Gastritis Dd

8/3/2019 Gastritis Dd

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Update on the pathologicalclassification of gastritis

Hala El-Zimaity, M.D.M.S. Epidemiology

McMaster UniversityHamilton, Ontario

Canada


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CLASSIFICATION

GASTRITIS GASTROPATHY

Chemical gastropathy(NSAID/Bile reflux)

1.Acute2.Chronic

3.Uncommon Forms


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92%92%

58%58%

8%8%

Gastric UlcerGastric Ulcer

00

%%

99%99%

3030

%%

Duodenal UlcerDuodenal Ulcer

PercentPercent

ofof

GroupGroup

CAUSES OF PEPTIC ULCERCAUSES OF PEPTIC ULCER

100 Consecutive DU and 154 GU PATIENTS100 Consecutive DU and 154 GU PATIENTSVAMC, Houston

Hp POSITIVEHp POSITIVE

NSAID USERNSAID USER

NSAID ONLYNSAID ONLY

El-Zimaity HMT


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Case 1: 45 year old with dyspepsia

El-Zimaity HMT

Gastropathy= no acuteinflammation(unless thereis an erosion)


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Q: Should we care?

1. OTC analgesics including NSAID are widely

used, frequently taken inappropriately, andusers are generally unaware of potential foradverse side effects.

2. Can cause serious side effects includingdyspepsia, peptic ulcer, hemorrhage, and even

result in death.

El-Zimaity HMT


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Q1: HOW OFTEN DO YOU SEE

THE TRIAD?

Triad is only seen in 30 % ofchronic NSAID users.

Triad is most seen at incisura(less marked at other regions ofthe stomach).

Remaining 70%: edema

foveolar hyperplasia only

Fibrosis

FH only or SMF-H only

Incisura

El-Zimaity et al Hum Pathol 1996; 27(12): 1348-54El-Zimaity HMT

Chemical gastropathy is common; you willnot always see the triad; suggest it whensuspected


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CLASSIFICATION

GASTRITIS

1.Acute2.Chronic

3.Uncommon Forms


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GASTRITIS

ACUTE

H. pylori Other

Other bacteria

(Heilmanni,mycobacteria)

Syphilitic

Viral Parasitic

Fungal

Chronic

H. pylori(chronicatrophic gastritis)

Autoimmune (body

predominant)


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GASTRITIS

ACUTE

H. pylori Other

Other bacteria

(Heilmanni,mycobacteria)

Syphilitic

Viral Parasitic

Fungal

Chronic

H. pylori(chronicatrophic gastritis)

Autoimmune (body

predominant)


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Anatomy of The Stomach

WHAT IS NORMAL?

El-Zimaity HMT


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corpus

antrum

El-Zimaity HMT

Anatomy of The Stomach

Acid


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Anatomy of The CORPUS

corpus

antrum

Antrum-corpus junction

G cells

D cells

Parietal cells

ECL

Chief

ECL

corpus

Mucous

El-Zimaity HMT

acid


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NORMAL CORPUS

Chief

ECL

El-Zimaity HMT


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Anatomy of The ANTRUM

corpus

antrum

Mucous

Antrum-corpus junction

G cells

D cells

Parietal cells

ECL

antrum

El-Zimaity HMT


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Acid Secretion Pathophysiology

G cell Gastrin

Parietal cellFood

ACIDACID

El-Zimaity HMT

ECL


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Should you care?

If you speak Arabic you have H. pylori! Yes, you should care.

N b t i lik t h id


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corpus

antrum

El-Zimaity HMT

No bacteria likes too much acid

including H. pylori

Acid

H. pyloristarts its life in theantrum where it is less acidic


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No bacteria likes acidStarts in the antrum

H. pylorisurrounds itself with a bicarbonate cloud tocounter gastric acidity

(it produces urease which converts urea (abundant in saliva &

gastric juices) to ammonia and bicarbonate)C=0(NH2)2 + H+ +2H20 --urease--> HCO3- + 2(NH4)


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Acid Secretion Pathophysiology

G cell Gastrin

Parietal cell

Food/H. pylori

ACIDACID

El-Zimaity HMT

ECL


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Duodenal

Ulcer

G cell Gastrin

Parietal cell

Acid

ACIDACID

100 G cells

100 Parietal cells

El-Zimaity HMT


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Inflammation Depth-Duodenal Ulcer

