophilic exudates is a

feature that should caution against making a diagnosis of malignancy.

Di ff erential diagnosis

Mallory-Weiss tear, peptic ulcers, esophageal variceal bleeding: clinical differentials ofupper GI bleeding.

Trauma related to nasogastric tube. Chronic active Helicobacter pylori gastritis: Onset is not acute as the name suggests.

Associated with superficial diffuse lymphoplasmacytic inflammation with neutrophilic

cryptitis. Modified Giemsa stain highlights the organisms.

Dysplasia, intramucosal carcinoma: True dysplastic change is present on the surface withnuclear stratification, hyperchromasia, and increased mitoses. There may be intestinal

metaplasia in the surrounding mucosa. Regenerative epithelial change is present in a setting

of erosion/ulcers, and the features are limited to deeper areas with presence of surface

maturation. The regenerative epithelial cells have abundant amphophilic cytoplasm,

prominent nucleoli, and smooth nuclear membrane.

Chemical gastropathy: chronic change associated with bile reflux, NSAIDs with mucosalelongation, smooth muscle hyperplasia in the lamina propria, and regenerative change.

Biopsy forceps trauma: commonly seen in mucosal biopsies and should not be mistaken foracute hemorrhagic gastropathy. Histologically characterized by superficial lamina propria

congestion without signs of injury or significant inflammation.

Prognosis and therapy

Most patients make an uneventful recovery within a short time period. Depending on the

hemodynamic state, management consists of supportive measures such as intravenous fluids and


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blood transfusion; stopping the offending agent, H2 blockers, proton pump inhibitors (PPIs),

prostaglandin analogues, and so forth. In cases of life-threatening bleeding, surgical intervention

may be necessary.

CHEMICAL (REACTIVE) GASTROPATHY [48-53]

Chemical gastropathy is a chemical-induced damage characterized by foveolar

hyperplasia, regenerative epithelial changes, smooth muscle proliferation in the lamina propria,

and vascular congestion of the gastric antral mucosa. Chemical gastropathy is synonymous with

type C gastritis, reactive gastritis, reactive gastropathy, and alkaline or bile reflux gastritis.

Clinical features

Chemical gastropathy is a fairly common diagnostic entity in gastric biopsies. Symptoms

range from vague upper abdominal pain to nausea, vomiting, gastroduodenal erosions or ulcers,

and GI bleeding. Both sexes show equal predilection. Etiologies include chronic aspirin or other

NSAID use, bile reflux following gastroenterostomies, vagotomy, and pyloroplasty. In

nonsurgical patients, bile reflux may be due to an incompetent pyloric sphincter or gastric

dysmotility. Other putative causes include alcohol intake and smoking. The pattern of injury in

chemical gastropathy reflects chronic repetitive bouts of injury followed by attempts at

regeneration and repair.

Pathologic features


The endoscopic findings are usually nonspecific, consisting of erythema and erosions in

the gastric antrum. Visible gastric bile staining on endoscopic examination can be helpful in

diagnosis.


The antral mucosa shows foveolar hyperplasia characterized by villiform change of the

surface epithelium and elongation and tortuosity of gastric pits with a corkscrew appearance. The


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surface epithelial cells are immature with cuboidal shape, depleted mucin, and enlarged nuclei,

which, when marked, can be mistaken for dysplasia. The lamina propria shows smooth muscle

proliferation and vascular congestion. There is usually a paucity of inflammatory cells. Focal

erosions may be associated with small pockets of neutrophils and eosinophils. The changes are

limited to the antrum. Chronic chemical gastropathy may also be associated with intestinal

metaplasia in the gastric antrum, which is thought to be the result of ulcer repair. Oxyntic

mucosa occasionally may show reactive changes of the surface, but the findings are usually

subtle. Bile reflux gastropathy following Billroth I-II surgery with antrectomy is present in the

body or fundus.

Histochemistry:

Giemsa (or immunohistochemical) stain forH. pyloriis negative Periodic acid-Schiff (PAS)/alcian blue at pH 2.5 is helpful (but not necessary for diagnosis)

in demonstrating depleted foveolar surface mucin


Hyperplastic polyp: The marked foveolar hyperplasia in chemical gastropathy may resemblehyperplastic polyps. On the other hand, small/early hyperplastic polyps with focal foveolar

hyperplasia may resemble chemical gastropathy. The endoscopic appearance of a

polyp/nodule is important in making the distinction.

Gastric antral vascular ectasia (GAVE): The typical endoscopic appearance of watermelonstomach and vascular thrombi in the lamina propria differentiate this entity.

Mucosa adjacent to an ulcer with foveolar hyperplasia and edema can histologicallyresemble chemical gastropathy. The clinical context of an ulcer is important in

distinguishing between these entities.

Mixed chemical/reactive gastropathy and chronic gastritis: This pattern can coexist inbiopsy samples and consists of a mild inflammation in the lamina propria and a

disproportionate degree of foveolar hyperplasia and edema. This mixed pattern may suggest

an overlap of chemical gastropathy in a background of mild chronic gastritis. Foveolar

hyperplasia, by itself, is not specific to chemical gastropathy and can also be seen with


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chronic H. pylori gastritis. However, the moderate to severe inflammation in H. pylori

associated gastritis is absent in chemical gastropathy.


This is a benign entity and management involves discontinuing the offending agents such

as NSAIDs and medical management with antisecretory drugs such as PPIs.

HELICOBACTER PYLORIGASTRITIS [54-71]

First described by Australian scientists J. Robin Warren and pathologist Barry J Marshall

in 1982, H. pylorigastritis is a chronic infectious form of gastritis caused by spiral, flagellated

gram-negative rods and characterized by superficial chronic active gastritis. H. pylorigastritis is

synonymous with Campylobacter pylori gastritis, diffuse antral gastritis, chronic superficial

gastritis, and type B gastritis.

