Hypertrophic gastritis: chronic, granular, erosive, antral

The key feature that allows us to distinguish hypertrophic gastritis from all types of inflammation of the gastric mucosa is the pathological proliferation of cells of the mucous epithelium, leading to its excessive thickness.

In this case, thickening of the mucosa is accompanied by the formation of more pronounced, but slightly mobile folds and the formation of single or multiple cysts, polypous nodes and epithelial-glandular tumors such as adenomas.

It is clear that without an endoscopic examination or ultrasound of the stomach, no specialist will identify morphological changes in the mucosa in this pathology.

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Epidemiology

As clinical practice shows, hypertrophic gastritis is diagnosed much less frequently than other types of gastric diseases.

According to experts from the American Society for Gastrointestinal Endoscopy, there are many more middle-aged men among patients with giant hypertrophic gastritis.

Superficial hypertrophic gastritis is detected in 45% of patients with chronic alcohol dependence.

According to some studies, 44% of cases of gastritis caused by H. pylori show mucosal hypertrophy, and 32% of patients have intestinal metaplasia in the antral part of the stomach.

Gastric polyps in this type of gastritis occur in 60% of patients, and these are mainly women over 40 years of age. Up to 40% of patients have multiple polyps. In 6% of cases, they are detected during endoscopic operations on the upper gastrointestinal tract. Hyperplastic polyps and adenomas are more common in the presence of H. pylori, and polyposis of the fundic glands, as a rule, develops after using drugs of the proton pump inhibitor group.

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Causes hypertrophic gastritis

Chronic hypertrophic gastritis is associated with a fairly wide range of causes of infectious, parasitic and non-infectious nature.

Hypertrophy and inflammation of the mucosa are associated with its damage by bacteria Helicobacter pylori, Haemophilus influenzae, Treponema pallidum; with persistent virus Cytomegalovirus hominis. Much less often, fungal infections are possible (Candida albicans, Candida lusitaniae, Histoplasma capsulatum, Cryptococcus neoformans). Also, the causes of pathology can be hidden in long-term invasion (Giardia lamblia, Ascaris, Anisakidae, Filariidae, Cryptosporidium), which over time manifests itself as eosinophilic inflammation of the stomach and small intestine.

In many cases, the development of hypertrophic gastritis with multiple granulomas in the gastric mucosa is caused by a humoral immune response in systemic autoimmune diseases such as lupus, scleroderma, and granulomatous enteritis.

It is necessary to keep in mind the presence of a genetic predisposition to changes in the gastrointestinal mucosa associated with certain mutations. In addition to Zollinger-Ellison syndrome, this includes hypertrophy of the folds of the gastric mucosa against the background of multiple polyps that imitate malignant neoplasms, associated with familial adenomatous polyposis syndrome. In 70% of cases, the true cause of this pathology is a mutation in the gene of the membrane protein APC/C (adenomatous polyposis coli), which acts as a tumor suppressor. See also - Gastric polyposis

The gastric mucosa is susceptible to hypertrophic processes in cases of food allergies, celiac disease or glucose-galactose intolerance; during long-term treatment with non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (which reduce the production of hydrochloric acid in the stomach), anti-cancer cytostatics (colchicine), iron preparations, and corticosteroids.

Malignant neoplasms can also cause the folds inside the stomach to become larger.

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Risk factors

Risk factors predisposing to the development of hypertrophic gastritis include the negative effects of poor nutrition, smoking and alcohol abuse, decreased immunity (especially in old age). This also includes frequent stress, in which pathological changes in the interstitial lining of the stomach begin due to increased production of gastrin and hydrochloric acid due to increased levels of adrenaline and noradrenaline.

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Pathogenesis

The pathogenesis of increased proliferation of mucous epithelial cells, due to which it thickens and modifies the relief of the stomach cavity, is not clearly defined in all cases. But, as gastroenterologists note, all studies associate it with the structural features of the mucous membrane and its functions.

Secretory exocrine cells of the superficial layer of the mucous epithelium (producing alkaline mucoid secretion) have increased regenerative properties and quickly restore damaged areas. Below is the proper plate (lamina propria mucosae) - a basal layer formed by fibroblasts with the inclusion of diffusely located micronodules of lymphoid tissue.

The main cells of this tissue – B-lymphocytes, mononuclear phagocytes, plasmacytoid dendrites and mast cells – provide local protection of the stomach by secreting antibodies (IgA), interferon (IFN-α, IFN-β and IFN-γ), histamine. Therefore, almost any pathogenic factor, by damaging the surface layer of the epithelium, acts on these cells, causing an inflammatory reaction.

