Reactive gastropathy

Reactive gastropathy
	External resources
EHVSC	10177
Wikipedia	reactive gastropathy

Reactive gastropathy
	Diagnosis in short
	; Reactive gastropathy. H&E stain.
LM	foveolar hyperplasia - esp. tortuosity of glands in the "neck" region (S shaped glands), smooth muscle hyperplasia, scant inflammatory cells, +/-edema, +/-erosions
LM DDx	hyperplastic polyp of the stomach, collagenous gastritis, amyloidosis, chronic gastritis
Site	stomach
Associated Dx	osteoarthritis (treated with NSAIDs)
Clinical history	classically NSAID use or alcohol use
Endoscopy	erythema, +/-erosions, +/-bile reflux
Clin. DDx	gastritis

Reactive gastropathy, abbreviated RG, a relatively common pathology of the stomach. It is also known as chemical gastropathy,^[1] and incorrectly referred to as chemical gastritis (see below).

General

May be seen in the context of a previous resection/surgical reconstruction, e.g. Billroth II.

Epidemiology

General assocations:

Increases with age.^[2]

Etologic factors - associated with:^[3]

Excess acid.
Alcohol use (excessive).
Bile (reflux).
- May be seen post-Bilroth II (distal gastrectomy).
Drugs.^[1]
- Iron (brown pigment on histology).
- NSAIDs - synergistic effect with corticosteroids.

Notes:

H. pylori uncommon in RG.^[4]

Drugs that cause erosions and/or ulcers - adapted from Genta:^[1]

Drug	Comment	Indication for Rx
NSAIDs	common cause	pain, reduce cardiovascular risk
Corticosteroids	synergistic effect with NSAIDs	rheumatologic diseases + others
Potassium (KCl)	common cause	renal failure
Bisphophonates	uncommon cause	osteoporosis
Ferrous sulfate	very common if symptomatic	iron deficiency anemia
Chloroquine	uncommon	only in the context of malaria
Sodium polystyrene sulfonate (Kayexalate)	rare	renal failure patients

Relation to gastritis

May mimic a (true) gastritis symptomatically and visually in an endoscopic examination.
"Chemical gastritis" is misnomer. Etymologically, the -itis in gastritis, implies an inflammatory process. Chemical gastropathy is not (predominantly) an inflammatory process.
- This type of confusion is not uncommon. Steatohepatitis is another example of this; it is not a process with significant inflammation yet, confusingly, carries the -itis ending.

Gross/endoscopic

Features:^[5]

Antral erythema +/- erosions.
+/-Bile.

Microscopic

Features - triad:^[6]^[1]

Foveolar hyperplasia.
- Tortuosity of glands in the "neck" region of the gastric glands.
- Associated with "mucin depletion" - cytoplasm not clear -- as is usual.
Smooth muscle fibre hyperplasia.
- Abundant eosinophilic lamina propria.
Scant acute & chronic inflammatory cells.

Additional features.

+/-Edema.
+/-Erosions.

Notes:

Triad rarely present; mild inflammation common.

DDx:

Images

RG - very low mag. (WC/Nephron)
RG - low mag. (WC/Nephron)
RG - low mag. (WC/Nephron)
RG - intermed. mag. (WC/Nephron)
RG - intermed. mag. (WC/Nephron)
RG - high mag. (WC/Nephron)

RG - low mag. (WC/Nephron)
RG - intermed. mag. (WC/Nephron)
RG - high mag. (WC/Nephron)

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STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITH REACTIVE GASTROPATHY, SEE COMMENT.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
This nonspecific finding may be due to a number of causes, including 
medications (especially NSAIDs), alcohol and bile reflux.

RG and mild chronic gastritis

STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITH REACTIVE GASTROPATHY AND MILD CHRONIC
  INACTIVE INFLAMMATION.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Not well-developed

STOMACH, BIOPSY:
- BODY-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- ANTRAL-TYPE GASTRIC MUCOSA WITH SMOOTH MUSCLE HYPERPLASIA,
  RARE GLAND TORTUOSITY AND NO SIGNFICANT INFLAMMATION, SEE COMMENT.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
These findings are suggestive of a reactive gastropathy; however, gland 
corkscrewing is not evident.

Not well-developed with minimal inflammation

STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITH SMOOTH MUSCLE HYPERPLASIA, RARE GLAND TORTUOSITY
  AND MINIMAL CHRONIC INACTIVE INFLAMMATION, SEE COMMENT.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
The smooth muscle hyperplasia and rare gland tortuosity are suggestive of a reactive
gastropathy.

Isolated smooth muscle prominence

STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITH PROMINENT SMOOTH MUSCLE, OTHERWISE WITHIN NORMAL
LIMITS.
- NEGATIVE FOR INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Genta, RM. (Nov 2005). "Differential diagnosis of reactive gastropathy.". Semin Diagn Pathol 22 (4): 273-83. PMID 16939055.
↑ Maguilnik, I.; Neumann, WL.; Sonnenberg, A.; Genta, RM. (Aug 2012). "Reactive gastropathy is associated with inflammatory conditions throughout the gastrointestinal tract.". Aliment Pharmacol Ther. doi:10.1111/apt.12031. PMID 22928604.
↑ ALS. 5 February 2009.
↑ Wolf, EM.; Plieschnegger, W.; Schmack, B.; Bordel, H.; Höfler, B.; Eherer, A.; Schulz, T.; Vieth, M. et al. (Dec 2014). "Evolving patterns in the diagnosis of reactive gastropathy: data from a prospective Central European multicenter study with proposal of a new histologic scoring system.". Pathol Res Pract 210 (12): 847-54. doi:10.1016/j.prp.2014.08.009. PMID 25238940.
↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 69. ISBN 978-0443066573.
↑ El-Zimaity. 18 October 2010.
↑ Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 69. ISBN 978-0443066573.

[pmid16939055-1] 1.0 ^1.1 ^1.2 ^1.3 Genta, RM. (Nov 2005). "Differential diagnosis of reactive gastropathy.". Semin Diagn Pathol 22 (4): 273-83. PMID 16939055.

[pmid22928604-2] Maguilnik, I.; Neumann, WL.; Sonnenberg, A.; Genta, RM. (Aug 2012). "Reactive gastropathy is associated with inflammatory conditions throughout the gastrointestinal tract.". Aliment Pharmacol Ther. doi:10.1111/apt.12031. PMID 22928604.

[3] ALS. 5 February 2009.

[pmid25238940-4] Wolf, EM.; Plieschnegger, W.; Schmack, B.; Bordel, H.; Höfler, B.; Eherer, A.; Schulz, T.; Vieth, M. et al. (Dec 2014). "Evolving patterns in the diagnosis of reactive gastropathy: data from a prospective Central European multicenter study with proposal of a new histologic scoring system.". Pathol Res Pract 210 (12): 847-54. doi:10.1016/j.prp.2014.08.009. PMID 25238940.

[5] Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 69. ISBN 978-0443066573.

[6] El-Zimaity. 18 October 2010.

[Ref_GLP69-7] Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. (2005). Gastrointestinal and Liver Pathology: A Volume in the Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 69. ISBN 978-0443066573.

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