Clinical features

Signs and symptoms include abdominal pain, nausea, vomiting, dyspepsia, weight loss,

iron deficiency anemia, and ulcer-related bleeding. H. pylori gastritis is a universal infection

prevalent in 50% of the worlds population. It is more prevalent in developing countries, where

up to 75% of population older than 25 years of age is infected, the prevalence reaching 80% to

90%. Most people acquire infection during childhood. Transmission of infection is human to

human, with poor sanitary conditions and overcrowding being risk factors. In developed

countries, the overall prevalence is 25% to 30%, and the seroprevalence ranges from 5% to 27%

in early childhood and exceeding 50% to 60% in adults older than 60 years of age. In the United

States, African Americans, Asian Americans, and Hispanics have a higher prevalence than

whites (70% versus 35%).

H. pyloriis a curved, gram-negative rod with S-shaped or seagull wing appearance. It is

motile, using single polar flagellum. It is a microaerophilic bacillus 0.5 m in width and 2.5 m


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in length. This organism has a tropism for gastric mucosa or metaplastic gastric mucosa in

organs such as the duodenum. The pathogenesis depends on its ability to colonize gastric

epithelium via adhesins such as BabA, SabA, urease; virulence factors such as Cag A, Vac A,

and urease, which in turn generates cytokines such as interleukin-8 to attract neutrophils.

The discovery of theHelicobacterorganism and its association with peptic ulcer disease,

gastric mucosaassociated lymphoid tissue (MALT) lymphoma, and carcinoma has

revolutionized modern understanding of disease processes and influenced patient management.

Warren and Marshall became the recipients of the Nobel Prize in Physiology or Medicine in

2005 for this significant discovery. The World Health Organization has classified H. pylorias a

group I human carcinogen of gastric cancer. Infected persons have a three- to six-fold greater

risk of developing gastric cancer over that of uninfected persons.

Pathologic features

Endoscopic findings

Endoscopic findings are variable and include gastric mucosal erythema, erosions,

granularity, and nodularity. The endoscopic appearance may even be normal, placing emphasis

on the value of histologic examination. There may be associated gastric and duodenal ulcers.

Mucosal nodularity simulating gastric lymphoma or carcinoma can be present. The nodularity isusually caused by florid lymphoid hyperplasia. For optimal evaluation, at least two mucosal

biopsy specimens, one each from the antrum and body, are recommended. Sampling of a single

site may reduce the test sensitivity.


H. pylori commonly colonizes both antrum and body mucosa. In severe infection, the

organisms can be present in biopsy samples of the cardia. The inflammation is prominent in the

superficial gastric mucosa and characterized by intense lymphoplasmacytic inflammation

admixed with neutrophils. Active or neutrophilic inflammation is prominent in the surface

epithelium and gastric pits, with cryptitis and crypt abscesses. Additional histologic features

include foveolar hyperplasia (not just limited to reactive gastropathy), degenerative changes,

erosion, hemorrhage, and lymphoid follicles.


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The organisms appear as slightly curved seagull wingshaped rods, most prominent in the gastric

mucus, overlying surface epithelium, and gastric pits. The organisms may be visible on

hematoxylin and eosin (H&E) examination, but adjunct stains are used and recommended to

confirm their presence. Active neutrophilic inflammation is usually a marker for the presence of

Helicobacter organisms.

Because of the widespread use of PPIs, it is not uncommon to find the Helicobacter

organisms in the body/fundus, but not in the antral mucosa: The changing microenviroment and

gastric pH may have a role to play. Often, the organisms are impossible to locate by

histochemical staining because of the coccoid shape and deep or even intracellular location

within glands, making it necessary to perform immunohistochemistry. This phenomenon also

emphasizes the need to educate GI specialists to obtain biopsy samples of the antrum and body,and to discontinue PPIs 2 weeks before the endoscopy, or else the infection may be missed.


Helicobacter heilmannii gastritis (Gastrospirillum hominis): Rare cause of Helicobactergastritis responsible for approximately 0.3% cases. Caused by a tight spiral bacterium that is

5 to 6 m in length, which is longer than H. pylori(Fig. 3-15A and B). It is also seen in cats

and dogs, raising the possibility of an animal source of infection. Because of their larger

size, they can be seen on H&E examination and are present in the gastric mucus and lumen

of gastric pits without coming in close contact with the epithelium. They are seen

intracellularly as well. Immunostain forH. pylorialso stainsH. Heilmannii, and treatment is

also the same.

Gastric marginal zone B-cell lymphoma or low-grade MALT lymphoma: The floridlymphoid hyperplasia in Helicobacter gastritis can be mistaken for low-grade MALT

lymphoma. However, immunostains for CD20 and CD3 demonstrate a reactive pattern

consisting of mixed T and B lymphocytes (CD20-positive in the germinal center B-cells and

mantle cuff, CD3-positive in peripheral T-lymphocytes). Unlike MALT lymphoma, which

is characterized by monomorphic B-cells extending below the muscularis mucosae,

Helicobacter gastritis causes superficial inflammation and lacks destructive

lymphoepithelial lesions. The neoplastic lymphoid cells in MALT lymphoma coexpress

CD20 and CD43 and may show light chain restriction. The intraepithelial lymphocytes in


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INFECTIOUS GASTRITIS [72-79]

The most common and important cause of infectious gastritis is H. pyloriinfection. The

following sections discuss various other etiologies of gastric infections. As is true with most

infections, these infections are more common in immunocompromised patients.

Viruses

Cytomegalovirus (CMV): The inclusions in CMV gastritis are often present in gastricglandular epithelium along with the mesenchymal cells such as endothelial cells and

fibroblasts. There are cytoplasmic and nuclear inclusions characterized by enlarged cells

with eosinophilic nuclear inclusions, perinuclear halo, and cytoplasmic reddish granules.

Infection of vascular endothelial cells causes a picture similar to ischemic gastritis can be

present on biopsies. Immunostains, molecular studies such as polymerase chain reaction,

and viral cultures are helpful adjunctive studies. CMV infection can present in children with

protein-losing enteropathy with enlarged gastric folds simulating Mntriers disease (MD).

Endoscopic appearance consists of gastric ulcers, polypoid lesions and may mimic an

infiltrative process. Diagnostic yield is increased by taking multiple biopsies from the base

as well as edge of an ulcer.

