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Gastritis and Gastropathy: More Than Meets The 10053 Omez advert pRR 5/29/12 6:04 PM Page 1 Gastritis and gastropathy: More than meets the eye This paper discusses the different types of gastritides and gastropathies, focusing on their wide range of aetiologies. W Nel, MB ChB, M Med (Anat Path) Anatomical pathologist, Ampath Pathology Laboratories, Pretoria Willie Nel did his undergraduate training at the University of the Free State and postgraduate training at the University of Pretoria. He joined the private practice of doctors Du Buisson and partners (Ampath) after two years as a consultant at the Institute of Pathology in Pretoria. Amongst his special interests are motorcycling and cattle breeding. Correspondence to: W Nel ([email protected]) Gastrointestinal symptoms such as conjunction with bicarbonate-secreting Acute gastritis in Helicobacter pylori dyspepsia, heartburn, epigastric pain, nausea surface epithelial cells and local prosta- infection and vomiting are extremely common and glandin production, as a protective barrier The initial phase of Helicobacter infection have been experienced by the majority against autodigestion and noxious agents. causes an acute inflammatory reaction of people at some stage in their lifetime. The gastric mucosa also has the ability to and degenerative changes in the surface These complaints are often as a result of proliferate and replace damaged epithe- epithelial cells of the gastric mucosa. pathology in the upper gastrointestinal tract. lium very rapidly. Symptoms may include epigastric pain, a Correlation between the clinical presentation bloated feeling and nausea; these most often (symptoms, signs and endoscopic findings) In 1990 the Sydney system was developed as resolve within a week. After approximately and pathology, including the degree and a guideline for the classification and grading two weeks the reaction evolves into an precise localisation of the disease process, of gastritis by a group of international active chronic gastritis. is unfortunately notoriously poor. This is experts in Sydney, Australia. This system mainly due to the absence of a somatic combines topographical, morphological Acute bacterial or phlegmonous nerve supply to the gut wall. The stomach is and aetiological information into a scheme gastritis a common site of pathology responsible for that helps generate a reproducible and This is exceedingly rare and in many upper gastrointestinal symptoms, which may clinically useful diagnosis. Four years later cases only identified at postmortem have an extremely wide range of causes. this system was updated and subsequently examination. Predisposing factors include modified to improve the criteria for immunosuppression, disability and chronic In pathological terms, gastritis is defined as evaluating atrophy. It recommends that at alcoholism. The most common infective inflammation of the gastric mucosa. It is, least five biopsy specimens (two from the organism is Streptococcus, but Staphylococcus, however, a term often used loosely for clini- greater and lesser curvatures of the corpus, Haemophilus influenzae, Escherichia coli cal conditions associated with any upper one from the incisura angularis and two and Proteus spp have also been implicated. gastrointestinal symptoms without clinical from the larger and lesser curvatures of These bacteria cause an intense acute or radiological signs. Gastropathy, on the the antrum) with mucosa and muscularis inflammatory response with ulceration other hand, refers to a nonspecific micro- mucosae represented in each biopsy be and abscess formation involving the full scopic injury pattern of stomach mucosa, evaluated. In practice, however, pathologists thickness of the gastric wall. Patients present with minimal or no inflammatory cell infil- are usually asked to make a diagnosis on one with nausea, vomiting, upper abdominal tration. Both gastritis and gastropathy may or two biopsy specimens as most types of pain and tenderness, usually associated with be clinically asymptomatic. gastritis can be diagnosed without extensive a neutrophilic leukocytosis. The condition tissue sampling. has a high mortality, but patients treated Acute gastritis is an acute mucosal surgically have a better chance of survival. inflammatory process, usually of transient The different types of gastritides and nature, while chronic gastritis refers to gastropathies and their wide range of Chronic gastritis chronic inflammatory changes which aetiologies will now be discussed. Helicobacter pylori (HP) gastritis may eventually lead to mucosal atrophy These tiny spiral-shaped bacilli in the and epithelial metaplasia. Gastritis is a Acute gastritis stomach were described for decades by dynamic process, which can vary from Acute haemorrhagic gastritis