Collagenous gastritis: a morphologic and immunohistochemical study of 40 patients

Management of collagenous gastritis in children: Case series and literature review

Collagenous gastritis (CG) is a rare histopathological finding on gastric biopsies in children. It is associated with abdominal pain and iron deficiency anemia, usually not respondent to oral iron supplements. The aim of this study was to describe our experience in the management of pediatric patients with CG. Moreover, we propose to review the literature on this topic. We retrospectively reviewed all pediatric patients diagnosed with CG at our centre from January 2014 to January 2019. Three pediatric patients (2 F, mean age 12.3) were diagnosed with CG during the study period. Two presented with moderate and one with severe anemia. Symptoms were abdominal pain, asthenia and headache in two and asthenia and abdominal pain in one. All underwent upper and lower gastrointestinal endoscopy. All were firstly started with oral iron supplements with no benefit, principally due to poor compliance secondary to the worsening of the epigastric pain and proton pump inhibitor resistance. Therefore, they underwent ferric carboxymaltose (FCM) infusion with good clinical and laboratory response. Patients received a mean of two infusions/year, with stable hemoglobin levels and no adverse outcomes. Our review failed to identify a consistent response to specific treatments. Considering the apparent benign nature of the disease, symptomatic and supportive treatments are advisable. Iron deficiency anemia is largely present and therapy with oral iron supplements is not always successful. In our study, FCM infusion was effective in increasing the key blood indices in patients who poorly tolerated oral supplements.

Histopathology of Eosinophilic Gastrointestinal Diseases Beyond Eosinophilic Esophagitis

Eosinophilic gastrointestinal diseases (EGID), such as eosinophilic gastritis (EoG), eosinophilic enteritis, and eosinophilic colitis (EoC), are chronic inflammatory conditions characterized by persistent gastrointestinal symptoms and elevated levels of activated eosinophils in the gastrointestinal tract. EoG and eosinophilic duodenitis (EoD) are strongly associated with food allergen triggers and TH2 inflammation, whereas EoC shows minimal transcriptomic overlap with other EGIDs. The level of expression of certain genes associated with TH2 immune response is associated with certain histopathologic findings of EoG, EoD, and EoC. Current immune therapy for EoG depletes tissue eosinophilia with persistence of other histopathologic features of disease.

Coexisting Th1 and Th2 cytokines in patients with collagenous gastritis and implications for its pathogenesis

OBJECTIVES

Collagenous gastritis (CG) is a rare cause of refractory dyspepsia and anemia that frequently affects children and young adults and whose histological hallmark is chronic mucosal inflammation with a subepithelial collagen band. The etiology remains obscure, and no established treatments exist. We investigated the pathogenesis of CG by determining the expression profiles of genes related to immunity and inflammation in index biopsies.

METHODS

Gastric biopsies from 10 newly diagnosed patients with CG were evaluated using the NanoString nCounter assay. Gastric biopsies from 14 normal individuals served as controls. The gene expression ratios for CG versus controls were determined in pooled samples and confirmed in individual samples by quantitative reverse transcription polymerase chain reaction. The results were compared with previously reported expression data from a cohort of patients with collagenous colitis, a colonic disorder with similar morphology, including subepithelial collagen band.

RESULTS

CG biopsies featured enhanced expression of key genes encoding both Th1 (IFNγ, TNF-α, IL-2, IL-10, IL-12A, IL-12B, and IL-18) and Th2 cytokines (IL-3, IL-4, IL-5, IL-6, and IL-13). In contrast, biopsies from patients with CC exhibited upregulated Th1 cytokines only.

CONCLUSIONS

We show in this first published gene expression profiling study that CG involves simultaneous upregulation of Th1 and Th2 cytokines. This finding is unique, contrasting with other types of chronic gastritis as well as with collagenous colitis, which shares the presence of a collagen band. Involvement of Th2 immunity in CG would support further investigation of potential dietary, environmental, or allergic factors to guide future therapeutic trials.

