Collagenous gastritis

Topic Completed: 22 January 2019

Minor changes: 11 December 2019

Revised: 21 January 2019

Copyright: (c) 2002-2019,, Inc.

PubMed Search: Collagenous gastritis

Matthew Morrow, M.D.
Raul S. Gonzalez, M.D.
Page views in 2019: 2,122
Page views in 2020 to date: 1,130
Cite this page: Morrow M, Gonzalez R. Collagenous gastritis. website. Accessed August 12th, 2020.
Definition / general
  • Poorly understood disease manifesting as thickened subepithelial collagen in the stomach
Essential features
  • An extremely rare disease characterized by the presence of a band of increased subepithelial collagen in the stomach, with associated chronic inflammation in the lamina propria
  • Often subtyped into pediatric and adult versions
  • No standard therapy
ICD coding
    ICD-10: K52.89 - Other specified noninfective gastroenteritis and colitis
  • Pediatric patients possibly more likely to have body / fundus predominant disease versus antrum in adults (Mod Pathol 2015;28:533)
  • Poorly understood etiology / pathophysiology
    Clinical features
    • Associated with celiac disease (Arch Pathol Lab Med 2001;125:1579), collagenous colitis, collagenous sprue and other autoimmune disease
    • Most common clinical symptoms include abdominal pain, anemia, diarrhea, nausea / vomiting, GI bleeding and weight loss
    • Through limited case reports, the disease has been phenotyped into adult and pediatric types (Am J Surg Pathol 2001;25:1174) but many patients may not fit either category
      • Pediatric type classically presents with upper GI symptoms including abdominal pain and anemia, which are a result of the disease process
      • Adult type is characterized by accompanying collagenous colitis, related to underlying autoimmune processes or celiac disease
      • Established by gastric biopsy
        Case reports
        • No standard therapy has been defined
        Clinical images

        Contributed by Matthew Morrow, M.D.
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        Gastric nodularity

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        Gastric mucosa with mild nodularity

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        Nodular gastric mucosa

        Gross description
        • Nodularity of the gastric corpus is the characteristic endoscopic finding but is not seen in all cases (World J Gastrointest Endosc 2015;7:265)
          • Depressed mucosa between the nodules shows atrophy and deposition of subepithelial collagen, whereas the nodular lesions themselves show unaffected mucosa (Dig Dis Sci 2007;52:995)
        • Other mucosal findings include erythema, erosions and exudate
        • Occasionally there are no findings (akin to collagenous colitis)
        Microscopic (histologic) description
        • Patchy increased subepithelial collagen, having a thickness ≥ 10 µm
          • Maximum thickness on average ranges from 15 to 115 μm, mean 55.1 μm (Mod Pathol 2015;28:533)
          • Often associated with the entrapment of red blood cells, inflammatory cells and superficial capillaries (Am J Surg Pathol 2001;25:1174)
          • Associated with the denudation or separation of the surface gastric epithelium
        • Increased chronic inflammatory infiltrate of the lamina propria including increased eosinophils and many times neutrophils
        • Increased intraepithelial lymphocytes, but fewer than in lymphocytic gastritis
        • Histologic features may persist for years (Mod Pathol 2015;28:533)
        Microscopic (histologic) images

        Contributed by Matthew Morrow, M.D.
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        Increased subepithelial collagen with lamina propria chronic inflammation

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        Denudation of surface gastric epithelium

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        Thickened subepithelial collagen

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        Collagenous gastritis 100x

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        Abundant eosinophils 40x

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        Thickened subepithelial collagen

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        Lamina propria inflammation

        Positive stains
        • Masson trichrome stain highlights the thickened subepithelial layer of collagen
        Negative stains
        Differential diagnosis
        • Amyloid deposition: positive for Congo red
        • Autoimmune gastritis or radiation therapy effect: may show diffuse collagen deposition, not specifically located in a subepithelial location
        • Scleroderma: fibrosis at all levels of the mucosa and possibly also deep to the mucosa (Ital J Anat Embryol 2010;115:115)
        • Tangential sectioning of normal subepithelial collagen: other features (e.g., increased inflammation) not seen; may need to correlate with clinical presentation
        Additional references
        Board review style question #1

          A 10 year old boy presents with chronic abdominal pain and anemia. The following is a biopsy from the stomach. Which of the following statements is true?

        1. Immunosuppression is standard therapy
        2. The absence of both HLA-DQ2 and HLA-DQ8 haplotypes essentially excludes the diagnosis
        3. The histologic features may persist for years
        4. The pediatric type of the disease is classically characterized by accompanying collagenous colitis
        Board review answer #1
        C. In one study, of the patients who had follow-up biopsies, three quarters had persistent histologic features, sometimes lasting up to 10 years (Mod Pathol 2015;28:533)

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        Board review style question #2
          Which of the following statements about collagenous gastritis is true?

        1. An increase in collagen is seen in the deep lamina propria and bowel wall
        2. If nodular gastric mucosa is seen, for diagnosis of this entity it is best to biopsy at the tips of the nodules
        3. It can be associated with celiac disease
        4. It is mainly a disease of the elderly
        Board review answer #2
        C. Collagenous gastritis can be associated with celiac disease

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