Clinical challenges and images in GI. Collagenous gastroduodenocolitis

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.

Protein-losing enteropathy secondary to collagenous colitis in a 2-year-old

Protein-losing enteropathy associated with collagenous colitis (CC) is a rare but described entity in the adult population. However, literature regarding this in the pediatric population is scarce. Here we describe a 2-year-old female who presented with fevers, accompanied by nonbloody, watery diarrhea, and decreased oral intake. Work-up was significant for severe hypoalbuminemia at 1.5 grams per deciliter (g/dL), pancytopenia, and elevated fecal alpha-1-antitrypsin at 1.13 milligrams per grams (mg/g). Gastrointestinal mucosal evaluation was normal endoscopically; however, histology was consistent with CC. She responded to 12-week treatment with budesonide with resolution of symptoms and laboratory values. At this point, she has not had a recurrence 1 year later.

Pediatric Collagenous Gastroenteritis and Colitis Presenting as Protein-Losing Enteropathy

There is a lack of literature on pediatric collagenous colitis. This is a report of a child with collagenous gastroenteritis and colitis who presented with chronic, nonbloody diarrhea and lower extremity edema secondary to protein-losing enteropathy. Collagenous colitis is rare in children; collagenous gastroenteritis and colitis are even less documented; and this diagnosis does not typically present with protein-losing enteropathy. The pediatric patient in this report had a presentation of a rare disease. Her disease self-resolved, and she has remained asymptomatic without pharmacologic intervention. This illness should be considered in a child presenting with this constellation of symptoms.

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.

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.

Chemical Gastroenterocolitis after Dental Root Canal Therapy with Camphorated and Mentholated Chlorophenol

A 78-year-old man with a history of pancolitis, after the treatment of dental abscess with oral antibiotics and local application of camphorated and mentholated chlorophenol (CMCP), presented with abdominal pain of 4-day duration, as well as hair loss in the area of moustache and finger nail lifting. He was already treated with rectal application of budesonide because of pancolitis, diagnosed 6 weeks ago and interpreted as an allergic reaction to clindamycin. For further investigation, we performed gastroscopy and colonoscopy, which showed the edematous mucosa with polypus-like changes of the whole mucosa of the stomach, duodenum, first part of the jejunum, distal ileum, complete colon, and rectum. The diagnosis was complicated and was achieved in synopsis with anamnestic details, such as endodontic application of camphorated chlorophenol. The patient symptoms abated after he commenced on mesalazine therapy.

Pediatric Collagenous Gastroenterocolitis Successfully Treated with Methotrexate

A two-and-one-half-year-old previously healthy female presented with a ten-week history of watery diarrhea, nonbilious and nonbloody emesis, and low-grade fevers. She was found to have severe hypoalbuminemia and hypogammaglobulinemia. Her symptoms persisted, and she became dependent on parenteral nutrition. Biopsies obtained during subsequent endoscopic and colonoscopic studies revealed findings consistent with collagenous gastroenterocolitis. She responded to an empiric course of prednisone, but her symptoms recurred shortly after transitioning to oral budesonide. After successful reinduction with intravenous prednisone, intramuscular methotrexate was initiated. She remained asymptomatic during a 15-month course of therapy, and she continued to do well clinically until approximately nine months after weaning off methotrexate. At that point, she experienced a recurrence of diarrhea, and repeat endoscopic evaluation confirmed collagenous colitis. This responded nicely to a short course of oral budesonide, and she has since remained asymptomatic and off any therapy.

Pediatric Collagenous Gastritis and Colitis: A Case Series and Review of the Literature

INTRODUCTION

Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands. Two phenotypes of the disease have been described: a pediatric-onset and an adult-onset type. The adult-onset form is associated with collagenous colitis and autoimmune disorders. No effective treatment has been identified to date.

OBJECTIVE

We aim to describe the clinical features and outcomes of patients in our cohort and provide a summary of published pediatric cases with collagenous gastritis and colitis reported to date to gather information that will contribute to improved knowledge of this rare condition.

METHODS

A retrospective chart review of all patients with collagenous gastritis and/or colitis who were treated at the Royal Children's Hospital, Melbourne, was performed. A literature review was also conducted.

RESULTS

A total of 12 cases of collagenous gastritis were reviewed. Three of 12 (25%) patients had associated collagenous colitis. The most common clinical presentation was iron deficiency anemia. Nine (75%) patients were followed up, and repeat endoscopies were performed in 8 (67%). Iron deficiency anemia resolved in all patients on oral iron supplementation. Histologic improvement was only identified in one patient with the adult phenotype who had been treated with oral corticosteroids and azathioprine.

CONCLUSIONS

Collagenous gastritis is a rare condition in children. A small proportion of children develop features of the "'adult" phenotype at a very young age. Patients with collagenous gastritis require long-term follow-up and monitoring of their disease. Further randomized clinical trials are needed to establish an effective therapeutic strategy.

Collagenous colitis associated with protein losing enteropathy in a toddler

Collagenous mucosal inflammatory disease is a rare gastrointestinal disorder that involves the columnar lining of gastric and intestinal mucosa and is characterized by a distinct subepithelial collagen deposition. Recent clinical and pathological evidence have indicated that collagenous mucosal inflammatory disease can be extensive disease that may concomitantly involve several gastrointestinal sites at the same time. This entity, however, occurs infrequently in children. It is even less common to find concomitant depositions of collagen in the mucosa of gastrointestinal sites other than the colon. Only two cases in pediatric literature reported concomitant involvement, one with gastric and colonic involvement and the other one with gastroduodenocolitis. We are reporting a 15-month-old boy who presented with severe diarrhea and diffuse edema secondary to hypoalbuminemia. Further testing documented protein losing enteropathy (PLE) associated with collagenous colitis.

Collagenous gastritis: reports and systematic review

Collagenous gastritis is a rare disorder first described in 1989. After encountering two cases, we decided to review the literature and evaluate the collagen band. A systematic review of PubMed and EMBASE databases was performed. Twenty-eight cases have been previously described and two patterns of presentations are identifiable: children or young adults (median age 12 years, range 2-22 years) presenting with symptoms attributable to the gastritis (anaemia and pain); and older adults (median age 52 years, range 35-77 years) presenting with loose stools, often associated with collagenous colitis or coeliac disease. Our two cases (one child and one adult) matched this pattern. Immunostaining of the collagen band for collagens II, III, IV and VI, and tenascin showed that the band in our cases was predominantly tenascin. In conclusion, collagenous gastritis is a rare entity whose presentation depends on the age of the patient. An autoimmune aetiology seems possible given its associations. Treatment is empirical. The 30 cases now reported show that the disorder can relapse or persist for years.