Herpes: Can rarely cause erosions and gastritis in immunosuppressed patients. Nuclearinclusions with ground-glass appearance and the three Ms: multinucleation, margination,

and moulding. Often associated with necrosis.

Bacteria

Mycobacteria tuberculosis: Still an important cause of infection in developing countries, thegranulomas show central caseation with Langerhans giant cells and lymphocytes. Stains for

acid-fast bacilli (often the organisms are very scarce, thus the need to use oil immersion)

and tuberculosis cultures are important. Patients can present with weight loss, anorexia,

night sweats, and indolent fever with symptoms of gastric outlet obstruction or bleeding

from an ulcer.

Mycobacterium avium intracellulare (MAI): Common opportunistic infection in patientswith acquired immunodeficiency syndrome (AIDS); the stomach is only rarely involved.


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The gastric mucosa is expanded by foamy histiocytes stuffed with acid-fast bacilli. Unlike

tuberculosis, granulomas are not a feature of MAI infection.

Syphilis: Presents with ulcers, thickened folds, and strictures (hourglass stomach). Intenseplasma cell infiltration, mononuclear vasculitis, presence of spirochetes, Treponema

pallidum. Silver stains such as Warthin-Starry are helpful.

Whipples disease

Fungal

Histoplasma Aspergillus, Mucor: Immunocompromised state; invasive forms are almost always fatal. Candida: Fungal colonization can be seen in approximately 20% of benign gastric ulcers.

The fungal yeasts and pseudohyphae are usually admixed in the ulcer exudate and do not

affect ulcer healing. Most ulcers heal with acid-suppressive medications and do not require

antimycotics. Nonhealing ulcers may benefit from fluconazole.

Parasites

Anisakiasis: Caused by ingesting raw fish and seen in countries such as Japan and theNetherlands.

Strongyloides stercoralis: Nematode infection; biopsy often shows all stages of the worm(adults, larva, eggs) embedded in crypts. Disseminated strongyloidiasis can be fatal.

Schistosoma mansoni. Cryptosporidiosis: Seen in patients with AIDS, although their prevalence is decreasing

owing to better and more widespread use of antiretrovirals.

Giardiasis: May rarely present in gastric mucosa with chronic atrophic gastritis and reducedgastric acidity. Invariably associated with intestinal giardiasis.

Phlegmonous (suppurative) gastritis

This is an almost invariably fatal condition detected in emergency laparotomy resection

of stomach or autopsy studies. Patients are usually older, alcoholic, and debilitated, with vague

abdominal pain and fever. The causative organisms are bacteria such as streptococci,


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staphylococci, Escherichia coli, and Proteus. The histologic section of stomach shows

predominantly submucosal and mural intense acute neutrophilic inflammation with necrosis and

mucosal sloughing. Gram stain demonstrates numerous gram-positive and gram-negative

bacteria. Acute emphysematous gastritis is a complication of phlegmonous gastritis, caused by

gas-producing bacteria such as Clostridium welchii. Grossly the gastric wall is crepitant.

EOSINOPHILIC GASTRITIS [80-84]

Eosinophilic gastritis is a manifestation of eosinophilic gastroenteritis (EG), a rare

inflammatory condition characterized by intense eosinophilic infiltration of the GI tract.

Synonyms include eosinophilic gastroenteritis and allergic gastroenteropathy.

Clinical features

The diagnostic criteria for eosinophilic gastroenteritis include (1) GI symptoms, (2)

histologic evidence of eosinophilic infiltration of the GI tract, (3) absence of eosinophilic

infiltration in extraintestinal organs, and (4) exclusion of known causes of eosinophilia, such as

parasitic infestation or drug reaction. Patients also present with history of allergy (50%), asthma,

food intolerance (52%), eczema, drug sensitivities, peripheral blood eosinophilia (80%), and

elevated serum immunoglobulin E levels. Although food intolerance has been postulated as an

etiologic factor, most cases lack a specific allergen and multiple allergens are cited as the cause.

Cytokines such as IL-5, IL-3, and eotaxins play an important role in the proliferation and

recruitment of eosinophils. EG may affect all races and any age group, although usually affecting

adults between 20 and 50 years of age. There is no sex predominance. Pediatric involvement is

common: 15% to 20% of cases are in children. Any part of the GI tract from the esophagus to the

rectum can be involved, and stomach antrum is the most common site of involvement.

Esophagus and small bowel are also commonly involved. Eosinophilic proctocolitis is seen mostoften in infants (an important cause of bloody stool) and is usually attributed to cows milk

allergy.

Eosinophilic gastritis can show preferential involvement of the mucosa, muscle layer, or

serosa (Klein classification). Symptoms depend on the site and extent of eosinophilic infiltration.


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Mucosal disease can present as abdominal pain, nausea, vomiting, diarrhea, weight loss,

malabsorption, protein-losing enteropathy, and anemia caused by GI bleeding. Patients with

involvement of submucosa and muscularis propria present with obstructive symptoms and

symptoms mimicking pyloric stenosis. Serosal involvement is characterized by eosinophilic

ascites, peripheral eosinophilia, and dramatic response to steroids. Rarely patients may present

with an acute abdominal emergency and perforation necessitating emergency laparotomy.

Radiologic features

Radiographic studies may demonstrate marked edema and thickening of gastric mucosal

folds, obstructive features (mural disease), or wall thickening.

Pathologic features


Gastric mucosa may be normal on endoscopic examination or reveal erosions, ulcerations

erythema, and nodularity.


Histologic examination is critical for diagnosis. Eosinophils are a normal cellular

component of the GI mucosa. Eosinophilic gastritis is characterized by intense eosinophilic

infiltration (>20 per high-power field) with prominent lamina propria eosinophils, intraepithelial

eosinophils, and eosinophilic crypt abscesses. The eosinophilic infiltration is accompanied by

epithelial damage, regenerative change, and marked edema. Eosinophils are the dominant cell

type and other inflammatory cells are not prominent. The presence of even small clusters of

eosinophils in the submucosa, muscularis, or serosa is abnormal. The eosinophilic infiltrate can

be patchy or diffuse, and mucosal biopsies can be nondiagnostic in up to 10% of cases. Multiple


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full-thickness and even open biopsies may be necessary to establish the diagnosis in cases with

only muscle or serosal involvement.


