The Stomach That “Cracked” Under Pressure

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• Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 44): Collagenous gastritis
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Question: A 17-year-old girl presented to her general practitioner with an unrelated problem, and was noticed to look pale. She experienced mild fatigue, but was otherwise asymptomatic. Her menses were normal and there was no overt bleeding. Her body mass index was 23.5 kg/m², and she had adequate dietary intake of iron. There was no salicylate, non-steroidal anti-inflammatory, or alternative/herbal medication use. Her only medical history was eczema for which she used mometasone ointment topically. A third cousin had celiac disease, but family medical history was otherwise unremarkable. Physical examination revealed pallor only.

Her hemoglobin was 41g/L, with a mean corpuscular volume of 57.6 fl. Ferritin was 16 μg/L, iron 7 μmol/L, transferrin 36 μmol/L, and saturation 10%. Vitamin B12 and folate were normal, and HbA2 and HbF were negative. Tissue transglutaminase and antigliadin antibodies were negative, with normal IgA levels.

She subsequently underwent a gastroscopy. Initial view of the stomach showed multiple flat to raised islands of pink mucosa ranging from 2–20 mm in diameter, with intervening areas of paler-looking mucosa, distributed throughout the stomach (Figure A). After several minutes of distension with air, fresh blood started to ooze out from the pale intervening mucosa (Figure B). The duodenum was normal to the third part. Gastric biopsy revealed the underlying pathology (Figure C).

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What is this condition and how should it be managed?

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Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 44): Collagenous gastritis 

Histological examination of the gastric mucosal biopsy revealed collagenous gastritis. The patient also underwent a colonoscopy, which was normal endoscopically and histologically. She was managed conservatively with daily oral iron supplementation and regular monitoring of her hemoglobin and ferritin levels.

Collagenous gastritis is a condition of unknown etiology and of uncertain natural history. Current available information is limited to several published case reports and case series. Diagnosis relies on the histological finding of prominent subepithelial collagen deposition with band (>10μm) formation, and associated inflammatory infiltrates.¹ Endoscopically, the gastric mucosa appears nodular, which has been described as “geographical”. The diagnosis is usually made either during investigation for anemia or non-specific upper gastrointestinal symptoms, or in association with collagenous colitis. The condition has been reported in both pediatric and adult populations, and has been associated with a range of intestinal and autoimmune disorders such as collagenous colitis, lymphocytic colitis, lymphocytic gastritis, Coeliac disease, Hashimoto's thyroiditis, and polymyositis. Its malignant potential is unknown. There is currently no specific recommended treatment; use of corticosteroids or proton pump inhibitors have been reported with limited success.

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Reference 

1. Leung ST, Chandan VS, Murray JA, et al. Collagenous gastritis: histopathologic features and association with other gastrointestinal disease. Am J Surg Pathol. 2009;33:788–798
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