Lymphocytic gastritis is characterized by an increase of intraepithelial lymphocytes in surface and foveolar epithelium, together with a variable amount of inflammation in the lamina propria of the gastric mucosa, which ranges from a predominantly lymphocytic pattern to a mixed chronic active pattern. The generally accepted criterion for the diagnosis of lymphocytic gastritis is the finding of 25 or more lymphocytes per 100 epithelial cells.39
Lymphocytic gastritis is thought to be a histologic response of the gastric mucosa to several antigens. The main interest comes from its association with
Table 7.2 Conditions associated with lymphocytic gastritis
Helicobacter pylori infection
Drug administration (ticlopidine)
seemingly diverse groups of disorders (Table 7.2), among them celiac disease, where this type of gastritis is very prevalent (see below).
Chronic varioliform gastritis is a rare disorder of unknown origin, commonly affecting middle-aged and elderly men. To date, few cases have been reported in the pediatric literature. In children, clinical signs arise insidiously, are often subacute or chronic and include epigastric pain, nausea and vomiting, anorexia, weight loss, anemia, protein-losing enteropathy and, in some cases, peripheral eosinophilia and increased serum IgE levels.40
The endoscopic features of chronic varioliform gastritis are enlarged and thickened rugal folds bearing erosions and widespread small nodules frequently surmounted by an umbilicated central crater or small rounded erosions (aphthoid nodules). According to the topography of the lesions, three forms can be distinguished: diffuse, when the whole stomach is involved; corporeal, when the lesions are limited to the fundus and proximal body of the stomach; and antral, when they are present only in the antrum. Histology shows a focal or diffuse infiltrate of intraepithelial lymphocytes in the surface and foveolar epithelium. Throughout the lamina propria an inflammatory infiltrate consisting of IgE plasma cells, lymphocytes, neutrophils and eosinophils is observed.
The etiology of chronic varioliform gastritis is still unsettled. An immunological mechanism related to food antigens is suggested by raised serum IgE levels and increased numbers of IgE staining plasma cells. However, owing to a decreased incidence of the disorder and to the fact that the histo-logical pattern is highly reminiscent of celiac gastritis (see below), it has been suggested that chronic varioliform gastritis is only a crude endo-scopic expression of a disease that has the characteristic features of lymphocytic intraepithelial infiltration. The macroscopic appearance might appear only at some periods in the evolution of the disease.
An association between lymphocytic gastritis and celiac disease has been reported in both adults and children. Lymphocytic gastritis is found in up to 45% of adults with celiac disease, with a range of prevalence from less than 10% to 45%. Wolberg et al identified ten of 22 adult patients with lymphocytic gastritis characterized by marked infiltration of the surface and superficial pit epithelium by lymphocytes, primarily T cells, with sparing of the deep glandular epithelium both in the antrum and in the body. The lamina propria showed an infiltrate of plasma cells, lymphocytes and rare neutrophils.41 Recently, it has been shown that the pattern of involvement of the gastric mucosa is predictive of duodenal villous atrophy. Patients with corpus-predominant lymphocytic gastritis are unlikely to have duodenal pathology, whereas those with an antrum-predominant or a diffuse pattern have a 50% chance of coexistent villous atrophy.42 In a study of 60 children with chronic gastritis, De Giacomo et al found lymphocytic
Crohn's disease 103
gastritis in nine of 25 children with celiac disease, but in none of 35 children without gluten-sensitive enteropathy. Children with celiac gastritis showed an average of 40 lymphocytes per 100 epithelial cells, compared with an average of three to five in control subjects or patients with H. pylori-associated gastritis. Interestingly, at endoscopy, all children showed resolution of the lymphocytic infiltrate after strict adherence to a gluten-free diet.43
Recently, some authors have suggested that celiac lymphocytic gastritis may represent an abnormal immunological response to gliadin. It is now recognized that there is a spectrum of gluten-induced intestinal changes, ranging from the classic 'celiac' lesions of total and/or subtotal villous atrophy to more subtle manifestations, such as an abnormal density and subtype distribution of intraepithelial lymphocytes in the small intestinal mucosa. It is conceivable that lympho-cytic gastritis, such as lymphocytic colitis, is another manifestation of a mucosal immune response to a luminal antigen, which is maximally expressed in the small intestine.44 Thus, it is believed that the presence of lymphocytic gastritis in dyspeptic children may be used as an indication to perform a small-bowel biopsy to rule out covert celiac disease.
Some authors have suggested that lymphocytic gastritis may represent an idiosyncratic immune response to some local antigen, such as H. pylori, although the relationship is still not clear. It has been shown that many cases of lymphocytic gastritis are associated with H. pylori infection, and that the eradication brings about significant reduction in the gastric intraepithelial lymphocytic infiltration and dyspeptic symptoms. On the other hand, in adults and pediatric series, H. pylori has been detected in a minority of patients with lympho-cytic gastritis, whereas the infection was more frequent in control biopsy specimens.
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What Is The Gluten Free Diet And What You Need To Know Before You Try It. You may have heard the term gluten free, and you may even have a general idea as to what it means to eat a gluten free diet. Most people believe this type of diet is a curse for those who simply cannot tolerate the protein known as gluten, as they will never be able to eat any food that contains wheat, rye, barley, malts, or triticale.