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Gastritis and Gastropathy: More Than Meets The 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. Willie 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: Willie Nel ([email protected]) Gastrointestinal symptoms such as chronic inflammatory changes which The different types of gastritides and dyspepsia, heartburn, epigastric pain, may eventually lead to mucosal atrophy gastropathies and their wide range of nausea and vomiting are extremely and epithelial metaplasia. Gastritis is a aetiologies will now be discussed. common and have been experienced dynamic process, which can vary from by the majority of people at some stage acute to chronic (active or inactive), Acute gastritis in their lifetime. These complaints are present in different stages of recovery or Acute haemorrhagic gastritis often as a result of pathology in the upper atrophy and may lead to complications. Acute haemorrhagic gastritis is characterised gastrointestinal tract. Correlation between The inflammation may be diffuse, or affect by the presence of hyperaemic, oedematous the clinical presentation (symptoms, signs predominantly the antrum or corpus. mucosa, erosions/ulcers and active bleeding, and endoscopic findings) and pathology, and is usually seen in stress situations (e.g. including the degree and precise localisation The mucosa of the stomach is covered severe burns), patients in ICU and after of the disease process, is unfortunately by a thin surface mucus layer serving, ingestion of large doses of aspirin, and notoriously poor. This is mainly due to in conjunction with bicarbonate- other types of NSAID or large quantities of the absence of a somatic nerve supply to secreting surface epithelial cells and local alcohol. the gut wall. The stomach is a common prostaglandin production, as a protective site of pathology responsible for upper barrier against autodigestion and noxious Acute gastritis in Helicobacter pylori gastrointestinal symptoms, which may have agents. The gastric mucosa also has the infection an extremely wide range of causes. ability to proliferate and replace damaged The initial phase of Helicobacter infection epithelium very rapidly. causes an acute inflammatory reaction In pathological terms, and degenerative changes in the surface In 1990 the Sydney system was developed as epithelial cells of the gastric mucosa. gastritis is defined as a guideline for the classification and grading Symptoms may include epigastric pain, a inflammation of the of gastritis by a group of international bloated feeling and nausea; these most often experts in Sydney, Australia. This system resolve within a week. After approximately gastric mucosa. combines topographical, morphological two weeks the reaction evolves into an and aetiological information into a scheme active chronic gastritis. In pathological terms, gastritis is defined that helps generate a reproducible and as inflammation of the gastric mucosa. clinically useful diagnosis. Four years later Acute bacterial or phlegmonous It is, however, a term often used loosely this system was updated and subsequently gastritis for clinical conditions associated with modified to improve the criteria for This is exceedingly rare and in many any upper gastrointestinal symptoms evaluating atrophy. It recommends that at cases only identified at postmortem without clinical or radiological signs. least five biopsy specimens (two from the examination. Predisposing factors include Gastropathy, on the other hand, refers to greater and lesser curvatures of the corpus, immunosuppression, disability and a nonspecific microscopic injury pattern one from the incisura angularis and two chronic alcoholism. The most common of stomach mucosa, with minimal or from the larger and lesser curvatures of infective organism is Streptococcus, but no inflammatory cell infiltration. Both the antrum) with mucosa and muscularis Staphylococcus, Haemophilus influenzae, gastritis and gastropathy may be clinically mucosae represented in each biopsy be Escherichia coli and Proteus spp have also asymptomatic. evaluated. In practice, however, pathologists been implicated. These bacteria cause an are usually asked to make a diagnosis on one intense acute inflammatory response with Acute gastritis is an acute mucosal or two biopsy specimens as most types of ulceration and abscess formation involving inflammatory process, usually of transient gastritis can be diagnosed without extensive the full thickness of the gastric wall. nature, while chronic gastritis refers to tissue sampling. Patients present with nausea, vomiting, February 2012 Vol.30 No.2 CME 61 Gastritis and gastropathy upper abdominal pain and tenderness, even atrophy, but there are no distinctive be performed 4 weeks after the end of usually associated with a neutrophilic endoscopic patterns of chronic HP gastritis. therapy, as the test may produce a false- leukocytosis. The condition has a high In the early phase an acute inflammatory negative result with persistent infection due mortality, but patients treated surgically response is elicited, which usually to temporary inactivation of the pathogen have a better chance of survival. progresses to an active chronic gastritis. shortly after treatment. HP serology is This may be antral-predominant, corpus- relatively sensitive and specific with no Chronic gastritis predominant or diffusely affect the stomach interference due to the intake of bismuth, Helicobacter pylori (HP) gastritis as a pangastritis (Fig. 1). After treatment, antibiotics and PPIs. There is no correlation These tiny spiral-shaped bacilli in the neutrophils disappear rapidly; their between the IgG antibody titres and the stomach were described for decades continued presence in biopsies is considered severity of the HP gastritis, however, and a by pathologists, but were dismissed as a valuable indicator of unsuccessful HP decrease in titres less than 6 months after irrelevant contaminants. In 1984 Warren eradication. After successful treatment therapy is of no diagnostic value in verifying and Marshall proposed their aetiological the intensity of the chronic inflammation successful eradication. role in chronic idiopathic gastritis due to declines, but patients may show persistence toxins released by the organisms directly of chronic inactive gastritis for several years. affecting the gastric epithelium and local Persistent infections may eventually lead to microcirculation. atrophic gastritis, which may be antrum- restricted or involve the stomach more Gastritis is a dynamic extensively. process, which can vary from acute to chronic (active or inactive), present in different Fig. 2. Curved Helicobacter pylori bacilli ad- jacent to the gastric epithelium on a methy- stages of recovery or lene blue stain. atrophy and may lead to complications. More than 50 species of Helicobacter have been described, but only a few have been Fig. 1. A biopsy demonstrating chronic shown to cause gastritis. In about 0.1 - HP gastritis has a high prevalence in active gastritis — a background of chronic 2.7% of cases H. heilmannii is identified. developing countries, but has been declining inflammation, with neutrophils present These organisms are twice as long as HP in areas due to improved sanitary conditions between the glandular epithelium. and usually cause a milder and patchier and the widespread use of antibiotics. gastritis. Treatment is similar to that for HP Natural acquisition of HP infection usually Diagnosis of HP infection can be rendered infections. occurs in childhood and may persist for life. using invasive and noninvasive tests. However, transient infections often occur. Invasive tests are based on endoscopy The initial phase of a Direct person-to-person spread is the most and histological examination of gastric likely mode of transmission, as no significant biopsies (Fig. 2). These have the advantage Helicobacter infection reservoir has been shown to exist outside of allowing direct evaluation the upper GI causes an acute the human stomach. Ingestion appears to tract for any superimposed complications. be the most common means of acquiring The number of organisms in biopsy material inflammatory reaction HP. Routes of transmission include gastric- may be markedly reduced (even absent) and degenerative oral (by refluxed gastric juice or vomitus), due to antibiotic treatment prior to biopsy, and the faecal-oral route (during episodes the use of proton pump inhibitors (PPIs) or changes in the surface of diarrhoea). Poor hygiene standards, in chronic atrophic gastritis. Noninvasive epithelial cells of the crowded households, deficient sanitation diagnostic tests include the C-urea breath gastric mucosa. and the absence of running water in the test (only performed in certain centres), home are associated with a high prevalence detection of serum IgG antibodies directed of HP infection. against HP and stool HP antigen tests, some Some patients with HP are asymptomatic of which can also be used for follow-up. and go undetected, but all patients in whom The endoscopist may find mucosal As a
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