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Types of Atrophic Gastritis in Patients with Primary Sjogren's Syndrome

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Types of Atrophic Gastritis in Patients with Primary Sjogren's Syndrome Annals ofthe Rheumatic Diseases 1991; 50: 97-1o00997 Types of atrophic gastritis in patients with primary Ann Rheum Dis: first published as 10.1136/ard.50.2.97 on 1 February 1991. Downloaded from Sjogren's syndrome Gy Pokorny, Gizella Karacsony, J Lonovics, J Hudak, J Nemeth, V Varr6 Abstract 51-9 years (range 22-76) and the mean duration Histological examination ofthe gastric mucosa of disease was 10-3 years (range 1-23). All was performed in 44 patients with primary patients met the criteria for primary SS. The Sjogren's syndrome with extraglandular Copenhagen criteria, with two modifications, symptoms (mean age 51.9, range 22-76). were used for the diagnosis of keratoconjuncti- Biopsy specimens were taken from each of vitis sicca and xerostomia. These were as three separate regions: the antrum, the follows: the parotid gland flow rate stimulated corpus, and the transitional zone between the with 2-0% citric acid solution was considered antrum and the corpus. The incidence of abnormal if -1-5 ml/10 min/gland, and chronic atrophic gastritis was considerably parotid gland scintigraphy or sialography, or higher in patients with Sjogren's syndrome both, were performed.34 than in the controls. In the young patients An Olympus GIF XQ fibrescope was used for with Sjogren's syndrome atrophic lesions endoscopic examination of the stomach. Two to were more common both in the antrum and in five mucosal biopsy specimens were taken from the corpus than in the control group. In the antrum, the corpus, and the transitional middle aged patients, however, only the zone between the antrum and the corpus for antrum, and in the elderly only the corpus, histological examination. The specimens were was much more commonly affected than in fixed in formaldehyde, embedded in paraffin, the controls. AU three types ofchronic atrophic and stained with haematoxylin and eosin in gastritis occurred in patients with Sjogren's accordance with a modified Zimmermann dif- syndrome. Decreased gastric acid secretion ferential method.5 Depending on the severity of was associated mainly with atrophic gastritis mucosal involvement, two forms of gastritis oftypes A and AB, whereas hypergastrinaemia were distinguished histologically. These were as occurred almost exclusively in gastritis of follows: (a) chronic superficial gastritis. In this type A. form the chronic inflammatory cell infiltration affected the superficial layer or the deeper parts http://ard.bmj.com/ of the mucosa, or both, without gland atrophy; Among the gastrointestinal manifestations of (b) chronic atrophic gastritis, which was further Sjogren's syndrome (SS), chronic atrophic divided into chronic preatrophic gastritis char- gastritis (CAG) is the most common finding. In acterised by partial, mild, and moderate atrophy several investigations the incidence of CAG in of the glands and severe atrophic gastritis with patients with SS was more than 65%. 1 2 In the total gland atrophy.6 When the atrophic lesions earlier studies, however, only a small number of were localised only to the corpus the CAG was on September 24, 2021 by guest. Protected copyright. relatively old patients with SS were examined, classified as type A, only to the antrum as type and the gastric involvement was analysed in a B, and when both regions were affected as mixed group of patients, including those with type AB.7 primary and secondary SS. Because only the Gastric acid secretion was determined by the corpus mucosa was studied the types of CAG Kay test with pentagastrin stimulation.8 The were not determined. results were expressed in terms of basal acid In our study histological examination of the output and calculated maximum acid output. antrum and corpus mucosa was performed The normal ranges of basal acid output and simultaneously in patients with primary SS. calculated maximum acid output originated Gastric acid secretion and serum gastrin concen- from the measurements and experience of the trations were also measured, and the type of gastroenterological team in our department. CAG was determined. Basal serum gastrin concentrations were First Department of measured by radioimmunoassay with Amersham Internal Medicine, RIA kits and were considered normal if <80 Albert Szent-Gyorgyi Medical School, Szeged, Patients and methods pglml. PO Box 469, H-6701, Forty four female patients with primary SS with Serum immunoglobulins and different Hungary extraglandular symptoms were studied because immunological variables, such as rheumatoid Gy Pokorny of cases G Karacsony abdominal complaints in 38 (epigastric factor, antinuclear antibodies, anti-SSA, anti- J Lonovics pain in 15 and dyspepsia with or without nausea SSB, and anti-native DNA (anti-nDNA) anti- J Hud&k in 23), and for other reasons, such as anaemia, bodies, LE cell phenomenon, complement C3 J Nemeth weight loss, or lack of appetite, in