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Practical Approach to the Pathologic Diagnosis of Gastritis

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Practical Approach to the Pathologic Diagnosis of Gastritis Practical Approach to the Pathologic Diagnosis of Gastritis Antonia R. Sepulveda, MD, PhD; Madhavi Patil, MD ● Context.—Most types of gastritis can be diagnosed on sentative gastric biopsy cases from a gastrointestinal pa- hematoxylin-eosin stains. The most common type of chron- thology practice to demonstrate the practical application ic gastritis is Helicobacter pylori gastritis. Reactive or of basic histopathologic methods for the diagnosis of gas- chemical gastropathy, which is often associated with non- tritis. steroidal anti-inflammatory drug use or bile reflux, is com- Conclusions.—Limited ancillary tests are usually re- mon in most practices. The diagnosis of atrophic gastritis quired for a diagnosis of gastritis. In some cases, special can be challenging if few biopsy samples are available and stains, such as acid-fast stains, and immunohistochemical if the location of the biopsies in the stomach is not known, stains, such as for H pylori and viruses, can be useful. Hel- such as when random biopsies are sampled in one jar. If icobacter pylori immunohistochemical stains can particu- the biopsy site is not known, immunohistochemical stains, such as a combination of synaptophysin and gastrin, are larly contribute (1) when moderate to severe, chronic gas- useful in establishing the biopsy location. tritis or active gastritis is present but no Helicobacter or- Objective.—To demonstrate a practical approach to ganisms are identified upon hematoxylin-eosin stain; (2) achieving a pathologic diagnosis of gastritis by evaluating when extensive intestinal metaplasia is present; and (3) in a limited number of features in mucosal biopsies. follow-up biopsies, after antibiotic treatment for H pylori. Data Source.—In this article, we present several repre- (Arch Pathol Lab Med. 2008;132:1586–1593) astritis refers to a group of diseases characterized by present. If the biopsy shows chronic gastritis, the follow- G inflammation of the gastric mucosa. Histologic ex- ing questions should be posed: amination of gastric mucosal biopsies is necessary to es- tablish a diagnosis of gastritis. In clinical practice, the role 1. Are there features of chronic gastritis present? Lym- of the pathologist who evaluates a gastric biopsy for gas- phocytic and plasmacytic inflammatory reaction indicates tritis is to find the cause of gastritis because that will pro- chronic gastritis. vide direct targets toward which therapeutic measures can 2. Are there neutrophils in the mucosa? The presence be directed. An etiologic classification of gastritis is pre- of neutrophils indicate active gastritis. sented at the end of this section. Comprehensive reviews 3. Is there Helicobacter? of gastritis have been published.1,2,3 The goal of this article 4. Is there glandular atrophy? Is intestinal metaplasia is to present a practical approach to the diagnosis of the present? most common types of gastritis encountered in a large 5. What is the topography of lesions (predominantly in practice of gastrointestinal pathology. The reader will be the oxyntic mucosa of the body and fundus, predomi- presented several cases representative of typical forms of nantly in antrum, or involving both locations)? 6. Are there special features (such as granulomas, fo- gastritis; for each case, the reader will be prompted veolar hyperplasia, viral inclusions)? through a series of questions to examine the histologic 7. What ancillary studies are indicated, and what are features of the mucosa, leading to a pattern of answers the results? and to a final diagnosis. The first question is aimed at determining whether or not there are features of chronic or acute (active) gastritis TYPES OF CHRONIC GASTRITIS Infectious Gastritis Accepted for publication January 10, 2008. Helicobacter pylori infection is the most common cause of From the Department of Pathology and Laboratory Medicine, Hos- pital of the University of Pennsylvania, Philadelphia. chronic gastritis. Other forms of infectious gastritis include The authors have no relevant financial interest in the products or the following: Helicobacter heilmannii–associated gastritis; companies described in this article. granulomatous gastritis associated with gastric infections Presented in part at the 47th Annual Meeting of the Houston Society in mycobacteriosis, syphilis, histoplasmosis, mucormyco- of Clinical Pathologists, Houston, Tex, April 21, 2007. sis, South American blastomycosis, anisakiasis or anisak- Reprints: Antonia R. Sepulveda, MD, PhD, Department of Pathology and Laboratory Medicine, University of Pennsylvania, 3400 Spruce St, idosis; chronic gastritis associated with parasitic infec- Founders Six, Philadelphia, PA 19104 (e-mail: [email protected]. tions; and viral infections, such as cytomegalovirus and upenn.edu). herpesvirus infection. 