Parasitic infestation: Parasitic infestation is associated often with intense eosinophilicinfiltration surrounding parasitic ova, larvae, or nematode such as anisakiasis,

Strongyloides, and Ascaris. Careful histologic examination for ova and parasites and

stool examination is important.

Drugs such as gold, azathioprine, carbamazepine, enalapril, and co-trimoxazole can alsocause eosinophilia in the GI tract.

Hypereosinophilic syndrome: Fatal disease characterized by peripheral eosinophilia(>1500/mm3) and diffuse infiltration of eosinophils in various organs such as

myocardium, lungs, and GI tract.

Eosinophils can be focally prominent in gastric Crohns disease, gastric carcinomas,lymphomas, connective tissue disorder, vasculitis such as Churg-Strauss disease, and

peptic ulcer disease.

Langerhans cell histiocytosis: Seen mostly in children; eosinophils are intermixed withLangerhans histiocytes with elongated bean-shaped nuclei. These are positive for CD1a

and S-100 and show intracytoplasmic Birbeck granules on electron microscopy.

Mast cell disease: Eosinophils can mask mast cells, which are positive for mast celltryptase, CD117, and CD25. Special stains such as toludine blue and Giemsa also

highlight the cytoplasmic granules. History of skin urticaria may be helpful.

Inflammatory bowel disease (IBD): Eosinophils can be a prominent component of IBD;more prominent in colonic biopsies.

Inflammatory fibroid polyp: This is characterized by a prominent eosinophilicinfiltration but presents as a mass lesion.


Patients with eosinophilic gastroenteritis show an excellent response to steroids. Discontinuation

may be followed by relapse. Patients have also shown good response to oral sodium


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24

chromoglycate. Surgical resection may be necessary in patients with obstruction or in refractory

cases.

AUTOIMMUNE GASTRITIS (AUTOIMMUNE METAPLASTIC ATROPHIC

GASTRITIS) [85-97]

Autoimmune gastritis is an immune-mediated chronic gastritis in which the antibodies

are directed against gastric parietal cells and intrinsic factor, resulting in loss of oxyntic cells,

hypochlorhydria, achlorhydria, and vitamin B12deficiency. Autoimmune gastritis is synonymous

with type A gastritis, diffuse corporal atrophic gastritis, atrophic gastritis, autoimmune chronic

gastritis, and autoimmune-associated gastritis.

Clinical features

First described by Thomas Addison in 1849, autoimmune gastritis affects nearly 2% of

the population older than 60 years old and is responsible for less than 5% of chronic gastritis. It

was classically described in individuals of northern European or Scandinavian descent but is now

known to be equally represented in African Americans and Latin Americans. White females in

their 50s and 60s are affected more (male-to-female ratio, 1:3). Autoimmune gastritis is an

immune-mediated injury to the gastric oxyntic mucosa, and serum analysis frequently

demonstrates antiparietal cell antibodies targeted against H+/K+-ATPase in 60% to 85% and

intrinsic factor antibodies in 30% to 50%. Patients present with abdominal pain, weight loss,

diarrhea, malabsorption, and neurologic complications, such as peripheral neuropathy and

subacute combined degeneration of spinal cord related to severe vitamin B12 deficiency. Iron

deficiency anemia can be seen in 20% to 40% of patients, whereas pernicious anemia is seen in

15% to 25% of patients. Reduced gastric acid plays a role in iron deficiency because gastric acid

is necessary to release iron from bound protein, as well as reduce ferric iron to ferrous state

necessary for absorption. Pernicious anemia is characterized by macrocytosis, megaloblasts,

pancytopenia, atrophic glossitis, low serum B12 concentration, and normal folate level.

Pernicious anemia is a late manifestation of autoimmune gastritis, taking 20 to 30 years to

develop, and is caused by progressive loss of parietal cells, which are necessary for intrinsic


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25

factor production, as well as autoantibody targeted at intrinsic factor preventing the formation of

B12-intrinsic factor complex. Patients may have other autoimmune disorders such as insulin-

dependent diabetes mellitus, Hashimotos thyroiditis, adrenal insufficiency, Graves disease,

vitiligo, or myasthenia gravis.

Helicobacterinfection can also be associated with autoantibody formation, with studies

implicating antibodies againstH. pyloridirected at H+/K+-ATPase of the parietal cells, as are the

antiparietal cell antibodies in autoimmune gastritis.

Pathologic features


Autoimmune gastritis affects the gastric body and fundus and spares the antrum. On

endoscopic examination, the body mucosa appears shiny and red, resulting from effacement of

rugal folds, with a prominent submucosal vascular pattern, which becomes visible as a result of

mucosal atrophy. Patients may present with multiple pseudopolyps that represent preserved

islands of oxyntic mucosa surrounded by flattened body mucosa. Other associations include

hyperplastic polyps (most common polyps), multiple carcinoids, and even adenocarcinoma.


The histologic findings are limited to the body/fundic mucosa with normal antral findings

and consist of (1) chronic gastritis with prominent lymphocytic and plasma cell infiltration of the

lamina propria directed at oxyntic glands (the chronic inflammation often being more prominent

in the deeper mucosa), (2) loss of oxyntic glands (i.e., chief and parietal cells), (3) pseudopyloric

metaplasia (glands that resemble mucous glands in the antrum but lack gastrin cells), and (4)

intestinal metaplasia with goblet and Paneth cells. Pancreatic acinar metaplasia and mild active

inflammation may be present. Findings may vary depending on the stage of the disease. Biopsy

specimens taken during early stages show chronic gastritis and some loss of oxyntic glands, but

intestinal metaplasia may be lacking. It is not unusual to see parietal cell pseudohypertrophy in

this early active stage. In late stages, the oxyntic mucosa can resemble small intestine complete

with villi lined by absorptive, goblet, and Paneth cells (so-called complete intestinal metaplasia).