pathologists, but were dismissed as irrelevant acute to chronic (active or inactive), Acute haemorrhagic gastritis is characterised contaminants. In 1984 Warren and Marshall present in different stages of recovery or by the presence of hyperaemic, oedematous proposed their aetiological role in chronic atrophy and may lead to complications. mucosa, erosions/ulcers and active bleeding, idiopathic gastritis due to toxins released by The inflammation may be diffuse, or affect and is usually seen in stress situations (e.g. the organisms directly affecting the gastric predominantly the antrum or corpus. severe burns), patients in ICU and after epithelium and local microcirculation. ingestion of large doses of aspirin, and The mucosa of the stomach is covered other types of NSAID or large quantities of HP gastritis has a high prevalence in by a thin surface mucus layer serving, in alcohol. developing countries, but has been declining 37 CME February 2013 Vol. 31 No. 2 Composite Gastritis and gastropathy in areas due to improved sanitary conditions and histological examination of gastric and the widespread use of antibiotics. biopsies (Fig. 2). Th ese have the advantage Your consulting pathologists Natural acquisition of HP infection usually of allowing direct evaluation the upper GI occurs in childhood and may persist for life. tract for any superimposed complications. However, transient infections oft en occur. Th e number of organisms in biopsy material Direct person-to-person spread is the most may be markedly reduced (even absent) likely mode of transmission, as no signifi cant due to antibiotic treatment prior to biopsy, reservoir has been shown to exist outside the use of proton pump inhibitors (PPIs) or the human stomach. Ingestion appears to in chronic atrophic gastritis. Noninvasive be the most common means of acquiring Fig. 1. A biopsy demonstrating chronic diagnostic tests include the C-urea breath HP. Routes of transmission include gastric- active gastritis — a background of chronic test (only performed in certain centres), oral (by refl uxed gastric juice or vomitus), infl ammation, with neutrophils present detection of serum IgG antibodies directed and the faecal-oral route (during episodes between the glandular epithelium. against HP and stool HP antigen tests, some of diarrhoea). Poor hygiene standards, of which can also be used for follow-up. crowded households, defi cient sanitation As a method to evaluate HP eradication, and the absence of running water in the the C-urea breath test should preferably be home are associated with a high prevalence performed 4 weeks aft er the end of therapy, of HP infection. as the test may produce a false-negative result with persistent infection due to temporary Th e endoscopist may fi nd mucosal inactivation of the pathogen shortly aft er hyperaemia, erosions, hypertrophy and treatment. HP serology is relatively sensitive even atrophy, but there are no distinctive and specifi c with no interference due to the endoscopic patterns of chronic HP gastritis. intake of bismuth, antibiotics and PPIs. Th ere is no correlation between the IgG antibody In the early phase an acute infl ammatory Fig. 2. Curved Helicobacter pylori bacilli titres and the severity of the HP gastritis, www.ampath.co.za response is elicited, which usually progresses adjacent to the gastric epithelium on a however, and a decrease in titres less than 6 to an active chronic gastritis. Th is may be methylene blue stain. months aft er therapy is of no diagnostic value antral-predominant, corpus-predominant or in verifying successful eradication. diff usely aff ect the stomach as a pangastritis Cystic fibrosis (CF) is an Clinical Findings: Sweat testing should always be (Fig. 1). Aft er treatment, neutrophils More than 50 species of Helicobacter have autosomal recessive disease • Prenatal Screening – Amniocentesis repeated on 2 separate occasions, and disappear rapidly; their continued presence been described, but only a few have been affecting all South African (SA) when both parents are identified sweat chloride testing may be negative shown to cause gastritis. In about 0.1 - 2.7% population groups. carriers (Identifying specific mutations in a small number of confirmed CF cases. of cases H. heilmannii is identifi ed. Th ese in parents), or restriction fragment C M Y CM MY CY CMY K The incidence of live births in South organisms are twice as long as HP and length polymorphism (RFLP) analysis Africa is 1 in 2800 for Whites, 1 in the case of one parent having Other laboratory tests in CF usually cause a milder and patchier gastritis. in 10000 for Coloureds and 1 in identified mutation but the couple evaluation include: Treatment is similar to that for HP infections. 52000 for Blacks. The defect is have a previously affected child .
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