Joint ESPGHAN/NASPGHAN Guidelines on Childhood Eosinophilic Gastrointestinal Disorders Beyond Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic gastrointestinal disorders beyond eosinophilic esophagitis (non-EoE EGIDs) are rare chronic inflammatory disorders of the gastrointestinal (GI) tract. Diagnosis is based on clinical symptoms and histologic findings of eosinophilic inflammation after exclusion of a secondary cause or systemic disease. Currently, no guidelines exist for the evaluation of non-EoE EGIDs. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) formed a task force group to provide consensus guidelines for childhood non-EoE EGIDs.

METHODS

The working group was composed of pediatric gastroenterologists, adult gastroenterologists, allergists/immunologists, and pathologists. An extensive electronic literature search of the MEDLINE, EMBASE, and Cochrane databases was conducted up to February 2022. General methodology was used in the formulation of recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet current standards of evidence assessment.

RESULTS

The guidelines provide information on the current concept of non-EoE EGIDs, disease pathogenesis, epidemiology, clinical manifestations, diagnostic and disease surveillance procedures, and current treatment options. Thirty-four statements based on available evidence and 41 recommendations based on expert opinion and best clinical practices were developed.

CONCLUSION

Non-EoE EGIDs literature is limited in scope and depth, making clear recommendations difficult. These consensus-based clinical practice guidelines are intended to assist clinicians caring for children affected by non-EoE EGIDs and to facilitate high-quality randomized controlled trials of various treatment modalities using standardized, uniform disease definitions.

Literature Review and a Relevant Case of Pediatric Collagenous Gastritis: A Rare but Important Etiology of Iron-Deficiency Anemia

An adolescent male with fatigue, weight loss, and iron-deficiency anemia failed to improve with iron supplementation and a gluten-free diet. Endoscopy revealed collagenous gastritis. Pediatric patients with refractory iron deficiency and family history of autoimmune disorders should be referred to pediatric gastroenterology for evaluation of collagenous gastritis and celiac disease.

Clinical and Pathologic Response to Vedolizumab in a Young Female Patient With Collagenous Gastritis

Collagenous gastritis is a rare form of gastritis that affects both children and adults. The underlying pathophysiology is not well-understood, and as a result, there are limited options for treatment. We report a case of a young female patient with chronic diffuse abdominal pain, nausea, regurgitation, and early satiety with esophagogastroduodenoscopy showing gastric erythema, atrophic gastric body, and significant gastric nodularity. Biopsies revealed focal erosion and increased subepithelial collagen deposition. She was successfully managed with intravenous vedolizumab infusions after initial therapy with topical budesonide did not result in clinical or endoscopic improvement.

Collagenous gastritis in children: A national cohort

BACKGROUND

Collagen gastritis is a rare disease that manifests in children mainly as isolated gastric involvement associated with martial deficiency anemia. There are no recommendations for the management and follow-up of these patients. We aimed to describe the clinical data, endoscopic findings, and treatments deployed in France's children with collagenous gastritis.

METHODS

All French pediatric gastroenterology centers and pediatric centers for rare digestive diseases (Centres de Maladies Rares Digestives) were contacted to collect cases of collagenous gastritis, defined on gastric biopsies and diagnosed before 18 years of age.

RESULTS

A total of 12 cases diagnosed (4 males and 8 females) between 1995 and 2022 could be analyzed. The median age at diagnosis was 12.5 years (7-15.2). The most frequent clinical presentation was abdominal pain (6/11) and/or nonspecific symptomatology attributed to anemia (8/10). Anemia was present in all children (11/11; Hb 2.8-9.1 g/dL). Nodular gastritis was present in 10 patients (antrum: 2; fundus: 4; in antrum and fundus: 4). All patients had a basement membrane thickening (from 19 to 100 μm). The treatments received were PPI (11), oral or intravenous martial supplementation (12), budesonide (1), and prednisone (1). Martial supplementation improved anemia in all cases. At discontinuation, nine of 10 patients had a recurrence of anemia.

CONCLUSION

Collagenous gastritis is an exceptional condition, clinically manifested in children as abdominal pain and iron deficiency anemia probably of hemorrhagic origin. Patients require long-term follow-up and monitoring of their disease to describe the risk of progression better.