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26

The low serum B12 in pernicious anemia can cause megaloblastoid change of the foveolar

epithelium.

The antral mucosa is not atrophic and usually has chemical gastropathy or a mild chronic

gastritis. The low acid state created by the loss of parietal cells stimulates gastrin cell hyperplasia

in the antrum, which in turn causes nodular and linear hyperplasia of the enterochromaffin-like

(ECL) cells in the body responsible for histamine secretion. These appear as linear hyperplasias

(linear arrangement of five or more neuroendocrine cells) or small neuroendocrine nodules at

mucosal base. Patients may also have multiple carcinoid tumors, mostly in the body. However,

hyperplastic polyps are the most common polyps seen.

Immunohistochemistry

Gastrin immunostain is useful in distinguishing body mucosa (lacks G cells) from the

antral mucosa, which contains G cells. In autoimmune gastritis, when the body mucosa becomes

antralized resulting from destruction of oxyntic glands and pseudopyloric metaplasia, gastrin

immunostain can be useful to check the biopsy location, especially when unspecified in the

requisition form. Gastrin highlights the G-cell hyperplasia in the antrum. Rare gastrin-positive

cells may be seen in foci with intestinal metaplasia.

Chromogranin A highlights the linear and nodular ECL cell hyperplasia (see Fig. 3-18C),

as well as gastric carcinoids.

H. pyloristains are negative.


Environmental metaplastic atrophic gastritis (Table 3-4).

Pernicious anemia related to autoimmune polyglandular syndrome type I: Rare disorder

presenting in childhood and characterized by a generalized loss of GI endocrine cells

including gastrin cells, caused by antibodies directed against endocrine cells. Patients have a

low serum gastrin and do not have antiparietal cell antibody. The gastric body can resemble

autoimmune gastritis, and the loss of parietal cells is a result of the low serum gastrin (a


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27

trophic factor for parietal cells).


Autoimmune gastritis carries a 2% to 9% prevalence of gastric carcinoids and a twofold

to threefold increase in the prevalence of gastric adenocarcinomas. Gastric carcinoid tumors

associated with autoimmune gastritis are usually indolent.

Medical therapies include administering vitamin B12injections. In patients with multiple

carcinoids, management includes endoscopic polypectomies with close surveillance or

antrectomy. Antrectomy has been shown to cause resolution of the hypergastrinemic state,

leading to reduction in the size of carcinoids. Screening is not advocated at present given the

high cost-benefit ratio.


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28

Practical Part


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Introduction

Despite all modern achievements in diagnostic, histologic examination of a gastric

biopsy (multiple site biopsies) remains the GOLDEN STANDARD in gastritis diagnostic.

When childrens are involved, the international experience is limited, because the

standard in western counties is to perform endoscopic examination under general anesthesia,

which is hard to be accepted in childrens. In Romania, the endoscopic procedure is done only

with a slight sedation, for this reason, the experience in children gastritis is better here than

other western countrys or even Japan (the lieder in experience about gastric pathology in

adults).

For this reason, we try in this thesis to make a correlation between endoscopic

(macroscopic) aspects and histology, based on a particularly reach local experience.

Hpgastritis is usually asymptomatic in children in the absence of duodenal ulcer, but

sometimes it may produce abdominal pain, interpreted in many instances as a recurrent painful

abdomen.

The causal relationship betweenHpinfection and recurrent painful abdomen in children

is denied in several studies, while others report an increased prevalence ofHpinfection in these

children and considerable relief of symptoms following treatment forHperadication.

Endoscopically, antral location of gastric lesions, as well as antral nodularity, a

consequence of the development of lymphoid follicles in the mucosa of this area, represent

frequent findings, recorded in more than 50% of patients with Hp infection. Some authors

consider this aspect specific for pediatric patients of all age groups.

Histologically, antralHpgastritis represents the most severe form of this disease. The

inflammatory infiltrate is mainly composed of lymphocytes, plasmocytes and often eosinophilsin chronic gastritis; neutrophils are observed in acute or active chronic forms of the disease;

lymphoid follicles, usually present, especially in children, are considered virtually

pathognomonic.

The atrophy of the gastric mucosa is considered to be a preneoplastic stage in adults.

However, since it is not a histological element routinely searched in all endoscopic evaluations

in children, its prevalence varies in children from 0 to 72%, depending on various studies. The

majority of researches concern children infected with H. pyloriand, as a result, the prevalence

of gastric atrophy caused by other etiologies remains unknown. The studies undertaken in


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children include all histological grades of gastric atrophy and intestinal metaplasia, while the

researches performed in adults consider only severe and moderate degrees. That is why the

prevalence reported in children might have been overestimated.

Cases of intestinal metaplasia, also considered to be precancerous lesions in adults, have

been more rarely reported in children. The prevalence in children varies depending on authors:

some suggest that intestinal metaplasia is never associated withH. pyloriinfection, while others

report prevalence below 5%. One research reporting a prevalence of 21% of intestinal

metaplasia among patients infected with H. pylori suggests a visible relation between the

bacteria and this precancerous lesion. On the other side, a different theory considers that

intestinal metaplasia is a host defense reaction againstH. pyloriinfection.

In the precancerous cascade, the first recognized histological change is an active chronic

inflammation, which may persist either as a non-atrophic chronic gastritis (no gland loss), or as

an advance to multifocal atrophic gastritis (MAG), the first real step in the precancerous

cascade. The following steps are: intestinal metaplasia (first incomplete, then complete), then

dysplasia, initially of low grade, then high grade, the latter being equivalent with insitu

carcinoma. It is well known that infection with H. pylori causes chronic gastritis, in most cases

asymptomatic, while according to Correas theory, the precancerous cascade requires also the

time factor (correa 2012). As a result, early infection with H. pylori increases the risk of

developing gastric cancer, and we should be aware of when gastric atrophy and intestinal

metaplasia appears during childhood.

Aim

To evaluate the correlation between endoscopic and histological findings in pediatric patients

with gastritis.

