A Middle-aged Woman with a Persistent Gastrointestinal Bleed

A 59-year-old female with a history of hypothyroidism and bronchial asthma presented to the emergency department with a 1 day history of hematemesis. She was well until 1 week prior to presentation when she developed profound fatigue and melena stool. There was no history of diarrhea or dyspepsia. Her medications included L-thyroxine, salbutamol inhaler PRN, and oral pantoprazole that was started 3 days prior to her hospital visit. She denied using aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive alcohol.

Physical examination revealed pallor and a mild orthostatic drop in blood pressure. Her hemoglobin was 55 g/L and other routine blood tests were normal. Esophagogastroduodenoscopy showed a clot at the lesser curvature and a clean-based ulcer at the pylorus. She was started on intravenous pantoprazole and given blood transfusion and supportive treatment. The patient continued to bleed and repeat esophagogastroduodenoscopy 2 days later showed healing of the pyloric ulcer and diffuse gastritis; multiple biopsies were taken from the body and antrum of the stomach. Biopsies were negative for Helicobacter pylori and showed the following [Figure 1].

Figure 1.

Gastric biopsy with H and E and trichrome stains

QUESTION

Q1. What is the diagnosis and what is the treatment?

ANSWER

The gastric biopsies showed lamina propria inflammation with scattered intraepithelial lymphocytes and irregular thickening of the subepithelial collagen band, highlighted by the trichrome stain; these findings are consistent with collagenous gastritis.

The patient was commenced on oral prednisone 20 mg/day for 1 month, and then underwent esophagogastroscopy, which showed noticeable improvement in her gastritis. The steroid dose was tapered over the following 4 weeks to 10 mg/day. Her hemoglobin was measured 2 months after starting therapy and it had increased to 127 g/L with iron supplementation.

Collagenous gastritis is a rare disorder first described in 1989 and characterized by the presence, in the gastric mucosa, of a patchily thickened subepithelial collagen band and intraepithelial inflammatory cells.[1] Patients present with anemia and epigastric pain with or without diarrhea.[1] The endoscopic appearance is variable, and may include nodularity of the gastric corpus mucosa, erythema, erosions, ulcerations, and discrete submucosal hemorrhage.[2]

The cause of collagenous gastritis is unknown. It has been associated with collagenous colitis,[3] lymphocytic colitis,[4] celiac sprue, collagenous sprue, and ulcerative colitis.[5]

Various treatments have been used, including corticosteroids, H2-blockers, proton pump inhibitors, and 5-ASA with variable success. Physicians should consider this rare disorder when more common causes of chronic gastritis, such as H. pylori and NSAID gastropathy have been ruled out.