Observer variation in immunohistochemical analysis of protein expression, time for a change?

AIM

Immunohistochemical analysis of protein expression is central to most clinical translational studies and defines patient treatment or selection criteria for novel drugs. Interobserver variation is rarely analysed despite recognition that this is a key area of potential inaccuracy. Therefore our aim was to examine observer variation and suggest the revision of current standards.

METHODS AND RESULTS

We analysed inter- and intra-observer variation, by interclass correlation coefficient (ICCC) and kappa statistics, in 8661 samples. Intra-observer assessment of nuclear, cytoplasmic and membrane staining for seven proteins in 1323 samples resulted in an ICCC of 0.94 and a kappa-value of 0.787. Interobserver reproducibility, assessed on 28 proteins by seven observer pairs in 8661 carcinomas, gave an ICCC of 0.90 and a kappa-value of 0.70. No significant effect of either antibody or cellular compartmentalization was observed.

CONCLUSION

We have demonstrated that ICCC is a consistent method to assess observer variation when a continuous scoring system is used, compared with kappa statistics, which depends on a categorical system. Given the importance of accurate assessment of protein expression in diagnostic and experimental medicine, we suggest raising thresholds for observer variation: ICCC of 0.7 should be regarded as the minimum acceptable standard, ICCC of 0.8 as good and ICCC of > or = 0.9 as excellent.

Expression levels of the JAK/STAT pathway in the transition from hormone-sensitive to hormone-refractory prostate cancer

The main cause of prostate cancer-related mortality is the development of hormone-refractory disease. Circulating serum levels of IL-6 are raised in hormone-refractory prostate cancer patients and evidence from cell line studies suggests that the IL-6R/JAK/STAT3 pathway may be involved in development of this disease. In the current study we investigate if expression levels of these family members are implicated in the development of hormone-refractory prostate cancer. Immunohistochemistry using IL-6R, JAK1, STAT3, pSTAT3(Tyr705) and pSTAT3(Ser727) antibodies was performed on 50 matched hormone-sensitive and hormone-refractory tumours pairs. An increase in expression of cytoplasmic IL-6 receptor, with the development of hormone-refractory prostate cancer was associated with reduced time to relapse (P=0.0074) while an increase in expression of cytoplasmic pSTAT3(Tyr705) was associated with reduced patient survival (P=0.0003). In addition, those patients with high expression of cytoplasmic pSTAT3(Tyr705) in their hormone-refractory tumours had significantly shorter time to death from biochemical relapse and overall survival in comparison to those patients with low expression of cytoplasmic pSTAT3(Tyr705) (P=0.002 and P=0.0027, respectively). Activation of STAT3, via phosphorylation is associated with reduced patient survival, suggesting that activation of the IL-6R/JAK/STAT3 pathway is involved with development of hormone-refractory prostate cancer.

Can critically timed sleep deprivation be useful in pregnancy and postpartum depressions?

BACKGROUND

The aim of this study was to test the efficacy of critically timed sleep deprivation in major mood disorders (MMD) occurring during pregnancy and postpartum.

METHODS

Nine women who met DSM-IV criteria for a MMD with onset during pregnancy or within 1 year postpartum underwent a trial of either early-night sleep deprivation (ESD), in which they were sleep deprived in the early part of one night and slept from 03:00-07:00 h, or late-night sleep deprivation (LSD), in which they were deprived of sleep in the latter part of one night and slept from 21:00-01:00 h. Mood was assessed before the night of sleep deprivation, after the night of sleep deprivation, and after a night of recovery sleep (sleep 22:30-06:30 h) by trained clinicians, blind to treatment condition, using standardized scales.

RESULTS

More patients responded to LSD (nine of 11 trials: 82%) compared with ESD (two of six trials: 33%) and they responded more after a night of recovery sleep (nine of 11 nights: 82%) than after a night of sleep deprivation (six of 11 nights: 55%). Pregnant women were the only responders to ESD and the only nonresponders to LSD.

LIMITATIONS

The small and heterogeneous sample size prevents us from making more definitive conclusions based on statistical analyses.

CONCLUSIONS

Although the findings are preliminary, the results suggest that with further study, critically timed sleep deprivation interventions may benefit women with pregnancy or postpartum major mood disorders and potentially provide a viable alternative treatment modality for those women who are not candidates for pharmacologic or psychotherapeutic interventions. Such interventions are needed to help prevent the devastating effects of depression during pregnancy and the postpartum period on the mother, infant, her family and society.