Material and Methods

Our group of study consist in 175 children, admitted in Pediatric Clinic 1 for gastroduodenal

symptomatology between January 1, 2011 and June 30, 2013.

The study group was extracted from the data base of anatomic pathology laboratory of the

Childrens Hospital Cluj, and introduced in an Excel sheet for statistic analysis.


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Endoscopic and microscopic images where used for illustration of the entities from the

personal collections of dr. Radu Serban (gastroendoscopist in Pediatric Clinic 1) and dr. Dan Gheban

(pathologist of Childrens Hospital Cluj).

The endoscopic and microscopic descriptions where codified according to Sydney Classification

of Gastritis:

Endoscopic classes of gastritis

1. Erythematous gastritis2. Erosive gastritis3. Nodular gastritis4. Atrophic gastritis5. Reflux gastritis6. Normal mucosa7. Other types

Microscopic classes of gastritis

1. Acute reactive gastritis2. Chronic reactive gastritis

a. Without atrophyb. With atrophy

3. Infectious gastritisa. HP without follicular reactionb. HP with follicular reactionc. HH gastritis

4. Mixt gastritis (infectious and reactive/reflux gastritis)5. Normal mucosa6. Unknown etiology gastritis7. Lymphocytic gastritis


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Endoscopic examination

Figure 1: Component and controls of a standard gastroscope


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Figure 2: Schematic of a typical endoscope air, water and suction system

HISTOLOGIC TECHNIQUE

Histological slides were stained in HE and Giemsa.

Paraff in inclusion

Its the method that permits the inclusion of the piece in a solid environment, from which

there can be selected thin sections, successive, in a ribbon, so the lesion can be traced. It

undergoes all the stains after all the fixations.

Material.

Slightly changed paraffin by addition of 5-10% of bee wax to make it homogeny andfusible at 52-56 degrees.

Paraffin solvents: xilene, benzen or toluen. Paraffin oven, adjustable at 56 Celsius degrees. Carved plug bottles. Ethanol of different concentrations or dioxane. Borrel glass battery.


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Technique

First step after fixation and proper wash of the piece is dehydration. This is done with

ethanol, methanol or dioxane.

With ethanol. The piece is passed in successive bathes of ethanol:

o bath I: alcohol 80 degreeso bath II: alcohol 90 degreeso bath III: alcohol 95 degrees (or absolute)o bath IV: absolute alcoholo bath V: absolute alcohol

Each bathing takes 1-6 hours, dependent on the nature and volume of the piece.

Dehydration must be perfect, on it depending the clarity and inclusion.

With methanol. Out of the 5 ethanol bathes (as above), it continues with another 3 bathes

of methanol. From here it passes straight into paraffin for inclusion. Being toxic and irritative

to the respiratory system, there must be a lot of care at the process.

With dioxane. Two or three bathes with pure dioxane of 8 hour duration, from where it

goes straight into paraffin for inclusion.

Clarificationconsists in the alcohol removal from the sample (xilene, benzen or toluen).

The sample being removed from the last alcohol, it will pass through 3 bathes of xilen

(benzen or toluen) of a duration of 1-8 hours each, depending on the volume of the piece. When

the piece becomes semitransparent it is clear. The xilen bath time must not be extended as it

hardens then piece!

Paraffin-wax inclusion. Consists of the imbibing of the piece in paraffin.

From the last xilen bath, the piece passes through 3 successive 560C melted paraffin

bathes, with the objective consisting of the substitution of the reactive clarification in the piece.

The duration of the bathes varies between 1 and 8 hours, and even more, until the complete

liberation of the solvent, so the piece doesnt retract.

This technique can also be done automatically, using a automated processor of tissues

for paraffin inclusion.


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Figure 3: Automatic paraffin-wax inclusion device

Specimen inclusion in paraffin block. After the Leckardt bars have been placed to

form the perimeter of the block, the melted paraffin is poured (from the 3rd bath) until the top

level of the perimeter, then with a 600C heated pence the piece is removed from the last paraffin

bath and introduced into the new formation. It is then left to cool down.

Figure 4: Paraffin block production

Paraffin sectioning

Preparation of the block is made by cutting it up with a blade, in the shape of a

parallelepiped, with lateral faces, to obtain a continuous and straight ribbon from sectioning.


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The portobject piece of the microtome is heated up, over which the block is placed with

its base, producing a slight melt and then left to cool down. The block remains attached to the

portobject.

Figure 5:Circular vertical microtome

Sectioning is made using a circular or linear microtome.

Figure 6:Sectioning the paraffin block

Posting the sections on the slide. The skimmed slides, kept in alcohol, are dried and

waxed, in the moment of usage, with Mayer albumin, in a very thin layer.


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Note. Absolute Ethanol is prepared from 95 degree ethanol, from which water is

removed.

Many methods are used. The most frequent one is the copper sulfate method.By adding

95 degree alcohol with calcinated CuSO4, this will absorb the water from the alcohol. 1 Volume

of CuSO4 is added to 2 volumes of 95 degree alcohol; it is then passed through 3 jars with

CuSO4in a 24-48 hour interval. The jars will be well sealed with a carved close. After 3-5 days

it will filter. An absolute alcohol is obtained, with an acidic pH.

Calcination of the CuSO4, which is added in the shape of blue-green crystals, is done in

a porcelain capsule through moderate heating until the crystals become a white-shadowy

powder.

How is absolute alcohol tested? In a well or tube a slight bit of xilene is poured, over

which is added a drop of the tested alcohol. The absolute alcohol doesnt have to bruise the

xylene, it is an alcohol that contains under 3% water.

The antrachinon probe is more sensible. It shows the presence of traces of water. One

small quantity of test alcohol is added at 1mg of antrachinon and 4mg of sodium amalgam. If

the alcohol contains even traces of water, a red color is produced. If it is anhydric, a green

coloration is produced.

The following colorations have been practiced:

H-E Masson Trichrome

o Green light versiono Anilinic blue version

General technique of section staining

A.Preparing and staining of the sections

Paraffin sections, whom are already spread and blended to the slide, must first be

treated to erase the paraffin with which they were dipped, this not being miscible neither with

water nor alcohol. In this purpose, before staining, they must be deparaffinated and then

hydrated.

