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Gastric Epithelium in the Duodenum

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Gastric Epithelium in the Duodenum Gut: first published as 10.1136/gut.5.4.285 on 1 August 1964. Downloaded from Gut, 1964, 5, 285 Gastric epithelium in the duodenum A. H. JAMES From the Medical Unit, Cardiff Royal Infirmary, Cardiff, Wales EDITORIAL SYNOPSIS It has been found that a 'gastric' type of epithelium tends to develop in the first part of the duodenum in patients with duodenal ulceration and is found in the second part of the duodenum in a patient with the Zollinger-Ellison syndrome. It is likely that 'gastric' epithelium appears when the duodenal acidity is high and it is resistant to ulceration. The stomach is normally lined by one kind of that the epithelium was either normal or more often epithelium and the duodenum by another. Islands undifferentiated, the cells having deeply stained of intestinal epithelium have long been known to nuclei and cytoplasm, and showing multiple layering; occur in the stomach, particularly when gastric goblet cells tended to be lacking in such cases. The acidity is low: this paper describes islands of gastric published photomicrographs are not of sufficient epithelium in the duodenum; they are especially magnification to exclude the presence of gastric common when gastric, and hence duodenal, acidity epithelium. Shiner (1957) took mucosal specimens is high. These anomalies mirror each other, and the from the duodenum by an aspiration biopsy tube; conditions which bring them about throw light, it the biopsies were taken from the first or second part will be suggested, upon the pathogenesis of peptic of the duodenum, and the histological study of them ulceration and the determination of its site. by Doniach and Shiner (1957) does not distinguish Taylor (1927), reviewing heterotopia in the between these different sites of origin. In most of the alimentary tract, described two instances of gastric biopsies the mucosa was normal and the epithelium http://gut.bmj.com/ epithelium in the duodenum. They were found well preserved. In some there was distortion or among 150 necropsies, and were recognizable as atrophy of the villi, and in these there might be slightly raised patches. Histological examination abnormalities of the epithelial cell nuclei and an showed these to be covered by well-preserved increase in the number of goblet cells. gastric epithelium and to contain gastric glands with Aronson and Norfleet (1962) took biopsies from both chief and parietal cells; Brunner's glands were the duodenum using the Crosby-Kugler capsule. In absent from the patches. In both cases the patches normal subjects and in a majority of patients with on October 4, 2021 by guest. Protected copyright. were found in the first part of the duodenum near duodenal ulcer the mucosal histology was un- the pylorus, and in one there was a duodenal ulcer. disturbed; in four of the 18 patients the villi were The presence of gastric glands places these patches in blunted or flattened; abnormalities of the epithelial a different category from those described in this cells are not mentioned, but the photomicrographs paper, where only the epithelium was abnormal. do not serve to exclude them. Patzelt (1936) reviewed the histology of the James (1963) described a patient in whom the pyloro-duodenal region in animals and man and diagnosis of Zollinger-Ellison syndrome was sus- quoted descriptions which showed that the line of pected but not proved: there was a high output of epithelial demarcation was not always sharp, there acid by the unstimulated stomach. Biopsies were being islands of intestinal epithelium on the gastric taken at operation from the mucosa of the second side of the pylorus and, much more rarely, of gastric part of the duodenum. There was an extensive epithelium on the intestinal side. His article contains abnormality of the surface epithelium, the cells an illustration of one such 'Magenepithelinsel' resembling gastric cells. It was to assess the signific- found in the duodenum of a woman; the island ance of this finding that the present survey of appears to cover an inflammatory polyp containing duodenal histology was undertaken. a lymph follicle; no gastric glands were present. Gastric epithelial cells have appeared in the Misplaced gastric epithelium has not been duodenum of the cat (Florey and Harding, 1935) mentioned in any of the studies of duodenal mucosa and of the pig (Florey, Jennings, Jennings, and in patients with duodenal ulcer. Puhl (1927), who O'Connor, 1939) in experiments which may help to obtained mucosa from operation specimens, found explain the same anomaly in humans, and which will 285 Gut: first published as 10.1136/gut.5.4.285 on 1 August 1964. Downloaded from 286 A. H. James therefore be discussed in the light of the findings sections and may easily be overlooked in sections now to be presented. stained with haematoxylin and eosin (contrast Fig. 4 with Fig. 3). The mucous droplet stains METHODS exactly the same colour with P.A.S. as does the similar droplet in gastric epithelium, whereas other Mucosa was obtained at operation by one of two P.A.S.