MNC

PMN

H. pylori ACIDACID

Zone

1

2

3

Body

Zone

1

32

AntrumEl-Zimaity HMT

Inflammation in antrum only

I fl i D h D d l Ul


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Inflammation Depth-Duodenal Ulcer

MNC

PMN

H. pylori

Zone

1

3

2

Antrum

El-Zimaity HMT

H. pylori

toxins

Cytokines

Massive inflammatory response

Destroy stomach

A id S i


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Acid Secretion

G cell Gastrin

Parietal cell

ACIDACID

El-Zimaity HMT

ECL

Parietal cell

GASTRIC ATROPHYDestroyed corpus = no acid = bacteria moves proximal

Food/H. pylori

I fl i D h G i Ul


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Inflammation Depth-Gastric Ulcer

MNC

PMN

H. pylori

Zone

1

32

Antrum

ACIDACID

Zone

1

2

3

BodyEl-Zimaity HMT

Inflammation in both antrum and corpus


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Why is this important?

If patient is H. pyloripositive

Receives acid suppressor therapy withouttreating the infection (e.g. GERD patient andH. pyloriinfection missed)

You will help him develop gastric atrophy

El-Zimaity HMT

A id S ti


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Acid Secretion

G cell Gastrin

Parietal cell

Food/H. pylori

ACIDACID

El-Zimaity HMT

ECL

Parietal cell

G cell Gastrin

ECL

G cell Gastrin

ECL

HYPERGASTRINAEMIA

ECL HYPERPLASIA

PPI treatment = high pH


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ANTRAL MUCOSA

Before After PPIEl-Zimaity HMT


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CORPUS MUCOSA

Before After PPIEl-Zimaity HMT

VAMC, Houston


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Corpus gastritis Pan-atrophicAntral Predom.

Gastritis Stages

El-Zimaity HMT

G t iti St


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El-Zimaity et al Am J Gastro 2001;96:666-672

Gastritis Stages

B

A

B

A

B

A

A

B

A

A

Corpus atrophy

Normal corpus

Normal antrum

Atrophic border (antral corpus

junction) moves proximally andtowards greater curve with disease

progression.

El-Zimaity HMT

Endoscopic Recognition of the Atrophic Border


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Endoscopic Recognition of the Atrophic Border

Kimura and Takemoto 1969

Endoscopy 1969;1:87-97

Eastern (Japanese) beliefs

El-Zimaity HMT


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El-Zimaity HMT

Lesser curvature


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Greater curvature

Lesser curvature

Advancing atrophic borderEl-Zimaity HMT


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3 questions to answer if youalready decided it is H. pylori

1. Is it in the antrum only or antrum andcorpus?

2. If in the corpus, is inflammationsuperficial or deep?

3. Is there corpus atrophy?

El-Zimaity HMT


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Gastric atrophy

Absence of what is normally there:

Simple absence of glands (reduced thickness,increased fibrosis)

Replacement of what is normally there (with intestinal

metaplasia or pseudopyloric metaplasia)

Phenotypic corpus

Atrophy in Gastric cancer


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Tumor

Intestinal metaplasia I & II

Intestinal metaplasia III

Phenotypic antrum

12 %n = 2

Atrophy in Gastric cancer

(Intestinal type)(a) advancing atrophic border

(b) total atrophy of antrum

advancing atrophic bordertotal atrophy of the antrum

88 %n = 14

El-Zimaity HMT


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Isolated intestinal metaplasia = not importantEl-Zimaity HMT


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Continuous sheets of atrophy (IM and/PPM) is ominous

irrespective of IM subtypeEl-Zimaity HMT

Continuous sheets of atrophy (IM and/PPM) is


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PGI in Pseudopyloric metaplasiaEl-Zimaity HMT

ominous


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We know how to recognize intestinal

metaplasia How do we recognize pseudo-pyloric

metaplasia?


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El-Zimaity HMT


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Pepsinogen I (PG I) Anatomic Corpus


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(pseudopyloric metaplasia)

ANATOMIC CORPUS

PGI

PGI

El-Zimaity HMT

GASTRIC ANTRUM


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GASTRIC ANTRUM

PEPSINOGEN I GASTRIN

El-Zimaity HMT



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(pseudopyloric metaplasia)

ANATOMIC CORPUS Gastrin

El-Zimaity HMT

PSEUDO-PYLORIC METAPLASIA


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PPM starts as early as 9 years old.

Atrophy always starts at antral corpus junctionand moves proximally and towards the greater

curve.

