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Introduction
Collagenous gastritis is a rare condition of unknown etiology characterized by subepithelial deposits of collagen in the stomach. Case reports suggest collagenous gastritis can be found in adults or children 1,2. It is often associated with either celiac disease or collagenous colitis 3,4.
We report a case of isolated collagenous gastritis in an adult including endoscopic and EUS images.
Case History
A 53 year old female presented with nausea, weight loss of 15 lbs and abdominal pain.
Three years earlier, she had presented with diarrhea and at the time of evaluation was found to have an acute colitis with some endoscopic features suggesting possible inflammatory bowel disease. The patient was started on mesalamine and her symptoms completely resolved. She continued mesalamine.
A year prior to presentation, the patient was evaluated for weight loss and abdominal pain. Imaging studies were normal. Colonoscopy was grossly normal, and biopsies of the ileum and colon were normal. An upper endoscopy was normal other than an atrophic appearing stomach. Duodenal biopsies were normal, but gastric biopsies revealed mucosal atrophy associated with fairly prominent band of subepithelial collagen deposition in the superficial half of the mucosa along with mild to moderate lymphocytic inflammation. The diagnosis of collagenous gastritis was suggested.
Over the next year, her symptoms persisted, and the weight loss progressed. Evaluation was requested to look for possible pancreatic disease, adenopathy, neoplasia or rheumatologic disease.
Her rheumatological work up included an elevated ANA at 12 units (nl <1.0), but double stranded DNA antibody, ENA antibody panel (SSA/SSB, Anti Smith, Anti RNP, SCL-70, JO-1) and anticentromere antibody levels were normal. Her p-ANCA was reported as positive with elevated myeloperoxidase (MPO) levels at 49 U/ml (nl <6.0), but ASCA and c-ANCA levels were normal.
CT scan was relatively unremarkable except for a gallstone (not shown) and some subtle gastric thickening on certain images. (Figures 1,2)
Colonoscopy was normal and biopsies of the colon and ileum were normal.
Upper endoscopy revealed a pale, pliable stomach which tended to bleed more than usual with biopsies (Video 1). EUS (Video 2) demonstated a markedly abnormal gastric wall with hyperechoic thickening of Echo layer 3 (submucosa). All other extragastric structures were normal. Biopsies of the esophagus and duodenum were normal. Gastric biopsies revealed persistence of abnormalities suggesting collagenous gastritis with marked fibrosis and glandular atrophy. (Figure 3,4)
Mesalamine therapy was suspended, and the patient is under continued surveillance.
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Discussion
Collagenous gastritis is an uncommon entity. First described in 1989 2, approximately 30 cases have been described in the medical literature. The etiology is unknown but there appears to be two subgroups: those with isolated gastropathy and those with an association with other collagenous enteropathies, such as collagenous colitis and collagenous sprue 1-4. Diarrhea may be profound especially when associated with colonic disease 3,4. Weight loss, as it our patient, can be a significant problem 5.
This patient appears to have isolated gastropathy. She previously had an acute colitis felt possibly due to early inflammatory bowel disease, but had no findings suggesting that entity in followup. Based on the normalization of colonic biopsies, her previous colitis could have been a self limiting process, or perhaps completely treated by mesalamine. The timing of her gastric process raises a question as to whether or not this condition was related to her previous colitis, or perhaps related to her use of mesalamine. A mesalamine reaction seems unlikely, since it is often used to treat microscopic colitis 6, but is still enough of a concern here that it was discontinued in our patient. A rheumatologic disease is also a concern here with the elevated ANA antibody and positive MPO, but a specific rheumatologic diagnosis, such as the concern for PAN or Microscopic Polyangiitis, has not been made at this time.
During the evaluation an EUS was performed. The findings in the gastric wall are quite pronounced and probably characteristic. This suggests EUS evaluation for infiltrative gastric processes might be useful in helping to identify patients with this entity and non-specific symptoms.
Conclusions:
In summary, a 53 year old woman with weight loss was found to have isolated collagenous gastritis. The etiology is uncertain at this point. Gastric biopsies are diagnostic of this condition and EUS appears to provide characteristic images.
References
1. Ravikumara M, Ramani P, Spray CH Collagenous gastritis: a case report and review. Eur J Pediatr. 2007 Aug;166(8):769-73
2. Colletti RB, Trainer TD Collagenous gastritis. Gastroenterology. 1989 Dec;97(6):1552-5
3. Vesoulis Z, Lozanski G, Ravichandran P, Esber E Collagenous gastritis: a case report, morphologic evaluation, and review. Mod Pathol. 2000 May;13(5):591-6
4. Lagorce-Pages C, Fabiani B, Bouvier R, Scoazec JY, Durand L, Flejou JF. Collagenous gastritis: a report of six cases. Am J Surg Pathol. 2001 (9):1174-9
5. Wang HL, Shah AG, Yerian LM, Cohen RD, Hart J Collagenous gastritis: an unusual association with profound weight loss. Arch Pathol Lab Med. 2004 Feb;128(2):229-32
6. Fernández-Bañares F, Salas A, Esteve M, Espinós J, Forné M, Viver JM. Collagenous and lymphocytic colitis. evaluation of clinical and histological features, response to treatment, and long-term follow-up. Am J Gastroenterol. 2003 Feb;98(2):340-7
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