Christine Yeh Hachem, MD; Hala El-Zimaity, MD Series Editor: Richard Goodgame, MD

Disclosures

September 27, 2007

Discussion

Lymphocytic gastritis represents a small subset among the numerous gastridities.[4] Its reported frequency in routine practice is 1% to 9% among patients undergoing endoscopy for dyspepsia and 15% to 45% among patients with celiac disease (also known as celiac sprue).[3] Differentiation between lymphocytic gastritis and other chronic gastritides and normal mucosa requires documenting intraepithelial lymphocytes, with the intraepithelial lymphocytes numbering approximately 20 to 30 per 100 epithelial cells.

The cause of lymphocytic gastritis is unknown. The most common disease associations include celiac sprue and H pylori infection. Approximately one third of patients with lymphocytic gastritis have concomitant celiac sprue; approximately 10% to 30% of patients with celiac sprue have lymphocytic gastritis.[12,18,19] It has been suggested that lymphocytic gastritis represents a host response to an intraluminal antigen, either gluten or another.[2] Hayat and colleagues[20] have found similar HLA antigens in both celiac sprue and lymphocytic gastritis.

It is estimated that one third of patients with lymphocytic gastritis have H pylori infection; approximately 4% of H pylori-infected patients have lymphocytic gastritis.[12] Multiple studies have demonstrated that eradication of H pylori infection can reduce lymphocytic infiltration and corpus inflammation and resolve dyspeptic symptoms and anemia.[13,20] The role of H pylori in this setting has been controversial because serologic evidence of infection frequently occurs in the absence of demonstrable identification of the organism by stain or other means.[21] This has led to the speculation that lymphocytic gastritis is an abnormal immune response associated with bacterial clearance.[20,21]

Most cases of lymphocytic gastritis have been described in asymptomatic patients older than 50 years of age. Symptoms that can occur include abdominal pain, nausea, vomiting, anorexia, and weight loss.[13,22,23] Case reports have noted initial presentations of iron-deficiency anemia[13] and gastrointestinal bleeding.[22] Multiple reports have attributed a protein-losing gastroenteropathy to lymphocytic gastritis.[23] Polypoid lesions seen in our case have not previously been associated with any specific symptoms. Bleeding can occur from erosions and ulcerations in gastric mucosa without the dramatic polypoid lesions seen in our case.[22]

The natural history of patients with lymphocytic gastritis is also unclear. Healing after therapy with histamine-2 receptor blockers or proton-pump inhibitors, as well as without any therapy, has been described.[5] The effect of H pylori eradication on severity of histologic abnormalities is also controversial.[20,21]

Although longitudinal studies have not been performed, there may be an association between lymphocytic gastritis and gastric lymphoma and adenocarcinoma. There is an increased prevalence of lymphocytic gastritis in both primary gastric MALT lymphoma and gastric adenocarcinoma.[24] At this time, there are no specific surveillance recommendations for patients with lymphocytic gastritis.

In summary, lymphocytic gastritis is an uncommon form of gastritis that may be an incidental finding at endoscopy or be a cause of hypoalbuminemia, gastrointestinal bleeding, anorexia, or weight loss. The discovery of lymphocytic gastritis should prompt clinical consideration of celiac sprue. Serologic testing for H pylori should also be performed and treatment initiated if results are positive.

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