Deparaffination of the sections is made by passing the slides through bathes of paraffine

dissolvent (benzene, xylene or toluene). Usually being used a battery with 6 Borrel glasses, first


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3 with benzene (xylene or toluene), and the last 3 bathes of alcohol (I 96 degrees; II 80

degrees; III70 degrees).

Hydration. From the last alcohol, the sliders with sections are passed in 2-3 glasses of

distilled water.

It is recommended that when passing the slides from a bath to another, these are to be

rapidly wiped from the excessed dissolvent, as the paraffin it includes would deposit in the next

bathes. The same thing will be done when passing from one alcohol to another.

Figure 9:Manual deparaffination of slides

Stainingwill be done by passing the slides in the Borell glasses with colorants, whether

by placing the slide horizontally on a staining tray and turning a sufficient quantity of colorant

over it, and the second case consuming large quantities of colorants and reactive.


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Figure 10:Manual staining kit for histological slides

Figure 11:Manual staining procedure

To avoid drying the sections, becoming thus unusable, care must be taken in all these

stages (deparaffination operations, hydration and staining) sections being covered in liquids

from the glasses that form the respective baths.

The coloration technique can be completely automatized in services with high working

volume and well equipped.


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Figure 12:Automatic staining of histological slides

Mayer hematoxi l ine eozine stain ing

Acidulated Mayer hemalaun substance: 75 g of alaun is dissolved in heat in 1000ml of

distilled water. 75ml hematoxiline is filtrated in heat (from the base solution of 10%) and 0.30

g of Potassium iodate in water. Then it all accidulates in 100ml of solution, 0.5 ml of acetic

acid.

Eozine. It is boiled into a jar:

100ml alcohol 70 1g alcoholic eozine (Eosinblau siritus soluble) 1g watery eozine (Eosingelb aqua soluble) 0,25g orange G 1ml officinalisHCl acid

After cooling 20 ml of saturated liquid substance of lithium carbonate is added. It is filtered.

Lithium carbonate substance:100ml of distilled water + 15g of lithium carbonate.

Technique :

- Mayer hemalaun stain, 10 minutes;- Wash in water;- Clorhydric alcohol differentiation, 1-2 seconds;- Wash in water;- Change in lithium carbonate, 2-4 minutes;- Wash in water;


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- Eozine coloration, 2-3 minutes;- Wash in water;- Ethanol dropped on slide until no more eozine;- Dehydration with absolute and 95alcohol;- Clarification in fenicated xylene, xylene.- Mounting in Canadian fabric.

Results:

nucleus: dark blue cytoplasm: pink-red red cells: bright red collagen: pale pink elastic fibers: bright pink


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RESULTS

The study group of 175 childrens where with age between 1 and 19 yrs. old, 114 of

them being girls and the rest of 61 being boys.

Figure 13: Sex distribution of our 175 childrens study group.

84 of 175 children were admitted in 2011, 67 of 175 in 2012 and 24 in the first 6 month

of 2013.

This childrens where admitted in hospital for different reasons, starting with abdominal

pains and finishing with upper digestive tract hemorrhages.

The endoscopic examination of the study group have find:

1. Erythematous gastritis 97 cases2. Erosive gastritis 11 cases3. Nodular gastritis 20 cases4. Atrophic gastritis 6 cases5. Reflux gastritis 17 cases6. Normal mucosa 23 cases7. Other types 1 case

Girls Boys


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Fig.17:Acute reactive gastritis. Congestion and microhemorhages can be seen in the

superficial corion of the mucosa.

Fig.18:Chronic reactive gastritis with moderate atrophia of the mucosa.


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Fig.19:Chronic reactive gastritis with moderate atrophia of the mucosa (detail of the previous

image). Pseudovilous architecture of the mucoasa.

Fig.20:Follicular gastritis with HP. General aspect.


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Fig.21: Cryptic abscess generated by PMN migration in the crypt attracted by the presence of

HP.

Fig.22:The same cryptic abscess in Giemsa stain. In this stain the presence of HP become

visible.


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Fig.23.Higher magnification to see the characteristic HP image in Giemsa stain

Fig.24:The more elongated image of HH infection in Giemsa stain


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Fig. 25:Argentic impregnation to see the spiralate shape of HH infection


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Fig.26:Cocoid aspect of intracellular HP infection. Giemsa stain x1000

Fig.27:Microhemorhages and inflammation in a mixt gastritis.


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1. ERYTHEMATOUS GASTRITISBeing the most frequent endoscopic picture seen in our study group (56% of cases), the

microscopic examination of erythematous gastritis with a more or less intense congestion of the

mucosa revealed the next entities:

1. Acute reactive gastritis 31 cases2. Chronic reactive gastritis 17 cases

a. Without atrophy 9 casesb. With atrophy 8 cases

3. Infectious gastritis 16 casesa. HP without follicle formation 11 cases

b. HP with follicle formation 3 casesc. HH 2 cases

4. Mixt gastritis 2 cases5. Normal mucosa 26 cases6. Unknown etiology 5 cases

Figure 28:Distribution erythematous gastritis according with microscopic classes of gastritis

32%

17%

16%

2%

27%

5%

1%

Acute reactive Chronic reactive Infectious Mixt Normal Unknown lymphocitic


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Figure 29:The erythematous gastritis. Gastric mucosa with isolated more or less intense,

more or less extended congestion.

The data in figure 28 reveals that the erythematous picture of gastritis is a highly

nonspecific one, the microscopic counterpart of this endoscopic entity being almost the same

with the general microscopic distribution of cases, without any particularity.


