Collagenous gastritis

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.

Host-related low-prevalence gastritides: Epidemiological and clinical characterization

INTRODUCTION

A recent consensus meeting (RE.GA.IN) addressed "host-related, low-prevalence gastritis": eosinophilic (EoG), lymphocytic (Hp-pos_LyG and Hp-neg_LyG), collagenous (CollG), and granulomatous gastritis (GrG). Our study evaluates their clinico-epidemiological characteristics.

MATERIALS AND METHODS

We extracted all patients with a diagnosis of EoG, LyG, CollG, and GrG from a clinicopathological database and compared their demographics, clinical and endoscopic characteristics, associated conditions, and clinical awareness to those of all other subjects in the database (controls).

RESULTS

There were 1,781,005 unique patients (median age 57 years; 55.7 % female). Hispanics were overrepresented amongst those with Hp-pos_LyG. Subjects with GrG had a high prevalence of erosions and ulcers. Clinical awareness of these conditions was dismal (<1:10,000 patients). Some clinical manifestations were more common in patients with certain gastritides (e.g., vomiting and diarrhea in CollG; anemia in LyG), but none were sufficiently distinctive to suggest a clinical diagnosis. EoG was associated with EoE; LyG had a strong association with celiac disease; CollG with microscopic colitis; and GrG with Crohn disease.

CONCLUSIONS

The diagnosis of these gastritides (between <1: in 1,000 and 1 in 5000 subjects) rests on histopathology. They remain poorly characterized and clinically neglected. Yet, their associations may herald other conditions: eosinophilic gastrointestinal diseases (EGID), celiac, and Crohn disease. Patients might benefit from increased detection and characterization.

Association of Collagenous Gastritis With Helicobacter pylori Infection

Helicobacter pylori is the most common infection and is mostly asymptomatic in infected individuals. Only a few cases of collagenous gastritis associated with H. pylori infection have been reported in the previous literature. We report a case of a 54-year-old female presenting with heartburn and epigastric pain associated with bloating, gas, and sometimes constipation. The physical examination was unremarkable with a soft, non-tender, and non-distended abdomen. Upper endoscopy showed erythema in the stomach with non-erosive gastritis. Our patient was diagnosed with H. pylori-associated chronic active gastritis with collagenous gastritis on histologic evaluation of the gastric biopsy specimen. After treatment with H. pylori eradication therapy, patients with collagenous gastritis associated with H. pylori infections showed a significant improvement in collagenous gastritis on endoscopy.

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 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.

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.

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.

Collagenous Gastritis and Helicobacter pylori Infection: A Mere Coincidence?

A 21-year-old woman presented to our clinic after 7 years of abdominal pain, diarrhea, and iron-deficiency anemia. Initial upper endoscopy revealed severe inflammation and nodularity of the gastric body and active Helicobacter pylori infection. After eradication therapy, esophagogastroduodenoscopy showed gastric atrophy with nodularity resolution. Histopathology revealed scattered plasma cells, eosinophils, and collagen deposition suggestive of collagenous gastritis. H. pylori can induce proinflammatory cytokines, resulting in fibroblast upregulation. Collagenous gastritis may be caused by an inflammatory response associated with type I, II, and III collagen. Although further research is warranted, we hypothesize that chronic inflammation from H. pylori may lead to collagenous gastritis.

Collagenous gastritis: a morphologic and immunohistochemical study of 40 patients

Collagenous gastritis is a rare condition defined histologically by a superficial subepithelial collagen layer. This study further characterizes the morphologic spectrum of collagenous gastritis by evaluating a multi-institutional series of 40 patients (26 female and 14 male). The median age at onset was 16 years (range 3-89 years), including 24 patients (60%) under age 18. Twelve patients (30%) had associated celiac disease, collagenous sprue, or collagenous colitis. Hematoxylin and eosin slides were reviewed in biopsies from all patients and tenascin, gastrin, eotaxin, and IgG4/IgG immunohistochemical stains were applied to a subset. The distribution of subepithelial collagen favored the body/fundus in pediatric patients and the antrum in adults. There were increased surface intraepithelial lymphocytes (>25 lymphocytes/100 epithelial cells) in five patients. Three of these patients had associated celiac and/or collagenous sprue/colitis, while the remaining two had increased duodenal lymphocytosis without specific etiology. An eosinophil-rich pattern (>30 eosinophils/high power field) was seen in 21/40 (52%) patients. Seven patients' biopsies demonstrated atrophy of the gastric corpus mucosa. Tenascin immunohistochemistry highlighted the subepithelial collagen in all 21 specimens evaluated and was a more sensitive method of collagen detection in biopsies from two patients with subtle subepithelial collagen. No increased eotaxin expression was identified in 16 specimens evaluated. One of the twenty-three biopsies tested had increased IgG4-positive cells (100/high power field) with an IgG4/IgG ratio of 55%. In summary, collagenous gastritis presents three distinct histologic patterns including a lymphocytic gastritis-like pattern, an eosinophil-rich pattern, and an atrophic pattern. Eotaxin and IgG4 were not elevated enough to implicate these pathways in the pathogenesis. Tenascin immunohistochemistry can be used as a sensitive method of collagen detection.