1586 Arch Pathol Lab Med—Vol 132, October 2008 Pathologic Diagnosis of Gastritis—Sepulveda & Patil examination reveals diagnostic H pylori bacterial forms in the surface mucus layer in close proximity to the apical aspect of surface epithelial cells. 4. Is there glandular atrophy? The biopsy sample avail- able is not adequate for evaluation of atrophic gastritis; multiple biopsies, including samples of gastric body, are necessary for adequate evaluation of glandular atrophy. Is there intestinal metaplasia? Yes. 5. What is the topography of lesions? The chronic gas- tritis in this case involves, at minimum, the gastric antrum; it is advisable to obtain biopsy samples of both gastric Figure 1. Helicobacter pylori–associated chronic active gastritis. A, antrum and body for a better evaluation of gastritis, as Chronic inflammation oriented toward the surface of the mucosa. Neu- recommended by the updated Sydney guidelines4 for clas- trophils cannot be seen at this magnification (original magnification sification of gastritis. ϫ10) but were identified with high power (hematoxylin-eosin stain). B, Circled area shows H pylori organisms within the mucus layer close 6. Are additional special features present? No. to the surface of gastric epithelial cells (hematoxylin-eosin, original 7. Are special stains recommended? No. magnification ϫ40). C, Gastric mucosa with intestinal metaplasia (he- matoxylin-eosin, original magnification ϫ20). Diagnosis. Gastric antral mucosa with H pylori–asso- ciated chronic gastritis, mildly active, and focal intestinal metaplasia. Noninfectious Gastritis H PYLORI–ASSOCIATED CHRONIC GASTRITIS Noninfectious gastritis is associated with autoimmune gastritis; reactive or chemical gastropathy, usually related The Helicobacter species consist of gram-negative rods that infect the gastric mucosa. Helicobacter pylori bacteria to chronic bile reflux or nonsteroidal anti-inflammatory ␮ drug (NSAID) intake; uremic gastropathy; noninfectious are 3.5 m long and are generally comma-shaped or have granulomatous gastritis; lymphocytic gastritis, including slightly spiral forms. Helicobacter heilmannii, a rare agent of chronic gastritis, is a 5- to 9-␮m-long bacterium, with gastritis associated with celiac disease; eosinophilic gas- 5 tritis; radiation injury to the stomach; graft-versus-host a characteristic tightly corkscrew-shaped, spiral form. disease; ischemic gastritis; and gastritis secondary to che- Helicobacter pylori infection usually is acquired during motherapy. childhood, persisting as chronic gastritis if the organism Many cases of gastritis are of undetermined cause and is not eradicated. During progression of gastritis over the present as chronic, inactive gastritis with various degrees years, the gastric mucosa undergoes a sequence of changes of severity.3 that may lead to glandular atrophy, intestinal metaplasia, increased risk of gastric dysplasia and carcinoma,6–9 and TYPES OF ACUTE GASTRITIS mucosa-associated lymphoid tissue lymphoma,10,11 report- ed as extranodal, marginal zone, B-cell lymphoma in the Many of the forms of chronic gastritis may present with 12 an acute form, with progression to chronic gastritis be- World Health Organization classification. cause of persisting injury or sequelae. This is the case of Helicobacter pylori infection is associated with the histo- gastritis associated with long-term intake of aspirin and logic pattern of active and chronic gastritis, reflecting the other NSAIDs and bile reflux into the stomach; excessive presence of neutrophils and mononuclear cells (lympho- alcohol consumption; heavy smoking; cancer chemother- cytes and plasma cells) in the mucosa, respectively. The apeutic drugs and radiation; acids and alkali in suicide term active gastritis is preferred to acute gastritis because H attempts; uremia; severe stress (trauma, burns, surgery); pylori gastritis is a long-standing chronic infection with ischemia and shock; systemic infections; mechanical trau- ongoing activity. Lymphoid aggregates and lymphoid fol- ma, such as intubation associated mucosal lesions; and vi- licles may be observed expanding the lamina propria, and ral infections. rare lymphocytes may enter the epithelium. Helicobacter pylori organisms are found within the gastric mucus layer Case 1 that overlays the apical side of gastric surface cells, and lower numbers are found in the lower portions of the gas- A 60-year-old man underwent esophagogastroduoden- tric foveolae. Helicobacter pylori may be found within the oscopy. A biopsy of gastric antrum was submitted to pa- deeper areas of the mucosa in association with glandular thology to rule out H pylori. The histologic findings are cells in patients on acid blockers, such as the commonly shown in Figure 1, A through C. used
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