Vitamin B-12 supplementation improves arterial function in vegetarians with subnormal vitamin B-12 status

OBJECTIVE

Vegetarians are more vascular-healthy but those with subnormal vitamin B-12 status have impaired arterial endothelial function and increased intima-media thickness. We aimed to study the impact of vitamin B-12 supplementation on these markers, in the vegetarians.

DESIGN

Double-blind, placebo controlled, randomised crossover study.

SETTING

Community dwelling vegetarians.

PARTICIPANTS

Fifty healthy vegetarians (vegetarian diet for at least 6 years) were recruited.

INTERVENTION

Vitamin B-12 (500 µg/day) or identical placebo were given for 12 weeks with 10 weeks of placebo-washout before crossover (n=43), and then open label vitamin B-12 for additional 24 weeks (n=41).

MEASUREMENT

Flow-mediated dilation of brachial artery (FMD) and intima-media thickness (IMT) of carotid artery were measured by ultrasound.

RESULTS

The mean age of the subjects was 45±9 years and 22 (44%) were male. Thirty-five subjects (70%) had serum B-12 levels <150 pmol/l. Vitamin B-12 supplementation significantly increased serum vitamin B-12 levels (p<0.0001) and lowered plasma homocysteine (p<0.05). After vitamin B-12 supplementation but not placebo, significant improvement of brachial FMD (6.3±1.8% to 6.9±1.9%; p<0.0001) and in carotid IMT (0.69±0.09 mm to 0.67±0.09 mm, p<0.05) were found, with further improvement in FMD (to 7.4±1.7%; p<0.0001) and IMT (to 0.65±0.09 mm; p<0.001) after 24 weeks open label vitamin B-12. There were no significant changes in blood pressures or lipid profiles. On multivariate analysis, changes in B-12 (β=0.25; p=0.02) but not homocysteine were related to changes in FMD, (R=0.32; F value=3.19; p=0.028).

CONCLUSIONS

Vitamin B-12 supplementation improved arterial function in vegetarians with subnormal vitamin B-12 levels, proposing a novel strategy for atherosclerosis prevention.

Wnt-signaling mediates the anti-adipogenic action of lysophosphatidic acid through cross talking with the Rho/Rho associated kinase (ROCK) pathway

Lysophosphatidic acid (LPA) is a bioactive phospholipid with a diverse range of biological activities including the modulation of adipogenesis. Treatment of 3T3-L1 cells and 3T3F44A cells with LPA inhibits adipogenesis and reduces expression of PPARγ through activation of RhoGTPase and its downstream Rho associated kinase (ROCK). The mechanism of suppression of PPARγ expression by Rho/ROCK is poorly understood. By treating the differentiating 3T3-L1 cells with various combinations of LPA and ROCK inhibitors, Y-27632 and fasudil, we observed that LPA treatment resulted in attenuation of adipogenesis and a significant reduction in PPARγ mRNA as early as 3 d post-induction. LPA treatment also resulted in significant but delayed upregulation of components of the canonical Wnt signaling, namely Wnt10b mRNA, β-catenin protein, and mRNA expression of β-catenin target genes, detectable at day 7, but not day 3. Treatment of the 3T3-L1 cells with ROCK inhibitors Y-27632 and fasudil revealed a tonic activation of β-catenin/target genes by ROCK. This study identified the existence of a novel cross talk between the Rho/ROCK pathway and the Wnt-signaling pathway. The LPA/Rho/ROCK pathway inhibits expression of PPARγ and adipogenesis in part through a delayed activation of the canonical Wnt-signaling pathway based on increased Wnt10b expression and β-catenin induction.

[3H]naltrindole: a potent and selective ligand for labeling delta-opioid receptors

Naltrindole (NTI) is a selective and potent delta-opioid antagonist which preferentially antagonizes a subset of selective delta-opioid agonists. The purpose of this study was to evaluate whether [3H]NTI, the first radiolabeled delta-opioid antagonist, could selectively label delta-opioid receptors in a synaptosomal preparation. Increasing temperature and protein concentration (0.1-1.6 mg protein) increased the specific binding of [3H]NTI. Monovalent and divalent cations (0.01-100 mM) had minimal effects on the binding properties of [3H]NTI, in contrast to their effects on binding of the delta agonists [3H]DPDPE and [3H]DSLET. Subfractionation of rat brain homogenates revealed that [3H]NTI and [3H]DSLET primarily labeled binding sites in synaptosomal and microsomal fractions, whereas [3H]DPDPE labelled half as many sites in synaptosomal fraction. The Bmax determined for [3H]NTI in crude synaptosomal fraction was 95 +/- 12 fmol/mg. The dissociation constant (Kd) was determined from three different methods to be 0.08 +/- 0.02 nM (Scatchard analysis), 0.07 +/- 0.02 nM (competition study) and 0.03 +/- 0.005 nM (kinetic analysis). [3H]NTI binding was not significantly inhibited by mu- or kappa-opioid ligands or by nonopioid compounds. These results demonstrate that [3H]NTI is a potent and selective radioligand for delta-opioid receptors in rat brain preparations.

