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http://ijs.sagepub.com/International Journal of Surgical Pathology

http://ijs.sagepub.com/content/18/6/534The online version of this article can be found at:

DOI: 10.1177/1066896908329588

2010 18: 534 originally published online 22 December 2008INT J SURG PATHOLRicha Jain and Runjan Chetty

Collagenous Gastritis

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International Journal of Surgical Pathology

18(6) 534536

The Author(s) 2010

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DOI: 10.1177/1066896908329588

http://ijsp.sagepub.com

Collagenous Gastritis

Richa Jain, MBBS, MD1 andRunjan Chetty, MB BCh, FRCPath, DPhil1

Abstract

A 25-year-old patient presented with epigastric pain, which on gastric biopsy revealed the characteristic appearance ofcollagenous gastritis. There was a thick prominent subepithelial band that was confirmed to be collagen with a Massonstrichrome stain. There was associated Helicobacter pylorigastritis but no evidence of a lymphocytic gastritis. The patientdid not have watery diarrhea. Collagenous gastritis can occur in young patients, be restricted to the stomach, and canbe associated with celiac disease.

Keywords

collagenous gastritis, collagen plate, collagenous colitis

Colletti and Trainer1 described the unusual entity of col-

lagenous gastritis in 1989. Like its colonic counterpart, it

is characterized by the presence of a thickened subepithe-

lial collagen band often entrapping capillaries and inflam-

matory cells within it. Recently, it has been accepted that

more than the thickness of collagen, it is the quality or

appearance of the collagen plate that is of diagnostic impor-

tance. The collagen table frequently is ragged and frayed of

variable thickness and, characteristically, there is artifactual

detachment of the surface epithelium, exposing underlying

the collagen band.

Several cases of collagenous gastritis have been described

in the literature.1-9 The purpose of this case report is to high-

light this uncommon entity and illustrate the striking thick-

ening of the gastric collagen plate in a young patient without

symptomatic or clinically evident celiac disease or associ-

ated collagenous colitis.

Case Report

A 25-year-old man presented with epigastric pain and

underwent upper gastrointestinal endoscopy for investiga-

tion of this complaint. The patient did not have any othersymptoms, was not on any medications, and there was no

history of watery diarrhea. The gastric and duodenal mucosa

was normal at endoscopy and only random gastric biopsy

was taken. Colonoscopy was not done.

Results

Histological examination of the gastric biopsy showed

the typical features of collagenous gastritis with markedly

thickened, frayed subepithelial collagen band (Figure 1).

Within the thickened prominent collagen table, entrapped

capillaries and inflammatory cells along with artifactual

detachment of overlying epithelium could be observed

(Figure 2). In addition,Helicobacter pylori infection was

present; however, there was no increase in intra-epithelial

lymphocytes. The dense homogenous material was high-

lighted with a Massons trichrome stain, which confirmed

the material to be collagen (Figure 3). Stains for amyloid

proved to be negative.

Discussion

Most examples of collagenous gastritis occur in adults, but

a wide age range of 1 to 77 years (mean: 34 years) has been

described. There is a slight female predominance. The pre-

senting complaints vary and include severe anemia, bleed-

ing, epigastric pain, chronic diarrhea, dyspepsia, and weight

loss. Some patients may be asymptomatic patients with the

lesion being detected incidentally following upper gastroin-

testinal endoscopy carried out for some other reason.

Lagorce-Pages et al2 have divided these patients into 3 distinct

clinicopathological groups:

1Department of Pathology, University Health Network, University of

Toronto, Ontario, Canada

Corresponding Author:

Runjan Chetty, MD, Department of Pathology, University Health

Network, The Toronto General Hospital, 200 Elizabeth Street,

11th Floor, Eaton Wing, Toronto, Ontario M5G 2C4 Canada

Email: [email protected].

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Jain and Chetty 535

1. young patients with severe anemia, nodular gas-

tric mucosa, and no extragastric involvement,

2. older patients with chronic diarrhea, erythema-

tous gastric mucosa, and simultaneous collagen-

ous colitis, and

3. the rest of the patients without the above features.

