Granulomatous Gastritis Causing Partial Gastric Outflow Obstruction
Authors: Rishi Goel, Harriet Deere, Viraj Kariyawasam
Journal: Clinical Gastroenterology and Hepatology (2013)

A 31-year-old woman was referred with dyspepsia and postprandial vomiting. She had been under the care of respiratory physicians for presumed pulmonary sarcoid but was discharged 3 years ago because she was asymptomatic.Gastroscopy revealed a 3-cm polypoidal lesion in the gastric antrum extending through the pyloric channel (Figure A), with a normal duodenum. Biopsies showed acute and chronic inflammatory changes with no dysplasia or malignancy. Computed tomography revealed circumferential pyloric thickening causing partial gastric outlet obstruction, with no evidence of distant disease, particularly lung involvement. Endoscopic ultrasound showed a superficial noninvasive multilobulated circumferential pyloric polyp with no associated lymphadenopathy. Endoscopic mucosal resection was unsuccessful because of underlying fibrosis, and elective surgery was planned.She presented acutely 3 days later because she was unable to tolerate anything orally and had generalized weakness and epigastric pain. A laparotomy with distal gastrectomy and Polya reconstruction was performed. Resection histology (Figure B, abnormal area on left) showed chronic inflammation with multiple non-necrotizing granulomas (Figure C; original magnification, ×200) predominantly within the lamina propria and occasionally seen in the submucosa. A diagnosis of florid active granulomatous gastritis (GG) was made. There were no intraoperative or postoperative complications, and she made an excellent recovery. At follow-up 1 month later, she was asymptomatic and eating a normal diet.GG is a morphologic description applied to the presence of epithelioid histiocytic aggregates. Gastric granulomas vary widely in morphologic appearance and are rare, with an incidence between 0.08% and 0.35%.1Srivastava A. Lauwers G.Y. Pathology of non-infective gastritis.Histopathology. 2007; 50: 15-29Crossref PubMed Scopus (37) Google Scholar Clinical, serologic, endoscopic, and radiologic investigations and specific histologic stains usually identify the underlying etiology.The most common cause of GG in the West is Crohn's disease (almost 50%), with gastric sarcoidosis accounting for 1%–21% of all cases.2Shapiro J.L. Goldblum J.R. Petras R.E. A clinicopathologic study of 42 patients with granulomatous gastritis: is there really an “idiopathic” granulomatous gastritis?.Am J Surg Pathol. 1996; 20: 462-470Crossref PubMed Scopus (104) Google Scholar Fewer than 7% of patients develop extrapulmonary sarcoidosis, with fewer than 1% developing gastrointestinal disease.3Shkolnik L.E. Shin R.D. Brabeck D.M. et al.Symptomatic gastric sarcoidosis in a patient with pulmonary sarcoidosis in remission.BMJ Case Reports. 2012; 10 (1136/bcr-2012-006559)Google Scholar The stomach is the most frequently affected, and the small bowel is the least. Gastrointestinal tuberculosis is uncommon and is diagnosed with tissue sampling revealing acid-fast bacilli. Rarer causes include syphilis, parasitic infections, foreign body reactions, Whipple's disease, adenocarcinomas, and mucosa-associated lymphoid tissue lymphomas.1Srivastava A. Lauwers G.Y. Pathology of non-infective gastritis.Histopathology. 2007; 50: 15-29Crossref PubMed Scopus (37) Google ScholarGastric sarcoidosis causes symptoms in 0.9% of patients including abdominal pain and gastrointestinal hemorrhage.4Liang D. Price J.C. Ahmed H. et al.Gastric sarcoidosis: case report and literature review.J Natl Med Assoc. 2010; 102: 348-351Crossref PubMed Google Scholar In a review of 20 cases of symptomatic gastric sarcoidosis, two-thirds of patients improved with oral steroids, with the remainder requiring surgery.5Chinitz M.A. Brandt L.J. Frank M.S. et al.Symptomatic sarcoidosis of the stomach.Dig Dis Sci. 1985; 30: 682-688Crossref PubMed Scopus (58) Google Scholar Recently, steroid therapy was effective in a patient with symptomatic gastric sarcoidosis whose pulmonary disease was in remission.3Shkolnik L.E. Shin R.D. Brabeck D.M. et al.Symptomatic gastric sarcoidosis in a patient with pulmonary sarcoidosis in remission.BMJ Case Reports. 