six cases. V Varr6 concentration, and circulating immune com- Twenty one of the 44 were taking non-steroidal plexes, were determined in all patients. Correspondence to: Dr Pokorny. anti-inflammatory drugs or corticosteroids, or For the histological examination 104 female Accepted for publication both, regularly, and 14 were taking them only patients with a mean age of 53 0 years (range 14 February 1990 occasionally. The mean age of the patients was 24-83) served as controls. They had- been 98 Pokormy, Kardcsony, Lonovics, Huddk, Nemeth, Varr6 Table I Histology of gastric mucosa according to the regions of the stomach affected in patients with primary Sjogren's sydrome (SS) and controls (C). Nunber (%) of patients is shown Ann Rheum Dis: first published as 10.1136/ard.50.2.97 on 1 February 1991. Downloaded from Histology Antrwn Corpus Transitional zone SS C SS C SS (n=44) (n= 104) (n=44) (n=104) (n=40) Normal 16 (36) 33 (32) 13 (30) 34 (33) 9 (23) Chronic superficial gastritis 6 (14) 41 (39) 14 (32) 45 (43) 11 (28) Chronic preatrophic gastritis 21 (48) 19 (18) 10 (23) 17 (16) 13 (33) Severe chronic atrophic gastritis 1 (2) 11(11) 7 (16) 8 (8) 7 (18) Chronic preatrophic+severe atrophic gastritis 22 (50) 30 (29) 17 (39) 25 (24) 20 (50) admitted because of abdominal complaints. Results Patients with ulcer disease, gastrointestinal Table 1 shows the histological results for the tumour, or autoimmune connective tissue gastric mucosa. In patients with primary SS disease were excluded from the study. Func- atrophic signs occurred more commonly in the tional diseases, such as irritable bowel syn- antrum than in the corpus, but the difference drome and Oddi sphincter dyskinesia, were was not statistically significant. The severity of established as the final diagnoses in 46 control atrophy was milder in the antrum than in the patients, and organic diseases, including gall- corpus, however. The occurrence of atrophic stone disease, acute and chronic cholecystitis, lesions was more than 1-5 times more common cholangitis, pancreatitis, Oddi sphincter in patients with primary SS than in controls, sclerosis, urinary tract infections, large bowel both in the antrum and in the corpus, but the diverticulosis, arteriosclerosis, and spondylosis, difference was significant only in the antrum in 58. Twelve patients from the control group (p=0024). were taking gastric irritants (corticosteroids or The incidence ofCAG depended on the age of non-steroidal anti-inflammatory drugs) before the patients with SS (fig 1). In the young the examination of the stomach. patients with SS atrophic mucosal lesions were two and a half times more common in the antrum, and four times more common in the STATISTICS corpus, than in the control group. The differ- After a one way analysis of variance the multiple ences between the two groups were not signifi- range test (least significant difference procedure) cant (antrum: p=0-206, corpus: p=0067), was applied for the statistical evaluation of the probably owing to the small number of young age of the patients, the duration of the disease, patients with SS. In the middle aged patients basal acid output, calculated maximum acid with SS only the antral atrophic lesions were output, concentrations of serum gastrin, significantly more common than in the controls immunoglobulins, complement C3 concentra- (p=0-016). In contrast, in the elderly the http://ard.bmj.com/ tions, anti-nDNA, and haematological variables. corpus was affected more commonly in the The exact Fischer test and McNemar test were patients with SS than in the controls, but the used for statistical analysis of the incidence of difference was not significant (p=022). antinuclear antibodies, rheumatoid factor, LE Table 2 shows the distribution of the types of cell phenomenon, SSB/SSA antibodies, and the CAG. In the 44 patients with SS gastritis of type histological findings on the gastric mucosa. A occurred in nine, gastritis of type B in 14, and gastritis of type AB in eight patients. In four on September 24, 2021 by guest. Protected copyright. cases the type could not be classified because the atrophic lesions occurred only in the Figure I Incidence of 75,1 AntruIn transitional zone between the antrum and the chronic atrophic gastritis corpus, and in the remaining nine cases the according to agegroup in 60- main regions of the stomach were not affected patients with primary Sjogren's syndrome (SS) D 45- 0 or showed characteristics of chronic superficial and in controls (C). gastritis only. The age distribution was similar 5 30- of with SS. o0-- in all histological groups patients 15- The duration of disease was significantly higher (p<005) only in patients with gastritis of type O- -44 45-59 60- A (mean 13 2 years) compared with those with a Age qroups (years) normal mucosa and chronic superficial gastritis 0 % Of patients with SS (mean 6-5 years). Corpus 0 Of controls 75-- % Figures 2 and 3 show the basal acid output, calculated maximum acid output, and the 60 serum gastrin concentrations in the different A.
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