Windsor University School of Medicine, St. Kitts Agenda Femi Akinyele. Roll #:1476 Presented: March 3, 2015. MD4 - Pathology II Windsor University School of Medicine, St. Kitts

Causes and Risk Factors Outline Introduction: Gastritis Overview - “The Family Tree” Causes and Risk Factors: Acute Gastritis Type-A Chronic Atrophic Gastritis Type-B Chronic Atrophic Gastritis Clinical Findings: Treatment: High Yield Points Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Introduction - The Gastritis “Family Tree” What is Gastritis? “Gastritis” describes a group of conditions with one thing in common: Inflammation Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors: Acute Gastritis Acute Gastritis Risk Factors: NSAID use - Inhibits COX, prostaglandin-E2 synthesis, bicarbonate synthesis, resulting in increased acid secretion, decreased mucin synthesis and decreased vascular perfusion. Alcohol, smoking (Uremia) CNS injury (Cushing’s ulcers) CMV and Candida in AIDS patients Anisakis (worm associated with consumption of raw fish) Acute gastritis with hyperaemic gastric mucosa Source: http://library.med.utah.edu/WebPath/GIHTML/GI016.html Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors Also seen with: Chemotherapy Systematic Infections: Viral - Norovirus, Rotavirus, Adenovirus Bacterial - Campylobacter, E.coli 0157, Salmonella, Shigella, S.aureus, B.cereus, C.perfringes. Parasites - Cryptosporidium, E.histolytica, G.lamblia Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors Severe stress: Trauma Burns Surgery Ischemia & shock Suicide - especially when acids and alkalis are used. Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors Mechanical trauma Bile reflux following digital gastrectomy Steroid use – causes phospholipase-C production and arachidonic metabolites which increase leukotrienes, which in turn result in inflammation of the stomach. Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors: Type A Chronic Atrophic Gastritis 5% of chronic gastritis cases. Autoantibodies from lymphocytes destroy parietal cells within the body and fundus of the stomach. Type A = Autoimmune Women (Scandinavian) Associated disorders: Systemic Lupus Erythematous Hashimoto’s Thyroiditis Myasthenia Gravis Lambert Eden Syndrome Green Immunofluorescence demonstrating antibodies to parietal cells Source: http://library.med.utah.edu/WebPath/GIHTML/GI147.html Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors: Type B Chronic Atrophic Gastritis 95% of chronic gastritis cases Most common reason for a peptic ulcer H.pylori attacks the Antrum of the stomach Destruction of mucin-producing cells causing ulceration of the epithelium Ulcer can lead to bleeding, perforation and in rare cases, death. Carries a risk of malignancy - Adenocarcinoma & Lymphoma Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Clinical Findings: Acute Gastritis Patient will present with one or more of the following symptoms: Hematemesis: vomiting blood Melena: dark sticky faeces containing partially digested blood Iron deficiency (possibly) - but seen more with Type-B Chronic Atrophic Gastritis which causes ulcers than Acute Gastritis which causes erosion. Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors Damage is limited to the muscularis mucosa Microscopic findings: Neutrophils - key sign for acute inflammation! Edema - caused by increased vascular permeability Congestion - caused by vasodilation Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Mucosal blood flow is reduced Pathogenesis: Acute inflammation causes breakdown of the muscularis mucosa, resulting in erosion. Mucosal cells experience further insult from the gastric acid and enzymes Mucosal blood flow is reduced Source: http://library.med.utah.edu/WebPath/GIHTML/GI128.html Source: http://www.kolumbus.fi/hans/gastrolab/e005.htm Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Morphological findings: Gastric mucosa undergoes a neutrophilic invasion. Edema Hemorrhage Changes in the composition of the mucosa as it regenerates Gastric Mucosa with neutrophilic invasion http://library.med.utah.edu/WebPath/GIHTML/GI017.html Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Clinical Findings: Type A Chronic Atrophic Gastritis Recall: There is an autoimmune destruction of parietal cells resulting in a deficiency of: Hydrochloric Acid Intrinsic Factor - (required to absorb Vitamin B12). Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors Patient may present with what appears to be a B12 deficiency (megaloblastic anemia). You give standard treatment of B12 and Folate, but will find that your patient is not responding. Since patient is unresponsive to therapy, this is case of Gastritis, which carries with it an increased risk of gastric adenocarcinoma Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Clinical Findings: Type B Chronic Atrophic Gastritis Recall: H.pylori association - tested for using a gastric biopsy of the anteropyloric region (gold standard). 2 common patterns of Type B chronic gastritis presentation: Anteral-type - Carries a high risk of duodenal ulcer because of high acid production Pangastritis pattern - Has an increased risk of adenocarcinoma Note: Type B Chronic Atrophic Gastritis is associated a risk of adenocarcinoma and lymphoma (MALT) Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Morphology: Persistent lymphoid activation results in the formation of germinal centers Discovery of goblet cells - indicative of intestinal metaplasia which can lead to adenocarcinoma M: Mucosa; SM: Submucosa; germinal center http://pathology.tmu.edu.tw/microscopy/show.asp?pic=2033-1.jpg&slides=1 Arrow head: intestinal metaplasia in chronic gastritis. Arrows show goblet cells & lymphocyte and plasma cell infiltration http://pathology.tmu.edu.tw/microscopy/show.asp?pic=2033-4.jpg&slides=4 Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors H. pylori is found in the mucus layer. Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Treatment: Acute Gastritis 2 strategies for treatment: Pharmacological: Synthetic Prostaglandin E2 - Restores bicarbonate production in pancreas. Proton pump inhibitors - stomach contents less likely to cause erosion. Non-pharmacological: i. Avoid irritant (i.e. NSAIDs, alcohol, etc) ii. Quit smoking! Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Treatment: Type A Chronic Atrophic Gastritis Surveillance - Gastroscopies at regular intervals looking for any new lesions and other changes. If found, biopsy! Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Treatment: Type B Chronic Atrophic Gastritis Medications that neutralize stomach acids (antacids) Medications that decrease the secretion of acid in the stomach: H2 blockers Proton pump inhibitors (“-prazole” drugs) Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors “High Yield” Acute gastritis - caused by the overuse of nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and alcohol. Acute gastritis is associated with neutrophilic invasion and erosion Type A chronic gastritis is caused by autoantibodies against parietal cells.This destroys the glands that secrete HCl and intrinsic factor. Lack of intrinsic factor prevents the absorption of Vitamin B12, leading to pernicious anemia. Type A chronic gastritis is associated with increased risk of gastric adenocarcinoma Type B chronic gastritis is caused by the H.pylori bacteria. It is associated with ulceration and increased risk of adenocarcinoma AND lymphoma. Type B chronic gastritis is associated ulceration and increased risk of adenocarcinoma and lymphoma Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”

Causes and Risk Factors Sources Rapid Review Pathology - Third Edition - Edward F. Goljian The Internet Pathology Laboratory for Medical Education. Mercer University School of Medicine, Savannah. http://library.med.utah.edu/WebPath/GIHTML/GI016.html http://library.med.utah.edu/WebPath/GIHTML/GI147.html http://library.med.utah.edu/WebPath/GIHTML/GI128.html Gastrolab - The Gastrointestinal site: http://www.kolumbus.fi/hans/gastrolab/e005.htm Pathology Department: Taiwan Medical University. http://pathology.tmu.edu.tw/microscopy/show.asp?pic=2033- 1.jpg&slides=1; http://pathology.tmu.edu.tw/microscopy/show.asp?pic=2033- 4.jpg&slides=4 Outline Introduction Causes and Risk Factors Clinical Findings Treatment “High Yield”