Stomach

• Erosive gastritis is loss of superficial epithelium of the gastric mucosa caused by impairment of mucosal defenses

• ICD-10: К29.60 - other gastritis without bleeding

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• Loss of superficial epithelium of the gastric mucosa
• Mild to moderate edema, congested vessels and scattered neutrophils in the lamina propria
• Ulceration, granulation tissue and hemorrhage in more severe disease
• Moderate to severe acute inflammatory infiltrate, fibrinopurulent exudate, mucosal sloughing, regenerative changes in the adjacent epithelium in late disease
• References: Arq Gastroenterol 2022;59:275, Korean J Gastroenterol 2017;69:278

Contributed by Iresha Vithanage, M.B.B.S., M.D. and Xiaoyan Liao, M.D., Ph.D.

• Clin Pract 2021;11:374, Histopathology 2021;78:48

A 58 year old man was admitted through the emergency department after suffering from polytrauma in a traffic accident. He becomes vitally stable after resuscitation, however, develops persistent nausea associated with epigastric pain. Gastroendoscopy shows small superficial mucosal erosions or erythematous lesions in the gastric body and fundus. Which of the following is true regarding the pathophysiology of development of this condition in this patient?

1. Angiotensin II is released, which increases blood flow to the gastric mucosa
2. Elevated levels of ACH and histamine in stress result in decreased acid production
3. Increased acid secretion leads to the development of gastric erosions
4. Naturally produced nitric oxide is an enhancing factor for gastric erosion
5. There is no significant dysregulation of gastric pH during the process

C. Increased acid secretion leads to the development of gastric erosions. One of the most common causes of erosive gastritis is stress. In the stressed state (may be due to physiologic stress related to severe trauma, severe burns, ventilator dependency or intracranial trauma), elevated levels of ACH and histamine result in increased acid production, thus inducing erosive gastritis, which can later on lead to hemorrhage if left undiagnosed / untreated. Naturally produced nitric oxide is believed to be protective against stress gastritis, as it leads to vasodilation. Angiotensin II is released as a result of stress, which decreases blood flow to the gastric mucosa, resulting in formation of reactive oxygen species (StatPearls: Stress Induced Gastritis [Accessed 6 February 2023]).

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Reference: Erosive gastritis

A 42 year old woman with rheumatoid arthritis presents with dyspepsia and bloating. Gastroendoscopy shows small erythematous lesions in the gastric body. On histopathology, there are surface erosions with ectatic superficial capillaries and mild edema in the lamina propria (see image above). Intestinal metaplasia is not seen. What is the diagnosis?

1. Erosive gastritis
2. Gastric antral vascular ectasia (GAVE)
3. H. pylori gastritis
4. Low grade dysplasia
5. Reactive gastropathy

A. Erosive gastritis. Longstanding NSAID use (in this case, for rheumatoid arthritis) predisposes a patient to erosive gastritis. In this patient, there were small erythematous lesions in the gastric body and histology is compatible erosive gastritis. GAVE usually shows watermelon stomach; endoscopically and histologically there is increase in blood vessel number and diameter with fibrin thrombi and fibromuscular hyperplasia. H. pylori gastritis will show active chronic gastritis with organisms which can be seen on H&E, special stain or immunostain. Low grade dysplasia will show hyperchromatic and pleomorphic nuclei within tall columnar epithelium. There will be abrupt transition from benign to dysplastic epithelium. Reactive gastropathy is characterized by foveolar hyperplasia, mucin depletion in surface epithelial cells and lamina propria expansion by fibromuscular and capillary hyperplasia (Cureus 2020;12:e10873).

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Reference: Erosive gastritis