Collagenous Gastritis Is an Underdiagnosed Cause of Anemia and Abdominal Pain: Systematic Scoping Review

BACKGROUND

Collagenous gastritis (CG) is a rare disease characterized by infiltration of the lamina propria with mononuclear cells and subepithelial deposition of collagen. Due to its nonspecific presentation, it is often misdiagnosed. The clinical characteristics, endoscopic, and histopathologic features, and treatment outcomes of CG have not been well defined.

AIMS

We aim to summarize the existing evidence of CG.

METHODS

According to the PRISMA Extension for Scoping Reviews, we performed a search on MEDLINE and EMBASE for articles with keywords including "collagenous gastritis" and "microscopic gastritis" from the inception of these databases to August 20, 2022.

RESULTS

76 Articles, including nine observational studies, and 67 case reports and series were included. There were 86 cases of collagenous colitis in the final analysis. Most patients presented with anemia (61.4%), followed by abdominal discomfort (60.5%), diarrhea (25.3%), and nausea/vomiting (23.0%). While 60.2% had gastric nodularity on endoscopy, erythema or erosions (26.1%) were also common, as well as normal findings (12.5%). 65.9% of histopathologic findings included subepithelial collagen bands, and 37.5% had mucosal inflammatory infiltrates. Common treatments employed were iron supplementation (42%), followed by PPI (30.7%), prednisone (9.1%), and budesonide (6.8%). Clinical improvement was seen in 64.2%.

CONCLUSION

This systematic review summarizes the clinical characteristics of CG. Further studies to establish clear diagnostic criteria and identify effective treatment modalities of this less-recognized entity are needed.

Collagenous Gastritis: An Atypical Presentation of a Rare Disease

Collagenous gastritis is a rare inflammatory condition of unknown etiology defined histologically by subepithelial deposition of collagen bands ≥ 10 µm in the lamina propria. Adults typically present with diarrhea, often attributed to concurrent collagenous sprue or collagenous colitis. Children more commonly present with abdominal pain and anemia, with inflammation typically limited to the stomach. Herein, we present a case of collagenous gastritis in a 38-year-old female with a history of iron deficiency and hypothalamic amenorrhea who presented with a one-year history of microcytic anemia. Celiac disease panel, Helicobacter pylori testing, and anti-parietal cell and intrinsic factor antibodies were negative. Esophagogastroduodenoscopy revealed diffusely erythematous and nodular gastric mucosa in the antrum and pylorus. Biopsy from the gastric body showed complete loss of oxyntic glands and deposition of a thick band of collagen under the surface epithelium infiltrated by a few eosinophils, consistent with collagenous gastritis with severe atrophy. She was treated with omeprazole 40 mg daily for six weeks and iron supplementation. Our patient's symptoms and endoscopic findings are consistent with previously described pediatric, but not adult, cases of collagenous gastritis, yielding insight into the variable clinical presentation of this rare disease.

Collagenous Gastritis: A Cause of Pediatric Iron Deficiency Anemia

Collagenous gastritis (CG) is a rare histopathological condition characterized by subepithelial collagen deposition and inflammatory infiltrates in the gastric mucosa. With less than 100 cases reported in current literature, clinical presentation is highly variable. We report a case of isolated CG in an 11-year-old girl who presented with a 6-month history of symptomatic severe iron deficiency anemia (nonexertional shortness of breath, palpitations, chest pain, and lethargy). CG is a rare condition in children require long-term follow-up and monitoring of their disease; and because of its rarity, a targeted treatment does not exist. The current therapeutic strategy is focused on symptom control and monitoring iron studies, in conjunction with regular follow-up.

Collagenous gastritis in a young Chinese woman: A case report

BACKGROUND

Collagenous gastritis (CG) is a rare condition whose pathogenesis may be related to immune abnormalities. We report a case of CG from China.

CASE SUMMARY

A 24-year-old woman presented with recurrent abdominal distension and discomfort for 3 mo. Upper gastrointestinal endoscopy found diffuse nodular elevation-depression changes in the mucosa of the entire gastric corpus. Endoscopic ultrasound showed predominant involvement of the lamina propria and submucosa, and computed tomography imaging showed mild enhancement of the gastric wall. Pathological histology revealed that the thickness of the subepithelial collagen band was about 40 μm, and the Masson trichrome staining result was positive and the Congo red staining result was negative. This case is consistent with the child-adolescent type of CG.