Cardona et al Journal of Clinical Pathology; 2005;58(11):1189-93.El-Zimaity HMT

Two things to remember


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Two things to remember

1.Look for the Atrophic Front (starts atantral corpus junction)

2.Recognize all forms of atrophy(absence of normal or replacementwith intestinal metaplasia and/or

pseudopyloric metaplasia)El-Zimaity HMT

What about Pernicious Anaemia?


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What about Pernicious Anaemia?

Scandinavian decent

Auto immune gastritis Parietal cell and

Intrinsic Factor

antibodies-megaloblastic anemia

Three to five foldincreased risk ofgastric cancer

El-Zimaity HMT

GASTRITIS PATTERN


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PA

GASTRITIS PATTERN

El-Zimaity HMT

pernicious anaemia


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Big overlap in the literature since most PA

studies were done beforeH. pylori era; some

deny its existence!

El-Zimaity HMT

In any H Pylori Gastritis


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In any H. PyloriGastritis

H. pyloripositive

patient

Use patients serum

as primary antibody Parietal cells stain

dark blue

= autoantibodies in every day H. pylorigastritis

El-Zimaity HMT

PERNICIOUS ANEMIA


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-

+

+

D

ECL

G

PD

Gastric acid

+ +

PERNICIOUS ANEMIA

2. G cells increase in number

1. Parietal cells disappear early

3. ECL cells keep growing

Gas

trin

El-Zimaity HMT

Acid production drops

much faster in PA; so, H.pyloriand associatedinflammation movesproximally much faster.

Parietal cell antibodiesMany folds higher


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Chromogranin GrimeliusEl-Zimaity HMT

PERNICIOUS ANAEMIA


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PERNICIOUS ANAEMIA

Corpus atrophy with

gastric cancer risk (intestinal type)

ECL hyperplasia and

eventually carcinoidsEl-Zimaity HMT

QUESTIONS TO ANSWER IN


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GASTRIC BIOPSIES?

1. Is it normal? Is it a gastritis or agastropathy?

2. Why it looks like H. pyloribut no bacteriafound?

3. Is there atrophy?

Landmark for NORMAL lymphoid


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infiltratesmuscularis mucosae


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Lymphoid infiltrate:

Loose next to muscularis mucosae Normal=

El-Zimaity HMT

Lymphoid Follicles in H. pylori


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infection

Pre-treatmentHave marginal zone,

mantle, and follicle center

Post treatmentLymphoid tissue first disappear

from marginal zone, followedby mantle zone.


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If you found this in a 45 year old


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El-Zimaity HMT

y y

with dyspepsia (mucosa looks

Safety Pin Appearance HP


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y pp

El-Zimaity HMT

NOT ALL BACTERIA IN THE


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STOMACH ARE H. pylori With PPI use, the gastric pH increases

which allows other bacteria to survive inthe stomach.

Make sure you are really looking at H.

pylori. Look for squiggle bacteria withsafety pin appearance.

Causes of (apparent) H.pylori


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negative gastritis Proton pump inhibitors (omeprazole etc.)

Recent antibiotics or eradication therapy

Missed organisms - few bugs

Focal chronic active colitis - Crohnsdisease

Other types of gastritis (e.g. lymphocyticgastritis)

GASTRITIS


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1.Acute2.Chronic

3.Uncommon Forms

LymphocyticEosinophilicCrohn's disease

SarcoidosisIsolated granulomatous

Lymphocytic Gastritis


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Protein loss.

Ratio of 25 CD3+ IEL/100 epithelial cells (focal).

Usually accompanied by lamina propriaplasmacytosis

Celiac Disease, Gastric Lymphoma, MenetriersDisease.

H. pylori(low H. pyloricount)

El-Zimaity HMT

Lymphocytic Gastritis


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El-Zimaity HMT

Crohns Gastritis


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Same as any other part of thegastrointestinal tract

El-Zimaity HMT

1.Focal enhanced inflammation

2.Granulomas


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Gastritis (acute and chronic) is multifocalEl-Zimaity HMT


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Granulomas in the Stomach


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1. Focally enhanced

gastritis (acute andchronic)

2. Granuloma

H. pylori Granuloma basics:

IBD

T.B. Sarcoid

Foreign body

El-Zimaity HMT

Crohns

Reporting gastritis


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1. Where am I? (Site - Antral, Oxyntic,

Cardiac, Pangastritis, Focal)2. Is it a gastritis or a gastropathy?

3. Are there epithelial/vascular changes(e.g. dysplasia or cancer)?

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Gastritis Dd