The pathogenesis of gastritis with mucosal hypertrophy is explained by increased expression of transforming growth factor (TGF-α) and activation of its transmembrane receptors (EGFR), which leads to expansion of the proliferation zone of secretory exocrine cells and acceleration of differentiation of basal fibroblasts - with excessive mucus secretion and deficiency of gastric acid.

In addition, in hypertrophic gastritis, gastroendoscopy reveals a significant increase in apoptotic epithelial cells and lymphocyte infiltrates in the basal layer - at the bottom of the pits (foveoli) at the exit sites of the gastric glands. It is these seals (often diagnosed as lymphocytic gastritis) that cause thickening of the mucosal folds.

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Symptoms hypertrophic gastritis

From a pathological point of view, gastritis is defined as inflammation of the gastric mucosa, but in the case of hypertrophic gastritis - with minimal pathological changes in the mucosa at the initial stage of the disease - clinical symptoms may be absent.

This type of gastritis is a chronic disease, and the first signs of thickening of the mucous membrane can manifest as a feeling of heaviness and discomfort in the epigastric region, especially after eating (due to the slowing down of digestive processes).

Later, general symptoms manifest as nausea, belching, spontaneous vomiting, attacks of dull pain in the stomach, intestinal disorders (diarrhea, flatulence).

Appetite significantly worsens, so the patient loses weight and feels general weakness, accompanied by dizziness. And the appearance of soft tissue edema of the extremities indicates a decrease in the protein content in the blood plasma (hypoalbuminemia or hypoproteinemia).

In case of erosion of areas of the gastric mucosa or polypous nodes, blood may appear in the stool, and melena is possible.

By the way, about polyps, which are usually asymptomatic in themselves and are considered by many doctors as a possible complication of the chronic form of common gastritis. In case of ulceration of the polyp, the symptoms may resemble a stomach ulcer, and large formations can become malignant.

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Forms

Despite the existence of an international classification of gastritis, many types of this disease are defined differently. Moreover, gastritis is primarily an inflammatory process, but this term is often used to describe not the inflammation of the mucosa, but its endoscopic characteristics. And this still causes considerable terminological confusion.

Experts distinguish the following types of hypertrophic gastritis:

• Focal hypertrophic gastritis, which has a limited area of damage.
• Diffuse hypertrophic gastritis (spread over a significant part of the mucosa).
• Superficial hypertrophic gastritis with damage to the upper layer of the gastric mucosa.
• Hypertrophic antral gastritis is defined by its localization in the antral part of the stomach. The primary detection may be thickening and compaction of the antral folds, as well as nodules in the upper layer of the mucosa, similar to polyps, erosions and changes in the contours of the lesser curvature.
• Polypous hypertrophic gastritis (according to another version - multifocal atrophic). Usually, several oval-shaped hypertrophic polyps are present at the same time; sometimes they ulcerate, which causes swelling of the surrounding mucosa. A less common type of gastric polyposis (10% of cases) include adenomas consisting of abnormal columnar intestinal epithelium; they are most often found in the antrum of the stomach (which is closest to the duodenum).
• Hypertrophic granular gastritis is determined by the presence of single or multiple cystic formations against the background of edematous mucosa, protruding into the stomach cavity and limiting its peristalsis and mobility of folds.
• Erosive hypertrophic gastritis is characterized by the presence of lesions on the gastric mucosa in the form of ulcers (erosions), which occur either due to exposure to increased concentrations of hydrochloric acid or as a result of infection (H. pylori), which causes an intense inflammatory response with neutrophilic leukocytosis.
• Atrophic hypertrophic gastritis that occurs with persistent infections and is caused by circulating autoantibodies (IgG) against parietal cell microsomes that produce hydrochloric acid and Castle factor. Destruction of these cells leads to hypochlorhydria and decreased pepsin activity in gastric juice. Endoscopically, lymphocyte and plasma cell infiltrates are detected, penetrating the entire thickness of the mucosa with disruption of the structure of the fundic glands and a reduction in their number.

Giant hypertrophic gastritis, an abnormal thickening of the gastric mucosa due to polyp-like clusters of inflammatory cells, requires special consideration. This pathology is also called tumor-like or folded gastritis, adenopapillomatosis, creeping polyadenoma, or Menetrier's disease. Among the suspected causes of its occurrence are elevated levels of epidermal growth factor (EGF), produced by the salivary glands and glands of the pyloric region of the stomach, and activation of its gastrointestinal receptors.

Today, many gastroenterologists (primarily foreign ones) consider giant hypertrophic gastritis to be synonymous with Menetrier's disease. However, with Menetrier's disease, excessive growth of secretory cells leads to the formation of thickened folds, but is very rarely accompanied by inflammation. On this basis, some specialists classify this disease as a form of hyperplastic gastropathy, seeing it as the cause of giant hypertrophic gastritis.