-positive material in the section, such as the methods, according to the procedure being undertaken. contents of Brunner's glands or of the goblet cells, At partial gastrectomy the freshly removed tissue was stained with a distinctly bluer tint. opened along the greater curvature, and the pylorus in size from a small identified by the fold of redundant mucosa which marks The mucous droplet varied it; a strip of duodenal mucosa was cut off and immedi- accumulation at the distal end of the cell up to a ately placed in formol-saline. If a pyloroplasty and mass which filled nearly the whole cell, and appeared vagotomy was being done, a small piece of duodenal to displace and deform the nucleus. Under high mucosa was excised after the pylorus had been identified magnification the mass of P.A.S.-staining material from the opened duodenum. seemed to be made up of smaller droplets, and There were 10 patients with duodenal ulcer, one of separate droplets could be seen forming on the basal whom also had a gastric ulcer, four with pyloric ulcer, side of the main mass and seemingly being added to eight with gastric ulcer, and 10 with gastric carcinoma. it. These cells were of the same height as their normal No comparable material has been obtained from cases of the Zollinger-Ellison syndrome, but tissue from the neighbours, but tended to be narrower and to have second part of the duodenum in one such case is more deeply staining cytoplasm. The brush border described. and mitochondria were lacking. Sections 6,u thick were stained with haematoxylin and Gastric epithelial cells were never seen singly but eosin and with periodic acid and Schiff's reagent (P.A.S.). always in contiguous groups of at least three or four The sections were examined in random order without and usually many more. They were most commonly knowledge of the diagnosis. Particular attention was found at or near the tips of villi; sometimes they paid to the surface epithelium, and the prevalence of were seen at the sides of villi and occasionally in the abnormal cells recorded as described below. The size crypts. and shape of the villi were noted, together with the degree of cellular infiltration of the lamina propria. They were more commonly seen on villi which were stunted, and when, as commonly happened, RESULTS villous atrophy occurred patchily in a section gastric cells were more prevalent on the short villi. http://gut.bmj.com/ VILLOUS ANATOMY Some of the sections showed Groups of them were, however, seen on normal normal intestinal villi. More often, however, the villi; that shown in Fig. 5 was the only one found in villi were shorter and blunter than those found lower 101 villi in a section from a patient with gastric down the intestine, and in some cases the villi were ulcer. In a few cases, such as that illustrated in Fig. 6, completely atrophic. Villous atrophy was common they covered small polyps. in duodenal ulcer, less common in pyloric ulcer, and These cells were obviously not goblet cells. Their rare in gastric ulcer or cancer. shape differed from that of a goblet cell, and their on October 4, 2021 by guest. Protected copyright. mucous droplet lacked the bluish tint and reticu- SURFACE EPITHELIUM In all sections a majority of larity which were characteristic of goblet cells. The the villi were covered with epithelial cells of normal distribution of goblet cells was the reverse of gastric appearance, with a brush border and prominent cells in that they were most common near the bases mitochondria. These cells were interspersed with of the villi and usually absent from the tips. Another goblet cells in normal numbers and concentrated point of distinction was that goblet cells were nearly near the bases of the villi. With P.A.S. the brush always isolated; even when very numerous they border is seen as a thin line of even width at the free were separated from each other by normal intestinal border of the cell. Commonly the epithelial cells cells. were shrunken and displayed the characteristics The transition from intestinal cell to gastric cell described by Puhl (1927) and mentioned in the was usually sudden; a cell was clearly of one sort or introduction: this abnormality was most prominent the other (Figs. 1, 3 and 5). No mitoses were seen when there was villous atrophy. in gastric cells: as is usual in the gut mitoses were A particular search was made for gastric epithelial deep in the crypts where the cells are relatively cells, that is, columnar cells lacking a brush border undifferentiated.
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