Stomach

• Helicobacter pylori gastritis is the most frequent and treatable form of gastritis, affecting more than half the world's population

Contributed by Tanner Storozuk, M.D. and Namrata Setia, M.D.

• Bismuth quadruple (PPI, bismuth subcitrate, tetracycline and metronidazole) or levofloxacin triple (PPI, levofloxacin, amoxicillin), rifabutin triple (PPI, rifabutin and amoxicillin) (Am J Gastroenterol 2017;112:212)
• Decision made based on risk factors for macrolide resistance and the presence of a penicillin allergy

Contributed by Tanner Storozuk, M.D. and Namrata Setia, M.D.

• Endoscopic appearance:
  • ~50%: normal
  • Others: mucosal erythema, friable gastric mucosa, diffuse antral nodularity and erosions (World J Gastroenterol 2015;21:11221)

• Chronic antral gastritis: infiltration of lamina propria by plasma cells, lymphocytes and a small number of eosinophils seen as a superficial band of inflammation
• Active chronic antral gastritis: when the above is associated with neutrophils; this should prompt a search for organisms
• Lymphoid follicles in antral mucosa are common but nonspecific
• Variation in histologic patterns:
  • May present as corpus predominant gastritis or pangastritis
  • Duodenum may show foveolar metaplasia and duodenitis, with or without H. pylori organisms
  • Use of PPIs facilitates proximal migration of the organisms to the oxyntic mucosa; the organisms also migrate deeper into the oxyntic glands
  • May be associated with hyperplastic polyps; eradication of H. pylori is recommended in patients with hyperplastic polyps (Ann Intern Med 1998;129:712)
  • An acute gastritis - initial transient stage followed by either resolution or onset of chronic gastritis
  • Coccoid morphology of H. pylori is found most often in patients with recent PPI use or eradication therapy; this morphology of H. pylori has a diameter that is one half to one third the length of spiral forms (Am J Clin Pathol 2002;118:719)
• Sequalae of H. pylori gastritis:
  • Atrophic antral and corpus gastritis
  • H. pylori related gastric ulcers: associated with pangastritis
  • H. pylori related duodenal ulcers: associated with antral gastritis, usually seen in the first part of duodenum, distal to the pylorus
  • Intestinal metaplasia often involving the incisura or the antrum
  • Lymphocytic gastritis
• Histologic features with regression of H. pylori gastritis:
  • Neutrophils disappear
  • Regression of chronic inflammation over several years
  • Slow decrease in the number of lymphoid follicles
• Sydney classification (Am J Surg Pathol 1996;20:1161):
  • Not used in routine practice
  • Records five histologic variables: chronic inflammation, activity, atrophy, intestinal metaplasia and H. pylori density; makes recommendations for obtaining optimal biopsy samples

Contributed by Tanner Storozuk, M.D. and Namrata Setia, M.D.

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• Easily recognized on routine H&E stain, upfront H. pylori immunohistochemistry not recommended (Am J Surg Pathol 2013;37:e12)
• Immunohistochemistry and special stains: histochemical stains do not distinguish H. pylori from other bacteria and immunohistochemical antibodies against H. pylori cross react with H. heilmanni
  • Immunohistochemistry: most common, associated with low false positive rare, also stains coccoid forms
  • Silver based stains: Warthin-Starry, Steiner, El-Zimaity dual stain, Genta
  • Nonsilver based stains: Diff-Quik, Giemsa, Leung Alcian yellow
• Gastrointestinal Pathology Society (GIPS) offers recommendations for ancillary stains in detecting H. pylori when evaluating gastric biopsies (Am J Surg Pathol 2013;37:e12)

A 55 year old man presents with abdominal pain and vomiting; imaging shows pneumoperitoneum and posterior duodenal wall perforation for which an exploratory laparotomy with antrectomy, proximal duodenectomy, Roux-en-Y gastrojejunostomy and truncal vagotomy is performed. The section of the gastric wall showed a dense band of superficial gastritis in the gastric antrum and body mucosa (as shown above) with several spiral shaped organisms in the gastric mucin. Which of the following is true about this gastritis?

1. A corpus restricted chronic gastritis is a typical presentation of H. pylori gastritis
2. A focally enhanced chronic active gastritis is a typical biopsy finding in H. pylori gastritis
3. H. pylori organisms are twice as long and considerably thicker than H. heilmannii organisms
4. It is associated with a risk of peptic ulcer disease, primary gastric lymphoma and gastric carcinoma
5. The treatment of H. pylori gastritis is optional as the infection is asymptomatic in the vast majority of infected individuals

D. H. pylori infection is associated with complications including gastroduodenal ulcers, atrophy, intestinal metaplasia, gastric cancer and mucosa associated lymphoid tissue (MALT) lymphoma. Choice A: a corpus restricted chronic gastritis is a typical presentation of autoimmune gastritis whereas an antral predominant gastritis is the most common pattern of H. pylori gastritis in the western world. Choice B: a superficial chronic active gastritis with a dense band of lymphoplasmacytic inflammation is typical for H. pylori gastritis. A focally enhanced chronic active gastritis is typical of Crohn's gastritis, especially when the findings are discrete and intense. Choice C: H. heilmannii organisms are twice as long and considerably thicker than H. pylori organisms. Choice E: according to AGA recommendations, all patients with a positive test of active infection with H. pylori should be offered treatment (Am J Gastroenterol 2018;113:1102).

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Reference: Helicobacter pylori

In patients with active peptic ulcer bleeding, what is the best method to diagnose H. pylori infection?

1. Bacterial culture
2. Breath test
3. Histology
4. Serology
5. Stool Antigen

C. Histology

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Reference: Helicobacter pylori

H. pylori immunohistochemistry may be used to help in diagnosis of H. pylori gastritis in which of the following scenarios?

1. Active chronic antral gastritis when no organisms are identified on H&E
2. For confirmation of H. pylori organisms that are clearly identifiable on H&E
3. In every case to rule out H. pylori infection in symptomatic patients
4. To distinguish between H. pylori and H. heilmannii organisms
5. When the clinician requests to rule out H. pylori despite no other histologic features

A. Active chronic antral gastritis when no organisms are identified on H&E

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Reference: Helicobacter pylori