CONCLUSION

Serum pepsinogen I, pepsinogen II, pepsinogen I/II ratio, and gastrin-17 may be potential non-invasive monitoring markers. Currently, treatments for CG vary, and the likely prognosis is unknown. Individual cases of gastric cancer in patients with CG have been reported.

Mixed lymphocytic and collagenous inflammation of the entire gastrointestinal tract under therapy with serotonin and norepinephrine reuptake inhibitors

Drug-induced injury to the gastrointestinal tract has gained growing significance in recent years, and the list of causative medications keeps expanding. Herein, we present the case of a 45-year-old female with major depressive disorder treated with two serotonin and norepinephrine reuptake inhibitors (venlafaxine and duloxetine). She developed nausea and weight loss. Endoscopic evaluation of the upper and lower gastrointestinal tract rendered grossly normal mucosa in all segments. Histological examination, however, revealed lymphocytic esophagitis, collagenous gastritis, celiac disease-like intraepithelial lymphocytosis of the duodenum, and incomplete collagenous colitis. Gastrointestinal side effects of psychoactive drugs are largely underrecognized. This is the first report of a mixed lymphocytic and collagenous pattern of injury affecting esophagus, stomach, duodenum, and colon triggered by combined treatment with venlafaxine and duloxetine. In patients with unclear symptoms, obtaining biopsies from mucosa that is normal upon endoscopic inspection may render decisive clues for clinical management.

Collagenous Gastritis: Characteristics and Response to Topical Budesonide

BACKGROUND AND AIMS

Collagenous gastritis (CG) is a rare disorder characterized by subepithelial collagen deposition in the stomach. Standard medications have been only moderately successful in treating CG. We report results of a large, retrospective, open-label noncontrolled study of topical budesonide for CG, with an aim of establishing an alternative therapy for the disease.

METHODS

We identified patients treated for CG at Mayo Clinic (2000-2017) with topically targeted budesonide (TTB) in 2 formulations: open-capsule budesonide or compounded immediate-release budesonide capsule. Demographic, clinical, biochemical, and histologic variables were assessed for all patients before and after treatment.

RESULTS

We identified 64 patients with CG (50 adults, 14 children). Most were female (68%), mean age was 41 ± 22.8 years, and body mass index was 23.1 ± 5.9 kg/m². In most pediatric patients, CG presented with abdominal pain and anemia; in adults, CG presented more often with weight loss (P < .001). Collagenous sprue or colitis were more common in patients >50 years of age (83%) vs those 19-50 years of age (27%) or <19 years of age (50%) (P < .001). Of the patients treated with TTB, 89% had a clinical response to TTB (42% complete, 46% partial), and 88% had a histologic response (53% complete, 33% partial).

CONCLUSIONS

Adults and children with CG have a wide variety of symptoms, and notably, TTB therapy produced clinical and histologic improvement after other therapy had failed.

Proteome-Wide Analysis Using SOMAscan Identifies and Validates Epidermal Growth Factor as a Disease Marker of Collagenous Gastritis

Background and Aims

Collagenous gastritis (CG) is a rare disorder characterized by increased subepithelial collagen deposition and inflammatory infiltrates. The mechanisms involved in CG pathogenesis are poorly understood, and no CG-associated biomarkers have been identified. This proteomics study identified serum biomarkers and pathogenic pathways to provide new knowledge about the pathobiology of CG, a disease reported in less than 100 patients.

Methods

Nine serum samples from pediatric patients diagnosed with CG were evaluated using novel aptamer-based proteomic technology and systems biology to generate new knowledge about the complex interactions between the differentially expressed proteins and candidate upstream regulators, using the Ingenuity Pathway Analysis in patients with non-CG and patients with normal gastric biopsies or nongastritis (NG).

Results

SOMAscan analysis identified 63 proteins significantly dysregulated in CG as compared to non-CG or NG patients that converged around enhanced inflammatory response and immune cell migration but reduced vascular functions. Principal component analysis using 15 of those proteins accurately separated the CG cases from the 2 comparator control groups. Using immunoassays, serum epidermal growth factor concentrations in CG patients, a protein involved in collagen production, were confirmed to be significantly lower than those in gastritis/NG patients.