Collagenous gastroduodenitis coexisting repeated Dieulafoy ulcer: A case report and review of collagenous gastritis and gastroduodenitis without colonic involvement

Collagenous gastritis (CG) is a rare disorder characterized by the thick collagenous subepithelial bands associated with mucosal inflammation. There have been approximately fifty reports in the literature since it was first described in 1989. According to previous reports, CG is heterogeneous and classified into two groups-(1) cases limited to the gastric mucosa in children or young adults, and (2) CG associated with collagenous colitis in elderly adults presenting with chronic watery diarrhea. In Japan, only nine previous cases were reported, and all of them were young adults. We report a case of CG with collagenous duodenitis in a 22-year-old female. She had repeated upper gastrointestinal bleeding from a Dieulafoy lesion of the fornix, but had no symptoms of malabsorption or diarrhea. Endoscopic findings revealed striking nodularity with a smooth islet-shaped normal area in the antrum and the body. The pathological findings of nodular mucosa showed the deposition of collagen bands just under the mucoepithelial lesion. In addition, she had collagenous duodenitis in part of the bulbs, and a colonoscopy showed no abnormalities. We provide a literature review of CG and collagenous gastroduodenitis without colonic involvement.

Proximal collagenous gastroenteritides: clinical management. A systematic review

AIM

While collagenous colitis represents the most common form of the collagenous gastroenteritides, the collagenous entities affecting the proximal part of the gastrointestinal tract are much less recognized and possibly overlooked. The aim was to summarize the latest information through a systematic review of collagenous gastritis, collagenous sprue, and a combination thereof.

METHOD

The search yielded 117 studies which were suitable for inclusion in the systematic review. Excluding repeated cases, 89 case reports and 28 case series were reported, whereas no prospective studies with or without control groups were identified. Further, no randomized, controlled trials were identified. The total number of patients with proximal collagenous gastroenteritides reported was 330.

RESULTS

An overview of clinical presentations, prognosis, pathophysiology and histopathology, as well as management of these disorders is presented. The prognosis of both collagenous gastritis and sprue seems not to be as dismal as considered previously. Data point to involvement of immune or autoimmune mechanisms potentially driven by luminal antigens initiating the fibroinflammatory condition.

CONCLUSIONS

To reach the diagnosis it is recommended that biopsies are obtained during gastroduodenoscopies. Therapies with anti-secretory strategies, glucocorticoids, and in some cases iron supplementation are suggested, although rational treatment options from randomized, controlled trials do not exist for these rare or even overlooked disorders.

[Gastritis and gastropathy]

Alterations of the stomach mucosa in response to different adverse effects result in various morphological and clinical symptoms. Gastric mucosa alterations can be classified on the bases of diverse viewpoints. It makes this overview difficult, that identical toxic effects may cause different mucosal changes and different toxic agents may produce similar mucosal appearance. The more accurate understanding of the pathological processes which develop in the stomach mucosa needs reconsideration. The authors make an attempt to define gastritis and gastropathy in order to classify and present their features. Gastritis is a histological definition indicating mucosal inflammation. Acute gastritis is caused by infections. The two most important forms of chronic gastritis are metaplastic atrophic gastritis with an autoimmune origin and Helicobacter pylori inflammation. Gastropathy is the name of different structural alterations of the mucosa. Its most important feature is the paucity of inflammatory signs. Gastropathies can be divided into 4 categories based on the nature of the underlying pathological effect, on its morphological appearance and the way of the development. Differential diagnosis is an important pathological and clinical task because different treatment methods and prognosis.

Clinical outcome of pediatric collagenous gastritis: Case series and review of literature

Collagenous gastritis (CG) is characterized by patchy subepithelial collagen bands. Effective treatment and the clinical and histological outcome of CG in children are poorly defined. The aim of this study is to summarize the published literature on the clinical outcome and response to therapy of pediatric CG including two new cases. We performed a search in Pubmed, OVID for related terms; articles including management and clinical and/or endo-histologic follow up information were included and abstracted. Reported findings were pooled in a dedicated database including the corresponding data extracted from chart review in our patients with CG. Twenty-four patients were included (17 females) with a mean age of 11.7 years. The clinical presentation included iron deficiency anemia and dyspepsia. The reported duration of follow up (in 18 patients) ranged between 0.2-14 years. Despite most subjects presenting with anemia including one requiring blood transfusion, oral iron therapy was only documented in 12 patients. Other treatment modalities were antisecretory measures in 13 patients; proton pump inhibitors (12), or histamine-2 blockers (3), sucralfate (5), prednisolone (6), oral budesonide in 3 patients where one received it in fish oil and triple therapy (3). Three (13%) patients showed no clinical improvement despite therapy; conversely 19 out of 22 were reported with improved symptoms including 8 with complete symptom resolution. Spontaneous clinical resolution without antisecretory, anti-inflammatory or gastroprotective agents was noted in 5 patients (4 received only supplemental iron). Follow up endo-histopathologic data (17 patients) included persistent collagen band and stable Mononuclear cell infiltrate in 12 patients with histopathologic improvement in 5 patients. Neither collagen band thickness nor mononuclear cell infiltrate correlated with clinical course. Intestinal metaplasia and endocrine cell hyperplasia were reported (1) raising the concern of long term malignant transformation. In summary, CG in children is a chronic disease, typically with a variable clinical response and an indolent course that is distinct from the adult phenotype. Long term therapy usually inclused iron supplementation but cannot be standardized, given the chronicity of the disease, variability of response and potential for adverse events.

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.

Collagenous gastritis

A 25-year-old patient presented with epigastric pain, which on gastric biopsy revealed the characteristic appearance of collagenous gastritis. There was a thick prominent subepithelial band that was confirmed to be collagen with a Masson's trichrome stain. There was associated Helicobacter pylori gastritis but no evidence of a lymphocytic gastritis. The patient did not have watery diarrhea. Collagenous gastritis can occur in young patients, be restricted to the stomach, and can be associated with celiac disease.