Microleakage of Posterior Composite Restorations Lined with Self-adhesive Resin Cements

Two self-adhesive resin cements resulted in minimal microleakage scores when used as liners in Class II composite restorations.

Patients' and providers' perceptions of outpatient treatment termination in a managed behavioral health organization

OBJECTIVE

A common complaint about managed care is that treatment decisions of patients and providers are frequently altered by concurrent review of ongoing outpatient treatment. The objective of this study was to examine this perception from the perspectives of patients and providers.

METHODS

A total of 190 patients and their providers were surveyed about the reason that outpatient treatment was terminated. The sample was randomly drawn from completed outpatient treatment episodes of a large national managed behavioral health organization.

RESULTS

In more than three-quarters of the cases, outpatient treatment ended because patients and providers agreed that treatment goals were partially or completely met. Only 5 percent of patients and 3 percent of providers said that treatment ended because the managed care organization denied ongoing treatment. Agreement between patient-provider pairs was generally poor regarding the perceived reason for termination, except when termination was attributed to concurrent review by the managed behavioral health organization.

CONCLUSIONS

In this study of a single large managed behavioral health organization, outpatient treatment was most likely to end based on the decisions of patients and providers rather than utilization review decisions.

Radiomics Can Distinguish Pediatric Supratentorial Embryonal Tumors, High-Grade Gliomas, and Ependymomas

BACKGROUND AND PURPOSE

Pediatric supratentorial tumors such as embryonal tumors, high-grade gliomas, and ependymomas are difficult to distinguish by histopathology and imaging because of overlapping features. We applied machine learning to uncover MR imaging-based radiomics phenotypes that can differentiate these tumor types.

MATERIALS AND METHODS

Our retrospective cohort of 231 patients from 7 participating institutions had 50 embryonal tumors, 127 high-grade gliomas, and 54 ependymomas. For each tumor volume, we extracted 900 Image Biomarker Standardization Initiative-based PyRadiomics features from T2-weighted and gadolinium-enhanced T1-weighted images. A reduced feature set was obtained by sparse regression analysis and was used as input for 6 candidate classifier models. Training and test sets were randomly allocated from the total cohort in a 75:25 ratio.

RESULTS

The final classifier model for embryonal tumor-versus-high-grade gliomas identified 23 features with an area under the curve of 0.98; the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.85, 0.91, 0.79, 0.94, and 0.89, respectively. The classifier for embryonal tumor-versus-ependymomas identified 4 features with an area under the curve of 0.82; the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.93, 0.69, 0.76, 0.90, and 0.81, respectively. The classifier for high-grade gliomas-versus-ependymomas identified 35 features with an area under the curve of 0.96; the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 0.82, 0.94, 0.82, 0.94, and 0.91, respectively.

CONCLUSIONS

In this multi-institutional study, we identified distinct radiomic phenotypes that distinguish pediatric supratentorial tumors, high-grade gliomas, and ependymomas with high accuracy. Incorporation of this technique in diagnostic algorithms can improve diagnosis, risk stratification, and treatment planning.

A162 RARE PRESENTATION OF EXTRANODAL NK/T-CELL LYMPHOMA INVOLVING STOMACH AND EYE: CASE REPORT AND LITERATURE REVIEW

Background

Extranodal NK/T-cell lymphoma (ENKTL) is a rare and aggressive form of non-Hodgkin lymphoma. ENKTL are predominantly localized to nasal and upper aerodigestive sites, but extranasal involvement including gastrointestinal tract are rarely seen. Small and large intestines are primary sites of gastrointestinal ENKTL. Gastric involvements are exceedingly rare accounting for less than 5% of all gastrointestinal ENKTL.

Purpose

We present a literature review on gastrointestinal ENKTL and a case report of gastrointestinal bleed secondary to ENKTL involving stomach and left orbit.