Hence, younger patients have a more localized disease

whereas the older ones have a more generalized involvement

of the gastrointestinal tract. The reasons for these differ-

ences are not entirely clear. Kamimura et al3 showed that

the nodularity is because of inflammation and edema and

the collagen deposition tends to occur between the nodules

resulting in mucosal thinning. Whether the nodules progress

to diffuse involvement of the mucosa is not known. The

cause of anemia is said to be upper gastrointestinal bleeding.4

It is also said that the mucosa overlying the collagen plate

strips off and the bleeding takes place from the entrapped

capillaries. The association of collagenous colitis with celiac

disease and ulcerative colitis has also been described in a

57-year-old man.5

The typical histological features are as described above

and closely simulate collagenous colitis. However, the

surface epithelium may be intact and not show intraepithe-

lial lymphocytosis and/or atrophy.2

The pathogenesis of collagenous gastritis is not known.

Because of the striking resemblance and frequent asso-

ciation with collagenous colitis, the same pathogenetic

mechanisms have been suggested. Among the 3 proposed

theories, the most favored one is that the collagen deposi-

tion is a result of inflammation followed by collagen

deposition.2,5 In support of this theory is the fact that the

type of collagen deposited is types I and III, which areknown to be associated with inflammation and repair.2

Also, like the association of collagenous colitis and

lymphocytic colitis, the gastric counterpart has also been

seen association with lymphocytic gastritis.2 However,

no infectious or autoimmune or drug etiology has been

proven. AlthoughH. pylori has been seen in some cases

with collagenous gastritis (as encountered in the case des-

cribed herein), most reports thus far have not commented

onH. pylori infection.

Figure 1. Low-power picture of the gastric biopsy with a

prominent subepithelial band and associated mild chronic gastritis.Note the focal artifactual separation of the surface mucosa fromthe underlying collagen plate (hematoxylin and eosin, 100)

Figure 2. High-power picture displaying entrapped capillariesand occasional inflammatory cells together with Helicobacterpylori organisms on the surface (hematoxylin and eosin, 400)

Figure 3. Massons trichrome stain shows the material to becollagen and corresponding to a thickened, irregular collagenplate. (Massons trichrome, 200)



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536 International Journal of Surgical Pathology 18(6)

The course of this collagenous gastritis is also some-

what unpredictable and long-term follow-up studies have

not been done. A few reports have documented that the

abnormal collagen band persisted despite symptomatic

relief in patients with or without medications.2,4,6 In a report

of 12-year follow-up of a patient with collagenous gastritis,

development of gastric neuroendocrine cell hyperplasia,intestinal metaplasia, and epithelial changes indefinite for

dysplasia was documented.8 Association with diabetes

mellitus and psoriasis has also been observed in 2 cases on

follow-up.9 Hence, more studies with long-term follow-up

of collagenous gastritis are warranted.

Awareness of collagenous gastritis will enable the patho-

logist to make the correct diagnosis and alert the clinician

to the possible association with celiac disease and/or col-

lagenous colitis.

References

1. Colletti RB, Trainer TD. Collagenous gastritis. Gastroenter-ology. 1989;97:1552-1555.

2. Lagorce-Pages C, Fabiani B, Bouvier R, Scoazec J-Y, Durand L,

Flejou J-F. Collagenous gastritis: a report of six cases.Am

J Surg Pathol. 2001;25:1174-1179.

3. Kamimura K, Kobayashi M, Narisawa R, et al. Collag-

enous gastritis: endoscopic and pathologic evaluation of

the nodularity of gastric mucosa. Dig Dis Sci. 2007;52:

995-1000.

4. Ravikumara M, Ramani P, Spray CH. Collagenous gas-

tritis: a case report and review. Eur J Pediatr. 2007;166:

769-773.

5. Vesoulis Z, Lozanski G, Ravichandran P, Esber E. Collage-

nous gastritis: a case report, morphologic evaluation, and review.

Mod Pathol. 2000;13:591-596.

6. Wang HL, Shah AG, Yerian LM, Cohen RD, Hart J. Collag-

enous gastritis: an unusual association with profound weight

loss.Arch Pathol Lab Med. 2004;128:229-232.

7. Dray X, Reignier S, Vahedi K, Lavergne-Slove A, Marteau P.

Collagenous gastritis.Endoscopy. 2007;39:E292-E293.

8. Winslow JL, Trainer TD, Colletti RB. Collagenous gastri-

tis: a long-term follow-up with the development of endocrine

cell hyperplasia, intestinal metaplasia, and epithelial changes

indeterminate for dysplasia. Am J Clin Pathol. 2001;116:753-758.

9. Colletti RB, Cameron DJS, Hassall EG, et al. Collagenous

gastritis: an international puzzle.J Pediatr Gastroenterol Nutr.

1998;26:540.


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