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2. EROSIVE GASTRITISPresent in only 6% (11 cases) of our cases, this endoscopic description have at

microscopic level the next correspondence:

1. Acute reactive gastritis 8 cases2. Chronic reactive gastritis 0 cases3. Infectious gastritis 1 case

a. HP without follicle formation 1 case4. Normal mucosa 1 case5. Lymphocytic gastritis 1 case

Figure 30:Distribution of erosive gastritis according with microscopic classes of gastritis

73%

9%

9%

9%

Acute reactive Infectious Normal lymphocitic


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Fig.31:Characteristic endoscopic aspect of an erosive gastritis

As seen in figure 30, the most frequent microscopic equivalent of erosive gastritis is the

reactive acute gastritis, cause by bile reflux or exposure of the mucosa to toxic/corrosive

chemical substances like fast food, coca cola drink or drugs.

This correlation is highly significant (p


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3. NODULAR GASTRITISPresent in 11% (20 cases) this endoscopic picture is the second most common pathologic

aspect encountered in our pediatric study group. The microscopic equivalent for this endoscopic

entity was:

1. Acute reactive gastritis 1 case2. Chronic reactive gastritis 1 case

a. Without atrophy 1 cases3. Infectious gastritis 10 cases

a. HP without follicle formation 4 casesb. HP with follicle formation 6 casesc. HH 2 cases

4. Mixt gastritis 1 case5. Normal mucosa 5 cases6. Unknown etiology 2 cases

Figure 32:Distribution of nodular gastritis according with microscopic classes of gastritis

5%5%

50%5%

25%

10%

Acute reactive Chronic reactive Infectious Mixt Normal Unknown


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Figure 33:The characteristic nodular endoscopic appearance of the nodular gastritis

The analysis of this endoscopic picture, reveal that half of cases have infectious gastritis,

with HP or HH. Other 15% are with unknown etiology or mixt gastritis, in both situation HP

infection being very probably present in the history of the case. In the cases in which the

microscopic examination did not reveal the presence of follicular aggregates of lymphocytes,

is probable only a problem of sampling. But still remain 25% of cases in which the nodular

endoscopic aspect was associated with a histologically normal looking mucosa. Because of this

cases, the correlation between nodular endoscopic aspect and HP infection is significant

(p


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4. ATROPHIC GASTRITISThis endoscopic picture of gastritis, is rare in our children study group, being present in

only 3% of cases.

At microscopic level, the correspondence of this endoscopic description was:

1. Acute reactive gastritis 1 case2. Chronic reactive gastritis 3 cases


3. Infectious gastritis 1casea. HP without follicle formation 0 cases

b. HP with follicle formation 0 casesc. HH 1 case

4. Mixt gastritis 0 cases5. Normal mucosa 1 case6. Unknown etiology 0 cases

Figure 34:Distribution of atrophic gastritis according with microscopic classes of gastritis

16%

50%

17%

17%

Acute reactive Chronic reactive Infectious Normal


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Fig.35:The typical endoscopic image of an atrophic gastritis with accentuation of vascular

draw of the mucosa.

A study1 of from another Pediatric Clinic from Cluj, on much a number of cases

concluded that the prevalence of the atrophic gastritis was 9.2% (299 cases), mean age

10.015.49 years (CI95% 9.39-10.64), F/M ratio 1.62/1. The endoscopic appearance was not

characteristic for gastric atrophy, only 8.7% of the patients had endoscopic aspect of atrophic

gastritis. The majority of the patients presented grade 2 atrophy (219 cases; 141 female), other

65 (35 female) had grade 3 atrophy. 85 cases were associated with duodeno-gastric biliary

reflux, 24 with H. pylori infection and 8 had mixed etiology. 21 patients (0.64%) had intestinal

metaplasia (9 incomplete), 6 were boys. Atrophic gastritis is present in childhood, even at very

young age (infants, toddlers). The endoscopic appearance is not characteristic for the presence

of atrophy. The degree of atrophy and intestinal metaplasia are not correlated with the age of

1Data in curse to be published


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the children. H. pylori is not the only etiological factor of atrophic gastritis, biliary reflux

induced chemical injury can also lead to gastric mucosal atrophy.

Out data came with the same conclusions but in much smaller study group. The

correspondence between the endoscopic and microscopic atrophy was present in 50% of cases,

but the vice versa analysis, says that in more than half of cases with microscopic atrophy of the

mucosa (57%) the endoscopic appearance was of a nonspecific congestion (erythematous

gastritis), only 21% of cases being diagnosed as atrophy at endoscopic level.

5. REFLUX GASTRITIS

This particular Sydney endoscopic class gastritis described in 10% of our cases (17

cases), had at microscopic level the next correspondence:

1. Acute reactive gastritis 7 cases2. Chronic reactive gastritis 3 cases


3. Infectious gastritis 3 casesa. HP without follicle formation 1 case

b. HP with follicle formation 1 casec. HH 1 case

4. Mixt gastritis 0 cases5. Normal mucosa 5 case6. Unknown etiology 0 cases


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Figure 38:Distribution of normal looking mucosa according with microscopic classes of

gastritis

Fig.39:Normal gastric mucosa

5%

95%

Acute reactive Normal


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CONCLUSIONS

1. The endoscopic aspects in childrens with clinically diagnosed gastritis are:erythematous gastritis - 50%; erosive gastritis6%; nodular gastritis11%; atrophic

gastritis3%, reflux gastritis10%; normal mucosa13%; other aspects1%.

2. The histopathology of this childrens revealed: acute and chronic reactive gastritis 43%; infectious gastritis 18%, mixt gastritis 2%; normal mucosa 33% and

unknown etiology gastritis in 4% of cases.

3. Comparing with a similar histopathology study conducted 15 years ago in the samehospital, the reactive gastritis rise in incidence from 22% to 43%; the infectious gastritis

decreased from 33% to 18% and the mixt gastritis decreased from 14% to 2%. Also the

ability to put a etiological diagnosis increased significantly, the unknown etiology of

gastritis being reported in only 4% comparing with 30% in the past.

4. Erythematous gastritis, the most frequent endoscopic type of gastritis in childrens, is ahighly nonspecific picture, at microscopic level being reported all types of gastritis in

the same proportion as in general distribution.

5. Erosive gastritis described at endoscopy is highly correlated (p0.05).

9. Normal endoscopicaly looking mucosa had the best correlation with microscopy(p


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65

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