Method

Case report and literature review.

Result(s)

33-year-old female was admitted to a tertiary hospital with 3-week history of epigastric pain and left periorbital swelling. Abdominal CT showed edema and thickening of gastric folds. Head CT showed grossly enlarged left lateral rectus muscle and periorbital soft tissue swelling suggestive of left orbital pseudotumor. Esophagogastroduodenoscopy revealed multifocal Forrest classification II-C ulcerations throughout her stomach and duodenum. Biopsies from stomach showed gastric mucosa with extensive infiltration by an atypical lymphoid cell population. Immunohistochemistry demonstrated high grade lymphoid cells with uniform expression of CD2, CD3, CD30, CD56, TIA1, perforin and granzyme B. EBV-encoded small RNA in-situ hybridization (EBER ISH) was strongly positive. Findings were consistent with gastric ENKTL. Left orbital biopsy revealed similar morphology and phenotypic features consistent with concurrent ENKTL involvement of her orbit. Patient was initiated on intravenous corticosteroids, but unfortunately developed hemorrhagic shock secondary to gastrointestinal bleeding from gastric ulcer and passed away.

Gastrointestinal ENKTL is a rare presentation of a rare disease. Gastric involvement is especially rare and described only in few case reports. Gastrointestinal ENKTL are often initially asymptomatic but can progress to abdominal pain, bleeding and even bowel perforation. Due its nonspecific clinical features and rarity, diagnosis can be difficult and requires careful examination by an experienced pathologist. This aggressive lymphoma is characterized by positive CD2, CD3, CD30, CD56, TIA, granzyme B, perforin and EBER ISH. Optimal treatment approach remains unclear due to lack of prospective clinical studies. Currently, treatment modalities used for other lymphomas including radiotherapy and non-anthracycline-based chemotherapy are used. Despite treatment, prognosis is grim with median overall survival period of 7-8 months.

Image

Conclusion(s)

We present a case of gastric and orbital ENKTL with gastric ulcer bleeding. Gastric ENKTL disease is a rare presentation of a rare disease. Due to non-specific clinical features, diagnosis is often difficult and relies on careful pathology examination by experienced pathologist. Prognosis is poor without optimal treatment approach due to rarity of disease and lack of validated data.

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Disclosure of Interest

None Declared

INFLAMMATORY BOWEL DISEASES

MECHANISMS AND TREATMENTS

CHWs trained in ARI management

Regular supervision and refresher trainings were the key to the success of a CHW (community health worker) training program in rural Bolivia. Since 1988, with the support of PLAN International, volunteer CHWs have been trained in 115 villages in Sucre, a rural health area lacking adequate health centers. CHWs educate the community, diagnose and treat pneumonia and refer severe cases to health centers or hospitals. CHWs who were already working on diarrheal disease control were chosen for the acute respiratory infection (ARI) case management training. A 3-day training program was organized for individual CHWs in their own homes and communities. The course included practicing on real ARI cases under the trainer's supervision. Since the program started, community respect for CHWs has risen. In one remote village, community leaders reported a marked improvement in child survival. Factors which explain the positive effects of CHWs include: a limited number of clearly defined tasks, provision of one-on-one appropriate training, periodic refresher courses, and continuous supervision. The main problems have been a lack of constant supply of essential drugs and some CHWs over-diagnosing pneumonia. However, once diagnosis is made, CHWs are careful about giving the correct antibiotic doses and instructions to mothers. Refresher training and supervision have helped to correct these initial problems. PLAN International and the Ministry of Health have organized supervision and training meetings every 2 months. The CHWs bring to these meetings reports of children treated and referred. Case management is analyzed, resupply of essential medicines is arranged and those with special problems are scheduled for a supervisory visit.

Evidence for chemical differentiation of delta opioid receptor subtypes by the sulfhydryl reagent N-ethylmaleimide