Conclusion

This is the first comprehensive analysis of the proteome in CG patients that reveals metabolic pathways relating inflammation and fibrosis as well as a new potential role of epidermal growth factor as a disease biomarker.

Concurrent Collagenous Gastritis and Collagenous Colitis: A Case Presentation and Review of the Literature

Collagenous gastritis is a rare gastrointestinal condition, and its presence with collagenous colitis may be an exception. We describe a 31-year-old man with simultaneous collagenous gastritis and collagenous colitis. The patient initially presented with dyspepsia, anemia, and weight loss. Endoscopy assessment revealed irregular gastric atrophy with the normal colon. Gastric biopsies illustrated increased thickness and subepithelial collagen band.

Collagenous gastroduodenocolitis in a Korean adolescent: first pediatric case report in Asia

Collagenous gastritis (CG) is a rare disease diagnosed histologically by the subepithelial deposition of collagen bands thicker than 10 µm and the infiltration of inflammatory mononuclear cells in the lamina propria. The definite pathophysiology is yet to be elucidated. However, recent studies have suggested that the collagen deposition may be the result of a reparative process in response to an earlier inflammatory, autoimmune, infectious, or toxic insult. CG is divided into the pediatric- and adult-type. While the pediatric-type is limited to the stomach, the adult-type involves not only the stomach but also the intestine and/or colon. We report a rare case of adult-type CG in a 15-year-old boy who initially presented with abdominal pain and iron-deficiency anemia. Esophagogastroduodenoscopy (EGD) revealed findings suspicious for Helicobacter pylori (H. pylori) gastritis. Although histology did not reveal the organism, campylobacter-like organism (CLO) test was positive. Based on the diagnosis of suspicious H. pylori gastritis, eradication was conducted using the triple drug regimen. However, symptoms of intermittent abdominal pain persisted and diarrhea newly developed one year later. Histologic results from biopsies from the stomach, duodenum, and colon revealed findings compatible with CG, collagenous duodenitis (CD), and collagenous colitis (CC). This is the first pediatric case of collagenous gastroduodenocolitis (CGDC) reported in Asia. It is no longer assumed that adult-type and pediatric-type CG should be classified as an independent disease, but should be considered as similar diseases on a continuous spectrum. Therefore, children and adolescents diagnosed with CG should also consider undergoing a colonoscopy for the evaluation of possible coexisting CC when concurrent lower gastrointestinal symptoms are present. Moreover, considering the possibility of negative findings on the first endoscopy, repeat endoscopy should be considered when symptoms persist.

Pediatric Collagenous Gastritis: Clinical and Histologic Outcomes in a Large Pediatric Cohort

OBJECTIVE

The aim of the study was to present the clinical characteristics, treatment, and outcomes of pediatric collagenous gastritis (CG).

METHOD

This is a retrospective cohort study. Patients were identified via query of the institutional pathology database. Clinical data was obtained by review of medical records.

RESULTS

Forty patients (57.5% female) were identified, mean age 11.3 ± 3.7 years (2-16years). Isolated CG was present in 66.7%, coexisting collagenous duodenitis (CD) in 17.5%, collagenous colitis (CC) in 7.5%, and collagenous ileitis in 2.5%. Atopic comorbidities were found in 25%, autoimmune comorbidities in 12.5%.

PRESENTING SYMPTOMS

Abdominal pain (77.5%), vomiting (65%), anemia (57.5%), nausea (55.5%), diarrhea (32.5%), anorexia (25.0%), weight loss (25%), gastrointestinal bleed (22.5%), poor growth (20%), poor weight gain (12.5%).

ENDOSCOPIC FINDINGS

All had abnormal endoscopic findings on esophago-gastro-duodenoscopy (EGD), most commonly gastric nodularity (77.5%), visible blood (20%), erosions/superficial ulcerations (10%), ulcers (7.5%). Histologically, all patients had increased subepithelial collagen deposition.

TREATMENT

A variety of medications aimed towards inflammation and symptomatic treatment were used. Patients with anemia received iron supplementation and responded. Otherwise, there was no significant association of clinical or histologic improvement with specific treatments.

