Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Case Report

Volume 6, Number 4, August 2013, pages 139-144

Collagenous Gastritis a Rare Disorder in Search of a Disease

Figure 1. Endoscopy. There is a nodular appearing gastric mucosa prominent in the gastric body and antrum. These nodules are well demarcated.

Figure 2. H and E stain. H and E stain shows surface disruption of the inflamed gastric mucosa with intraepithelial lymphocytosis. The lamina propria contains a mixture of plasma cells, lymphocytes and eosinophils. There is capillary trapping and vascular dilatation.

Figure 3. Trichrome stain. Corresponding Trichrome stain shows irregular thickening of the supepithelial band and increased collagen deposition around dilated capillaries. The lamina propria contains a lacelike pattern of increased collagen. In the most affected area the collagen deposition measures 15 microns.

Figure 4. H and E stain after 6 months. Compared to previous findings, follow up gastric biopsy after 6 months shows flattening of the surface foveolar epithelium with increased intraepithelial lymphocytes. There is also lymphoplasmacytic expansion of the lamina propria.

Figure 5. Trichrome stain after 6 months. Corresponding trichrome stain shows prominent subepithelial basement membrane thickening in a well organized pattern with increased collagen deposition measuring up to 25 microns in thickness which was previously 15 microns in thickness.

**Table 1.** Comparison of the Three Collagenous Disorders of the Gut
	Collagenous Colitis	Collagenous Sprue	Collagenous Gastritis
Involvement	Colon	Small Intestine, mainly proximal	Stomach
First Described	1976 by Windstorm	1970 by Winestein	1989 by Colleti and Trainer
Gender Prevelance	Female: Male 20:1	Female > Male 2:1	Not many cases to comment on gender prevelance
Age Prevelance	> 40 years, Peak in 6th and 7th decades	40 - 80 years	Children and Adults
Most common symptoms	Watery non bloody diarrhea	Chronic diarrhea due to malabsorption, Weight loss	Abdominal pain, anemia in children Chronic watery diarrhea, irritable bowel symptoms in adults
Associated Drugs	NSAIDS, SSRI, Ranitidine. Possibly Aspirin, Acarbose, ticlopinine, PPI
Autoimmune diseases association	Celiac disease, thyroiditis, collagenous gastritis, collagenous colitis	Celiac disease, collagenous gastritis, collagenous colitis	Isolated in most children Adult form associated with collagenous colitis, lymphocytic gastritis, celiac disease and other autoimmune diseases
Colonoscopy findings	Mostly normal appearance to mucosal edema or hyperemia in some	Non specific: loss of mucosal folds, scalloping, mucosal erythema, mosaicism	Normal mucosa, diffuse gastric erythema, erosions, gastric hemorrhages, nodular mucosa
Biopsy findings	Chronic inflammatory infiltrate of plasma cells, lymphocytes and eosinophils in lamina propria with thickened subepithelial collagen bands ( > 10 mm)	Villous atrophy, crypt atrophy, chronic inflammatory infiltrate of plasma cells, lymphocytes and eosinophils in lamina propria with thickened subepithelial collagen bands ( > 10 mm)	Chronic inflammatory infiltrate of plasma cells, lymphocytes and eosinophils in the lamina propria with thickened subepithelia collagen bands (> 10 mm)
Treatment	-Spontaneous remission in some -Loperamide, sulfasalazine, bismuth, cholestyramine. -Budesonide/Corticosteroids -Azathioprine/Methotrexate -Colectomy/ileostomy	-Gluten free diet -Corticosteroids -Azathioprine/Methotrexate -Total parenteral nutrition -Intestinal transplant	-No definite therapy -Dietary modification -The following have been tried with varying results: sucralfate, ranitidine, mesalamine, elimination of gluten, loperamide, cholestyramine, budesonide and prednisione
Complications	Colonic fractures after endoscopic instrumentation, colonic ulceration due to concomitant NSAID use. Evolution into Ulcerative colitis and Crohns disease have been reported	Nutrient deficiencies and progressive weight loss due to malabsorption. T cell Lymphoma similar to as in Celiac disease, Ulcerative jejunitis have been reported	Anemia in children Rare: Upper GI bleed, perforating gastric ulcer, dysphagia due to Plummer Vinson syndrome reported in adults
Clinical Outcome	-Good	-Poor with only few cases reported to have complete resolution of symptoms	-Fair but mostly unknown

Table 1. Comparison of the Three Collagenous Disorders of the Gut

Collagenous Colitis

Collagenous Sprue

Collagenous Gastritis

Involvement

Colon

Small Intestine, mainly proximal

Stomach

First Described

1976 by Windstorm

1970 by Winestein

1989 by Colleti and Trainer

Gender Prevelance

Female: Male 20:1

Female > Male 2:1

Not many cases to comment on gender prevelance

Age Prevelance

> 40 years, Peak in 6th and 7th decades

40 - 80 years

Children and Adults

Most common symptoms

Watery non bloody diarrhea

Chronic diarrhea due to malabsorption, Weight loss

Abdominal pain, anemia in children
Chronic watery diarrhea, irritable bowel symptoms in adults

Associated Drugs

NSAIDS, SSRI, Ranitidine.
Possibly Aspirin, Acarbose, ticlopinine, PPI

Autoimmune diseases association

Celiac disease, thyroiditis, collagenous gastritis, collagenous colitis

Celiac disease, collagenous gastritis, collagenous colitis

Isolated in most children
Adult form associated with collagenous colitis, lymphocytic gastritis, celiac disease and other autoimmune diseases

Colonoscopy findings

Mostly normal appearance to mucosal edema or hyperemia in some

Non specific: loss of mucosal folds, scalloping, mucosal erythema, mosaicism

Normal mucosa, diffuse gastric erythema, erosions, gastric hemorrhages, nodular mucosa

Biopsy findings

Chronic inflammatory infiltrate of plasma cells, lymphocytes and eosinophils in lamina propria with thickened subepithelial collagen bands ( > 10 mm)

Villous atrophy, crypt atrophy, chronic inflammatory infiltrate of plasma cells, lymphocytes and eosinophils in lamina propria with thickened subepithelial collagen bands ( > 10 mm)

Chronic inflammatory infiltrate of plasma cells, lymphocytes and eosinophils in the lamina propria with thickened subepithelia collagen bands (> 10 mm)

Treatment

-Spontaneous remission in some
-Loperamide, sulfasalazine, bismuth, cholestyramine.
-Budesonide/Corticosteroids
-Azathioprine/Methotrexate
-Colectomy/ileostomy

-Gluten free diet
-Corticosteroids
-Azathioprine/Methotrexate
-Total parenteral nutrition
-Intestinal transplant

-No definite therapy
-Dietary modification
-The following have been tried with varying results: sucralfate, ranitidine, mesalamine, elimination of gluten, loperamide, cholestyramine, budesonide and prednisione

Complications

Colonic fractures after endoscopic instrumentation, colonic ulceration due to concomitant NSAID use. Evolution into Ulcerative colitis and Crohns disease have been reported

Nutrient deficiencies and progressive weight loss due to malabsorption. T cell Lymphoma similar to as in Celiac disease, Ulcerative jejunitis have been reported

Anemia in children
Rare:
Upper GI bleed, perforating gastric ulcer, dysphagia due to Plummer Vinson syndrome reported in adults

Clinical Outcome

-Good

-Poor with only few cases reported to have complete resolution of symptoms

-Fair but mostly unknown