Older Female with Nausea/Vomiting, GERD and Esophageal Ring.

Laura E. Michael, D.O.

Specimen Type:

Duodenum/ Ileum and Stomach Biopsies

History:

83 year old female with nausea/vomiting, GERD and esophageal ring. Biopsies of small bowel/duodenum, and stomach obtained.

Pathologic Features:

Duodenum and small bowel: total villous atrophy with crypt hyperplasia, intraepithelial lymphocytes and acute inflammation. Helicobacter pylori immunostain was negative. CD 3 showed an increased in T lymphocytes.

Sections of stomach show an intraepithelial lymphocytosis as well as scattered acute inflammation. Helicobacter pylori immunostain is negative. CD 3 immunostain shows an increase in T lymphocytes.

Differential Diagnosis:

Duodenum/ small bowel:

  • Celiac sprue
  • Autoimmune ileitis
  • Active chronic (Peptic) duodenitis/ileitis
  • Helicobacter pylori infection - partially treated?
  • Crohn’s disease

Stomach:

  • Lymphocytic gastritis
  • Active chronic gastritis with partially treated Helicobacter pylori infection
  • Autoimmune gastritis
  • Crohn’s disease

Diagnosis:

Gluten Sensitive Enteropathy/Celiac sprue - Confirm by gluten free diet. Lymphocytic Gastritis (associated with Celiac sprue).

This case is a classic Celiac sprue, except for the acute inflammatory component seen in both biopsies. (not appreciated in the photos) Additional information obtained from the gastroenterologist: IGA anti-tissue transglutaminase level was 175. Results over 4 considered positive for Celiac sprue, confirmed the histologic findings.

Lymphocytic gastritis is associated with Celiac sprue, as well as lymphocytic colitis. 10-45 % of gluten sensitive enteropathy and 4-10 % of Helicobacter pylori infections.

Both peptic duodenitis and celiac disease show villous atrophy and increased chronic lamina propria inflammation. Crohn’s disease would need granulomas and disease elsewhere in the gut for diagnosis. The key to the diagnosis is the abundant intraepithelial lymphocytes and the TTG serology. Autoimmune enteritis is rare, but can be seen in adults in conjunction with thymomas.

References:

  1. Emory, T, Sobin L, ATLAS OF GASTROENTESTINAL ENDOSCOPY AND ENDOSCOPIC BIOPSIES.
  2. Greenson, Diagnostic Pathology, Gastrointestinal pps 3-16, 3-18, 3-26 and 2-32 2009.