CLINICAL AND HISTOLOGIC OUTCOMES

87.5% reported improvement or resolution of symptoms at the last follow-up (34.8 ± 27.0 months). Persistent sub-epithelial collagen was noted in 73.1% on the last EGD.

CONCLUSIONS

Despite persistent findings of increased sub-epithelial collagen deposition during the follow-up period, most patients with CG show remission or resolution of clinical symptoms. Anemia responds to iron supplementation in all patients.

Collagenous gastritis: Epidemiology and clinical associations

BACKGROUND

the rare occurrence of collagenous gastritis (CG) makes its epidemiology difficult to investigate. We designed a study to determine the demographic and clinical characteristics as well as the associations of CG with other upper gastrointestinal diseases in a large national clinicopathological database.

METHODS

from the IDEA database we extracted all patients with histopathologically documented CG and, in a case-control study, we compared 168 subjects with and 1,286,165 subjects without CG using odds ratios (OR) with their 95% confidence intervals (CI).

RESULTS

the prevalence of CG was 13 per 100,000 EGDs. CG was significantly more common among female than male patients (OR: 1.69, 95% CI: 1.20-2.39) and was characterized by a bi-modal age distribution (first peak in patients aged 10-19, second peak primarily in females aged >60 years). CG patients presented with diarrhea (18%), anemia (12%), weight loss (11%), and vomiting (10%). CG was significantly associated with other lymphocytic disorders of the upper gastrointestinal tract, including celiac sprue (2.12, 1.55-2.88), duodenal intraepithelial lymphocytosis (3.71, 2.30-5.98), and lymphocytic gastritis (23.2, 10.9-49.5). CG persisted in 69% of patients who underwent multiple consecutive endoscopies.

CONCLUSIONS

the epidemiologic features of collagenous gastritis reflect on different etiologies contributing to its occurrence in children and adults.

Collagenous Gastritis: An Unusual Presentation With Tubular Shaped Stomach

Collagenous gastritis is a rare histopathologic entity that causes marked subepithelial collagen deposition in the gastric mucosa. Clinical presentation is diverse, considering only less than 100 cases have been reported. However, we report a unique case of isolated collagenous gastritis in a 71-year-old female who presented with a 6-month history of dyspepsia and 27 kg weight loss. Her endoscopic findings revealed a tubular shaped stomach with diffuse gastric mucosal atrophy, findings that differ with previous case reports of a cobblestone pattern. Treatment remains unclear.

Collagenous Gastritis in Children: Incidence, Disease Course, and Associations With Autoimmunity and Inflammatory Markers

Collagenous gastritis (CG), a rare disorder of unknown etiology, has been postulated to have immune-mediated mechanisms. We investigated (i) the incidence and prevalence of CG in a pediatric population; (ii) the clinical, endoscopic, and histologic characteristics of childhood-onset CG; and (iii) the evidence for autoimmunity and/or inflammatory activity in these patients.

Beyond Helicobacter: dealing with other variants of gastritis-an algorithmic approach

In daily practice, the presence of inflammation in gastric biopsies prompts a mental algorithm, an early question being whether the lesion present is Helicobacter-associated. If Helicobacter organisms are not found, then there is a further algorithm, governed by the predominant type of inflammatory cells present, and the presence of other features such as intraepithelial lymphocytosis, a subepithelial collagen band, granulomas, coexisting chronic inflammation, focality, and superimposed reactive changes including erosions and ulcers. Each of these generates its own differential diagnosis. If no inflammation is present, then the two major changes specifically looked for are the changes associated with hypergastrinaemia, by far the most common cause of which is treatment with proton pump inhibitors, and reactive changes. These may be present with and without accompanying inflammation, and, when the epithelial changes dominate, the term gastropathy is preferred. In this article, we present an approach to non-Helicobacter inflammation and gastropathies.

Daily Dilemmas in Pediatric Gastrointestinal Pathology

The evaluation of gastrointestinal pathology in children often requires a different approach from that in adults. In this concise review, the authors outline 3 diagnostic challenges that are often encountered in daily practice; these include eosinophilic diseases, duodenal intraepithelial lymphocytosis with preserved villous architecture, and terminal ileal inflammation in the setting of idiopathic inflammatory bowel disease.