In this study, the delta receptor-selective nonequilibrium affinity ligands, 5'-NTII and DALCE, and the nonspecific sulfhydryl reagent NEM were evaluated over a range of concentrations and treatment conditions for their ability to selectively alter the binding properties of delta 1- or delta 2-preferring opioid radioligands in brain homogenate. Treatment of tissue preparations with DALCE (0-10,000 nM) or NTII (0-10,000 nM) resulted in an equivalent concentration-dependent loss of binding capacity for the delta 1 agonist 3H-DPDPE and the mu/delta 2 agonist 3H-DSLET. In contrast, treatment of tissue with NEM (0-8000 microM) resulted in greater loss of 3H-DPDPE binding. Scatchard analysis of the binding of 3H-DPDPE, 3H-DSLET, and 3H-NTI in 3 mM NEM-treated rat brain P2 preparation revealed an equivalent decrease in affinity for the agonist ligands, but a significantly greater decrease in Bmax for 3H-DPDPE compared with control tissue values. Comparison of the K(i) values for a series of delta-selective compounds against 3H-DSLET binding in control vs 3 mM NEM treated P2 fraction showed differential effects of NEM on affinity within the series that were consistent with a selective depletion of delta 1 sites. Overall, these results indicate that NEM treatment selectively reduced delta 1 receptor binding, resulting in a preparation that is enriched in delta 2 sites.

Antinociception produced by oral, subcutaneous or intrathecal administration of SC-39566, an opioid dipeptide arylalkylamide, in the rodent

This study characterized the prototypic "minimum structure" enkephalin SC-39566 [2,6-dimethyl-L-tyrosinyl-D-alanine-(3-phenyl-1-propyl)-amide hydrochloride]. SC-39566 bound with highest affinity to mu opioid receptors (Ki, 0.13 nM), as well as to delta (Ki, 4.0 nM) opioid receptors in the rat brain, and with much lower affinity to kappa opioid receptors (Ki, 83.8 nM) in the guinea pig brain. In the mouse, SC-39566 inhibited phenylbenzoquinone-induced writhing and increased tail-flick and hot-plate latencies in a dose-dependent manner after either s.c. or p.o. (i.g.; intragastrical) administration. This antinociception was antagonized by the opioid antagonist naloxone, but not by alpha adrenergic, serotonergic, histaminergic, muscarinic cholinergic or dopaminergic receptor antagonists. In the rat, SC-39566 dose-dependently inhibited acetic-acid-induced writhing after s.c. or i.g. administration and increased response latencies in the tail-flick and hot-plate test after s.c. or intrathecal (i.t.) administration. The increase in tail-flick latency produced by s.c. SC-39566 in the rat was antagonized by s.c. naloxone with an apparent pA2 value of 7.9. Pretreatment with naltrindole, a delta opioid receptor antagonist, increased the ED50 of SC-39566 by only 1.7-fold. In addition, the increase in tail-flick latency produced by i.t. SC-39566 was not antagonized by i.t. administration of naltrindole or nor-binaltorphimine, a kappa receptor antagonist. These data suggest that the antinociceptive activity of SC-39566 is mediated predominantly by mu opioid receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Trimethaphan camsylate (Arfonad) and human plasma cholinesterase

These results for the first time document that the brief duration of action of the ganglionic blocker, Arfonad (trimethaphan camsylate), is not due to inactivation by plasma cholinesterase. Inhibition of the enzyme in vitro by Arfonad was not altered by prior incubation of the drug in plasma at 37 degrees C for up to 16 hours nor by treatment with NaOH at 100 degrees C for 10 minutes. Both procedures inactivated succinylcholine. These results in vitro were confirmed in vivo by finding that the toxicity of Arfonad in mice was not significantly altered by these procedures whereas they rendered succinylcholine inocuous. Arfonad is a noncompetitive whereas succinylcholine is a competitive inhibitor of plasma cholinesterase using benzoylcholine as the substrate. The camphorsulfonate moiety of Arfonad was inactive in vitro but caused mild tremors in mice at relatively high doses.

A97 LARGE NON-PEDUNCULATED COLONIC POLYP (LNPCP) OUTCOMES REFERRED FOR ENDOSCOPIC RESECTION IN BRITISH COLUMBIA: A QUALITY ASSURANCE INITIATIVE

Background

Endoscopic resection techniques have become the primary treatment strategy for the vast majority of large (≥ 20mm) non-pedunculated colonic polyps (LNPCPs). Despite this, surgery is still commonly performed with evidence suggesting an increasing trend over time. There is limited Canadian data confirming the effectiveness and safety of an endoscopic management strategy for LNPCPs.

Purpose

To investigate clinical outcomes of patients referred for endoscopic management of a LNPCP.

