Stomach

Other nonneoplastic

Reactive (chemical) gastropathy


Editorial Board Member: Wei Chen, M.D., Ph.D.
Deputy Editor-in-Chief: Catherine E. Hagen, M.D.
Tiffany Sheganoski, D.O.
Aaron R. Huber, D.O.

Last author update: 8 June 2022
Last staff update: 8 June 2022

Copyright: 2003-2022, PathologyOutlines.com, Inc.

PubMed Search: Reactive chemical gastropathy

Tiffany Sheganoski, D.O.
Aaron R. Huber, D.O.
Page views in 2021: 16,431
Page views in 2022 to date: 9,623
Cite this page: Sheganoski T, Huber AR. Reactive (chemical) gastropathy. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/stomachchemical.html. Accessed July 6th, 2022.
Definition / general
  • Gastric mucosal pattern of injury induced by endogenous (bile / pancreatic reflux) or exogenous (chronic use of nonsteroidal anti-inflammatory drugs [NSAIDs], acetylsalicylic acid, ethanol or chemotherapeutics) agents (Pathologe 2001;22:44)
  • Second most common diagnosis on gastric biopsy (Arch Pathol Lab Med 2007;131:86)
Essential features
  • Gastric epithelial pattern of injury in response to an endogenous or exogenous irritant
  • Histology is characterized by foveolar hyperplasia, mucin depletion in surface epithelial cells and lamina propria expansion by fibromuscular and capillary hyperplasia
  • No prominent inflammatory cells on histology
Terminology
ICD coding
  • ICD-10: K31.9 - disease of stomach and duodenum, unspecified
Epidemiology
Sites
  • Gastric surface epithelium
  • Antral mucosa > oxyntic mucosa, typically
Pathophysiology
  • Insult to gastric surface epithelium results in excessive cellular exfoliation, leading to foveolar hyperplasia
  • NSAID induced:
    • Permeation of gastric cell membranes, due to their nature as weak organic acids, allows direct access to mucosal lining
    • Inhibition of cyclooxygenase enzymes prevents synthesis of prostaglandin from arachidonic acid and production of leukotrienes
    • Disruption of cellular proliferative / reparative processes, microcirculation and growth factor expression
    • Reduced secretion of bicarbonate and mucin results in diminished hydrophobic nature of gastric surface mucous gel layer
    • References: Arch Pathol Lab Med 2007;131:86, Mediators Inflamm 2013;2013:258209
  • Bile reflux induced:
Etiology
Clinical features
  • Potential indigestion, epigastric discomfort, diarrhea, bloating, nausea, vomiting
  • May be asymptomatic
  • Minor correlation with chronic inactive gastritis, Helicobacter negative chronic active gastritis and intestinal metaplasia
  • Patients with reactive gastropathy are more likely to have duodenal peptic injury and intraepithelial lymphocytosis
  • Other significant associations: H. pylori gastritis, active ileitis, focal active colitis and collagenous colitis (Aliment Pharmacol Ther 2012;36:736)
  • High rates of concurrent conditions in certain ethnic groups: Hispanics - diabetes, African Americans - hypertension, Caucasians - tobacco / alcohol use (Gastrointest Tumors 2021;8:115)
Diagnosis
  • Endoscopic observation of mucosal erythema or friability
  • Endoscopic biopsies of gastric antrum or corpus
  • Definitive diagnosis via identification of histopathologic criteria (Pathol Res Pract 2014;210:847)
Prognostic factors
  • Prognosis is good and recurrence rate is generally low with removal of offending agent
  • If gastropathy is sequela of gastrectomy, it may contribute to pathogenesis of stump carcinoma / remnant gastric cancer (Eur J Gastroenterol Hepatol 2003;15:35)
Case reports
Treatment
  • Removal of offending agent
  • Prevention via combination therapy of NSAIDs with gastroprotective agent(s) or alternative use of selective COX2 inhibitors (Mediators Inflamm 2013;2013:258209)
Clinical images

Images hosted on other servers:

Bile with erythematous mucosa

Erythema / edema
after choledocho-
duodeno
anastomosis

Gross description
Microscopic (histologic) description
Microscopic (histologic) images

Contributed by Aaron R. Huber, D.O.
Reactive epithelium

Reactive epithelium

Epithelial injury without inflammation

Epithelial injury without inflammation

Negative stains
Videos

Gastritis versus gastropathy

Sample pathology report
  • Stomach, antrum, biopsy:
    • Reactive (chemical) gastropathy
    • No Helicobacter organisms identified on routine H&E stained sections
Differential diagnosis
Board review style question #1

A 48 year old woman with rheumatoid arthritis presents with dyspepsia and bloating. Endoscopy shows erythematous mucosa. Histopathology is significant for serrated gastric pits, foveolar hyperplasia, paucity of mucin in surface epithelial cells and ectatic superficial capillaries (see figure). What is the diagnosis?

  1. Gastric antral vascular ectasia
  2. H. pylori gastritis
  3. Low grade dysplasia
  4. Reactive gastropathy
Board review style answer #1
D. Reactive gastropathy. Histology of low grade dysplasia includes intestinal metaplasia, mucosal atrophy and pencillate, hyperchromatic nuclei within tall columnar epithelium. Gastric vascular ectasia will also have distended capillaries but with fibrin thrombi and without foveolar hyperplasia. Histology of H. pylori gastritis should emphasize more inflammation, especially epithelial neutrophils and plasma cells in the lamina propria.

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Reference: Reactive (chemical) gastropathy
Board review style question #2
A patient suffers severe reflux following sleeve gastrectomy and is diagnosed with a gastric injury pattern characterized by papillary foveolar extension, expanded lamina propria lacking inflammation and mucin depleted superficial cells. What condition does this potentially predispose her to?

  1. Gastric mucosal atrophy
  2. Gastric outlet obstruction
  3. Gastric ulcer
  4. Remnant gastric cancer
Board review style answer #2
D. Remnant gastric cancer. The other answer options are more closely associated with chronic gastritis. The described histology is classic for reactive (chemical) gastropathy, which can contribute to the pathogenesis of stump / remnant gastric cancer.

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Reference: Reactive (chemical) gastropathy
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