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Complications and consequences

In addition to the decrease in digestive functions of the stomach felt by patients – chronic maldigestion – the consequences and complications of hypertrophic gastritis include:

• irreversible loss of a significant portion of glandular tissue with atrophy of the gastric mucosa;
• decreased synthesis of acid in the stomach (hypochlorhydria);
• slowing of gastric motility;
• enlargement of the stomach (in 16% of patients) or narrowing of its cavity (9%).

Hypoproteinemia in giant hypertrophic gastritis can lead to ascites. Also, the development of anemia associated with a lack of vitamin B12 is noted, the absorption of which is prevented by the production of immunoglobulin G (IgG) to the intrinsic Castle factor. Progression of the pathology into malignant megaloblastic anemia is not excluded.

Atrophic hypertrophic gastritis localized in the body or fundus of the stomach causes physiological hypergastrinemia, which in turn stimulates proliferation of neuroendocrine enterochromaffin-like (ECL) cells of the fundic glands into the submucosal layer. And this is fraught with the development of neuroendocrine tumors - carcinoids.

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Diagnostics hypertrophic gastritis

Diagnosis of hyperplastic gastritis is possible only by visualizing the condition of the gastric mucosa.

Therefore, instrumental diagnostics – using endogastroscopy and endoscopic ultrasonography – is the standard method for identifying this pathology.

Blood tests are also necessary - clinical, biochemical, for H. pylori, for antibodies and the tumor marker CA72-4. A stool test is taken, and the pH level of the stomach is determined.

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Differential diagnosis

Differential diagnostics (which may require CT and MRI) are performed to identify pathologies that have the same symptoms, as well as to identify – based on the results of histological examination of biopsy material – sarcoma, carcinoma, gastrointestinal stromal tumors.

Treatment hypertrophic gastritis

Treatment prescribed for hypertrophic gastritis takes into account the causes of the pathology, the nature of structural changes in the mucosa, as well as the intensity of symptoms and concomitant diseases of patients.

If the tests show the presence of Helicobacter infection, then triple therapy (to destroy the bacteria) is started with antibiotics Amoxicillin, Clarithromycin, etc., read more - Antibiotics for gastritis

For stomach pain, No-shpa or belladonna tablets Besalol are traditionally prescribed, but they dry out the mouth and can increase the pulse rate, in addition, this remedy is contraindicated in glaucoma and problems with the prostate gland. Drugs that reduce the production of hydrochloric acid (H2-histamine receptor blockers and m-anticholinergics) are not used for this type of gastritis. For more details, see - Tablets for stomach pain

To improve digestion, drugs based on pancreatic enzymes are used: Pancreatin (Pancreasim, Pankral, Pancitrat, Penzital, Pancreon, Creon, Festal, Mikrazim and other trade names). Dosage: one or two tablets three times a day (before meals). Possible side effects include dyspepsia, skin rashes and increased levels of uric acid in the blood and urine.

See also – Treatment of heaviness in the stomach

If the protein content in the blood plasma decreases, Methionine is prescribed, which should be taken one tablet (500 mg) three times a day, the course of treatment is 14-21 days.

Patients with hypertrophic gastritis are prescribed vitamins B6, B9, B12, C and P.

In case of hypertrophic gastritis, surgical treatment is necessary if there is a suspicion of oncology: laparotomy with biopsy and urgent histology is performed, after which suspicious neoplasms are removed.

Physiotherapy treatment is described here - Physiotherapy for chronic gastritis

A diet for hypertrophic gastritis is necessary, and, given the decrease in the production of hydrochloric acid in the stomach, it should not only help maintain the integrity of the epithelial layer of the gastric mucosa, but also normalize the digestion process. Therefore, the most suitable Diet for gastritis with low acidity

Folk remedies

Traditional treatment of hypertrophic gastritis mainly uses herbal treatment. A water infusion is prepared from a mixture of chamomile, plantain leaves and peppermint; decoctions are made from calendula flowers and sandy immortelle, bogbean, centaury, dill seed, calamus roots, knotweed and dandelion (a tablespoon of herbs is taken per glass of water). During the day, the infusion or decoction is taken in several sips approximately 30-40 minutes before meals. Detailed information in the material - Herbs that increase appetite

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Prevention

Standard prevention includes following hygiene rules and proper nutrition: small portions up to five times a day, no fatty or fried foods, canned or semi-finished products, and, of course, no alcoholic beverages.

It is essential to drink water (not carbonated) – at least a liter a day.

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Forecast

Gastroenterologists emphasize that hypertrophic gastritis is a chronic disease, and its development is impossible to predict, especially since there is a risk of serious complications - up to and including transformation into oncology.

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