Method

Retrospective single-centre analysis of patients referred to a single endoscopist for the management of LNPCPs within a tertiary referral practice. LNPCPs were further subdivided into non-complicated (NC-LNPCP) or complicated (C-LNPCP) defined as those involving the ileocecal valve, appendiceal orifice, circumferential or previously attempted. Performance outcomes were evaluated by the frequencies of technical success (removal of all polypoid tissue during index procedure) and need for colorectal surgery. Safety was evaluated by the frequencies of clinically significant intraprocedural bleeding (CSIPB), clinically significant post-endoscopic resection bleeding (CSPEB), intra-procedural perforation and delayed perforation. Recurrence (either endoscopic or histologic) was evaluated at first surveillance colonoscopy (SC1). Continuous variables were summarized using median (IQR). Categorical variables were summarized as frequencies (%). To test for association between categorical variables, the Pearson χ2 or the Fisher exact test were used, where appropriate. For continuous variables, the Mann-Whitney U test was used. A probability (p) value of <0.05 was considered statistically significant.

Result(s)

Between January 2021 to March 2022, 263 LNPCP were referred for endoscopic resection and 41 LNPCP were excluded (23 pedunculated, 14 optical evaluation suggestive of deeply invasive cancer, 4 other). 222 LNPCP (188 NC-LNPCP, 34 C-LNPCP) underwent endoscopic resection. Median size was 25mm (IQR 20-30mm) with the majority undergoing cold snare resection (115, 51.8%). Polyposis (Adenomatous or serrated) was present in 23 (12.6%) cases respectively. Technical success was 97.3%. Cancer was present in 5 (2%). Clinically significant bleeding (CSPEB) occurred in 2.7%, DMI IV in 1.8% and there were no delayed perforations. Recurrence occurred in 4 (3.5%) at SC1 and 11 (5%) required surgery due to technical failure, submucosal invasion on pathology and clinically significant bleeding.

Image

Conclusion(s)

Endoscopic resection as the primary treatment strategy for LNPCPs offers a safe and effective alternative to surgery in British Columbia.

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Disclosure of Interest

None Declared

A59 A RARE PRESENTATION OF COLLAGENOUS GASTRODUODENITIS WITH 10 YEAR FOLLOW UP

Background

Collagenous gastritis(CG) is a rare form of gastritis defined histologically by the presence of &gt;10um of subepithelial surface collagen deposition. CG can further be categorized in childhood onset CG and adult onset CG. The prevalence of childhood CG is 2.1/100,000 in children aged younger than 18. Adult onset CG remains a rare entity. Here, we describe a rare presentation of collagenous gastroduodenitis in an adult patient and the interval progression over a 10 year period.

Aims

To increase awareness of a rare condition with limited data on available treatment modalities and clinical outcomes in adults.

Methods

Case Report

Results

A 35 year old female with no past medical history presented with worsening fatigue and increased shortness of breath with no overt gastrointestinal bleeding symptoms. There was no previous history of radiation exposure or family history of autoimmune disease. Laboratory investigations revealed iron deficiency anemia with a hemoglobin of 69 and a ferritin of 11. TTG serology and anti-parietal antibody was also negative. Esophagogastroduodenoscopy biopsies confirmed the diagnosis of collagenous gastritis localized to the gastric body with the presence of acute and chronic inflammatory changes. The patient was started on proton pump inhibitor therapy. In the interval period, the patient denies any new onset of gastrointestinal symptoms other than occasional heartburn. She remains iron deficient and requires regular iron infusions. Follow up endoscopy 10 years later now demonstrates diffuse mucosal abnormalities with a nodular contour involving the entire stomach and extending into the duodenal bulb. Biopsies showed features compatible with collagenous gastroduodenitis with active inflammation and pyloric metaplasia(Figure 1). There was atrophy of the stomach mucosa with no parietal cells identified and no endocrine hyperplasia. Immunostaining for Helicobacter pylori was negative. Flexible sigmoidoscopy was also performed revealing endoscopically normal colonic mucosa to the descending colon.

Conclusions

CG is a rare disease entity with unclear pathogenesis. Multiple case reports describe some association with autoimmune disease such as celiac disease. To date, no standard treatment has been identified for the management of CG. CG presents endoscopically with nodular changes, mucosal atrophy and collagen deposition. Over time, adult onset CG can progress to involve the entire stomach. Clinically, adult onset CG usually presents with a diarrhea predominant phenotype with associated collagenous colitis. Treatment modalities that have been trialed include PPI, corticosteroids, sucralfate, azathioprine,5-aminosalicylates, iron supplementation and hypoallergenic diets. Here we describe a rare presentation of collagenous gastroduodenitis and subsequent 10 year follow up in order to better understand this disease entity.

Funding Agencies

None