An Unusual Case of Collagenous Gastritis: Incidental Finding in a Patient Presenting with Dysphagia

Collagenous gastritis is a condition characterized by subepithelial deposition of collagen in the gastric mucosa. This condition is rare, with less than 100 cases reported in the literature. Patients with collagenous gastritis typically present with pain or diarrhea. Here, we present a case of a young woman with dysphagia who was found to have esophageal webs and an incidental finding of diffuse gastritis with a cobblestone appearance of the mucosa on endoscopy. Subsequent histology demonstrated features of collagenous gastritis, including mucosal inflammatory infiltrates and collagen deposition. This is one of the few case reports of incidental collagenous gastritis and highlights the importance of judicious use of biopsies.

Collagenous Gastritis, a Rare Cause of Dyspepsia Resistant to Treatment; A Case Report

Collagenous gastritis is hardly ever found in children and adults. Based on the extent of collagenous changes in the bowel, various symptoms may develop including iron deficiency, anemia, and abdominal pain in most of the patients.

We present a 30-year-old man with persistent abdominal pain and anemia due to collagenous gastritis.

An elderly patient's complete response to steroid therapy for collagenous gastritis

An 85-year-old woman presented with 9.1 kg (20 lb) weight loss over 5 months and an acute onset crampy abdominal pain. Examination revealed a diffusely tender abdomen, with gastric wall thickening noted on CT scan. Upper endoscopy showed diffuse severe erythema and friability. Histologic examination with hematoxylin and eosin staining revealed collagenous gastritis characterized by active chronic inflammation with sub-epithelial collagen deposition and erosion. The patient was started on steroid therapy with rapid clinical improvement and tapered off over 2.5 months. At 6 months, the patient reported an improved appetite with resolution of her abdominal pain. Repeat endoscopy revealed a grossly normal stomach and normal mucosal biopsies. She remains without complaints 1 year later. Collagenous gastritis, rare in the elderly, is a histologic diagnosis characterized by the deposition of a sub-epithelial collagen band thicker than 10 µm with an inflammatory infiltrate. In all ages the mucosa typically appears nodular and erythematous, caused by an uneven inflammation in the surrounding depressed mucosa with atrophic changes. Specific therapy has not been well-established, and the prognosis and potential for endoscopic or histological resolution remains unclear. While anecdotal, the success of steroids may offer a reasonable starting point for treatment of similar cases.

Patterns of Gastric Injury: Beyond Helicobacter Pylori

Gastric biopsies are routinely obtained from patients with symptoms related to the gastrointestinal tract and, as a result, a variety of histologic changes are observed in patients with or without endoscopic evidence of mucosal injury. Although Helicobacter pylori-related gastritis is still common, several other patterns of mucosal injury are increasingly encountered. These patterns of injury are classified based on the nature and distribution of inflammation, location of epithelial cell injury, presence of crystal or pigment deposition, and/or other unique features. This article discusses each of these patterns and provides a differential diagnosis for each.

Iron deficiency anemia in celiac disease

Iron is an important micronutrient that may be depleted in celiac disease. Iron deficiency and anemia may complicate well-established celiac disease, but may also be the presenting clinical feature in the absence of diarrhea or weight loss. If iron deficiency anemia occurs, it should be thoroughly evaluated, even if celiac disease has been defined since other superimposed causes of iron deficiency anemia may be present. Most often, impaired duodenal mucosal uptake of iron is evident since surface absorptive area in the duodenum is reduced, in large part, because celiac disease is an immune-mediated disorder largely focused in the proximal small intestinal mucosa. Some studies have also suggested that blood loss may occur in celiac disease, sometimes from superimposed small intestinal disorders, including ulceration or neoplastic diseases, particularly lymphoma. In addition, other associated gastric or colonic disorders may be responsible for blood loss. Rarely, an immune-mediated hemolytic disorder with increased urine iron loss may occur that may respond to a gluten-free diet. Reduced expression of different regulatory proteins critical in iron uptake has also been defined in the presence and absence of anemia. Finally, other rare causes of microcytic anemia may occur in celiac disease, including a sideroblastic form of anemia reported to have responded to a gluten-free diet.