2012; 10 (1136/bcr-2012-006559)Google Scholar However, in our case acute deterioration necessitated surgical resection, which proved to be effective management with an excellent outcome. A 31-year-old woman was referred with dyspepsia and postprandial vomiting. She had been under the care of respiratory physicians for presumed pulmonary sarcoid but was discharged 3 years ago because she was asymptomatic. Gastroscopy revealed a 3-cm polypoidal lesion in the gastric antrum extending through the pyloric channel (Figure A), with a normal duodenum. Biopsies showed acute and chronic inflammatory changes with no dysplasia or malignancy. Computed tomography revealed circumferential pyloric thickening causing partial gastric outlet obstruction, with no evidence of distant disease, particularly lung involvement. Endoscopic ultrasound showed a superficial noninvasive multilobulated circumferential pyloric polyp with no associated lymphadenopathy. Endoscopic mucosal resection was unsuccessful because of underlying fibrosis, and elective surgery was planned. She presented acutely 3 days later because she was unable to tolerate anything orally and had generalized weakness and epigastric pain. A laparotomy with distal gastrectomy and Polya reconstruction was performed. Resection histology (Figure B, abnormal area on left) showed chronic inflammation with multiple non-necrotizing granulomas (Figure C; original magnification, ×200) predominantly within the lamina propria and occasionally seen in the submucosa. A diagnosis of florid active granulomatous gastritis (GG) was made. There were no intraoperative or postoperative complications, and she made an excellent recovery. At follow-up 1 month later, she was asymptomatic and eating a normal diet. GG is a morphologic description applied to the presence of epithelioid histiocytic aggregates. Gastric granulomas vary widely in morphologic appearance and are rare, with an incidence between 0.08% and 0.35%.1Srivastava A. Lauwers G.Y. Pathology of non-infective gastritis.Histopathology. 2007; 50: 15-29Crossref PubMed Scopus (37) Google Scholar Clinical, serologic, endoscopic, and radiologic investigations and specific histologic stains usually identify the underlying etiology. The most common cause of GG in the West is Crohn's disease (almost 50%), with gastric sarcoidosis accounting for 1%–21% of all cases.2Shapiro J.L. Goldblum J.R. Petras R.E. A clinicopathologic study of 42 patients with granulomatous gastritis: is there really an “idiopathic” granulomatous gastritis?.Am J Surg Pathol. 1996; 20: 462-470Crossref PubMed Scopus (104) Google Scholar Fewer than 7% of patients develop extrapulmonary sarcoidosis, with fewer than 1% developing gastrointestinal disease.3Shkolnik L.E. Shin R.D. Brabeck D.M. et al.Symptomatic gastric sarcoidosis in a patient with pulmonary sarcoidosis in remission.BMJ Case Reports. 2012; 10 (1136/bcr-2012-006559)Google Scholar The stomach is the most frequently affected, and the small bowel is the least. Gastrointestinal tuberculosis is uncommon and is diagnosed with tissue sampling revealing acid-fast bacilli. Rarer causes include syphilis, parasitic infections, foreign body reactions, Whipple's disease, adenocarcinomas, and mucosa-associated lymphoid tissue lymphomas.1Srivastava A. Lauwers G.Y. Pathology of non-infective gastritis.Histopathology. 2007; 50: 15-29Crossref PubMed Scopus (37) Google Scholar Gastric sarcoidosis causes symptoms in 0.9% of patients including abdominal pain and gastrointestinal hemorrhage.4Liang D. Price J.C. Ahmed H. et al.Gastric sarcoidosis: case report and literature review.J Natl Med Assoc. 2010; 102: 348-351Crossref PubMed Google Scholar In a review of 20 cases of symptomatic gastric sarcoidosis, two-thirds of patients improved with oral steroids, with the remainder requiring surgery.5Chinitz M.A. Brandt L.J. Frank M.S. et al.Symptomatic sarcoidosis of the stomach.Dig Dis Sci. 1985; 30: 682-688Crossref PubMed Scopus (58) Google Scholar Recently, steroid therapy was effective in a patient with symptomatic gastric sarcoidosis whose pulmonary disease was in remission.3Shkolnik L.E. Shin R.D. Brabeck D.M. et al.Symptomatic gastric sarcoidosis in a patient with pulmonary sarcoidosis in remission.BMJ Case Reports. 2012; 10 (1136/bcr-2012-006559)Google Scholar However, in our case acute deterioration necessitated surgical resection, which proved to be effective management with an excellent outcome.