Gastritis and Gastropathy of Childhood

The term gastritis is often used somewhat loosely. Not infrequently, clinicians refer to a patient with epigastric pain or dyspepsia as having "gastritis," and radiologists sometimes diagnose "gastritis" on the basis of nonspecific radiographic changes, such as mucosal irregularity or swelling. However, gastritis is neither a clinical nor a radiologic diagnosis. Most often, it is a purely histologic diagnosis, made by the use of random or targeted endoscopic biopsies. Although some conditions that injure the gastric mucosa may result in inflammation, others do not. Thus, "gastritis," as the suffix -itis implies, is characterized by the presence of inflammatory cells. In contrast, gastropathy is used to refer to conditions in which inflammation is not a prominent feature, although there may be epithelial damage and regeneration. In gastropathies, there are often abnormalities of the mucosa visible at endoscopy, with or without histologic changes. Sometimes the mucosal appearance at endoscopy is typical or diagnostic of a particular condition. Therefore, in the case of gastritis, the diagnosis is always based on biopsy, whereas gastropathies are sometimes diagnosed on endoscopy alone, sometimes histology alone, and sometimes both. (Strictly speaking, the word gastropathy refers to any and all disorders of the stomach, but in this article, we use its more recent application). The categorization of entities into gastritides and gastropathies is an important concept and helps narrow the diagnostic possibilities in a given case. In this article, for the sake of simplicity, the term gastritis is often used generically to refer to both gastritides and gastropathies. One purpose of this article is to propose an approach to and a classification of pediatric gastritis that is pertinent to practicing pediatric endoscopists. In so doing, we hope to focus attention on this little-studied area and to facilitate diagnosis of the various entities that comprise the classification. Further, by offering practical advice for endoscopists regarding endoscopic landmarks, terminology, and acquisition of biopsy specimens, we hope to facilitate consistency of communication among endoscopists and between endoscopists and pathologists. This, it is hoped, will lead to further work in pediatric gastritis and to improved diagnostic accuracy. HIGH-YIELD GASTROSCOPY Once a child is scheduled for diagnostic upper gastrointestinal endoscopy, the endoscopist has an obligation to maximize the diagnostic potential of the procedure. Central to this must be the recognition that the ability to make a diagnosis based on macroscopic appearances alone is limited (1-5). For example, gastric mucosa that appears normal at endoscopy may harbor marked inflammation visible on microscopic analysis. The converse is also true-that is, a markedly red mucosa at endoscopy may be normal or may result from contact with the endoscope. Redness may reflect underlying microvascular congestion without the presence of inflammatory cells. Thus, there is often poor correlation between endoscopic and histologic findings. It follows, therefore, that multiple gastric biopsies must be an integral part of a proper examination of the gastric mucosa (1-5). In children, gastritis remains underrecognized and poorly characterized because of the flawed tendency to rely on macroscopic appearances at endoscopy, and an apparent reluctance to perform multiple gastric biopsies. In evaluating specimens obtained in such biopsies, collaboration with a pathologist with special expertise in gastrointestinal histopathology is of inestimable value. A high yield of accurate diagnoses, including the definitive ruling out of mucosal disease, largely depends on the endoscopist's care and attention to detail in the following areas. Endoscopic Landmarks and Histologic Zones In reporting endoscopic appearances, the endoscopist is describing the gross pathologic appearance of disease. Gastric disorders often have a predilection for a particular area or zone of the stomach, and it is therefore important to identify endoscopic landmarks accurately. Inaccurate landmark identification may result in poorly targeted biopsies and erroneous or missed diagnoses. The largest region of the stomach is the gastric body or corpus, characterized at endoscopy by thick mucosal folds or rugae. The body or corpus extends distally to the incisura or angulus on the lesser curvature. The fundus is the dome-shaped area immediately above the gastric body and abutting the diaphragm. Both corpus and fundus are comprised of oxyntic mucosa. The gastric antrum occupies the lower quarter or third of the stomach. When the stomach is distended with air to allow visualization, the antrum is seen to begin on the greater curvature where folds of the gastric body end. The antrum ends at the pylorus and consists of mucus glands. The gastric cardia comprises a short zone-in children, extending in length from a few millimeters to perhaps one centimeter from immediately below the Z-line-composed of mucus glands. Figure 1 shows anatomic landmarks of the stomach.FIG. 1: Anatomic regions of the stomach. Reprinted with permission from Rudolph AM, Hoffman JIE, Rudolph CD, eds.Rudolph's Pediatrics. 20th ed. 1996, Appleton & Lange, Stanford, CT .The different histologic zones of the stomach correspond to the different gross anatomic zones thereof, although not precisely, because there is always some over-lap and interdigitation of histologic zones at areas of transition. Therefore, the term transitional mucosa applies to these. Gastric landmarks and their histologic correlates are described in more detail elsewhere (6-8). Although the number of inflammatory cells in the gastric mucosa of normal has not there are some elsewhere of or in poor of and endoscopy It is therefore more to endoscopic in The endoscopist or in that is and and be in the or part of the endoscopy For example, use of the term "gastritis" from to the mucosa is it be as red or or and not as or gastritis, because inflammation may not be the is not a is a mucosal that not the whereas an extends the into the of but there are some are often multiple and have is by a of When have their may be refers to a red appearance of the mucosa in or not with a visible mucosal Although the term sometimes is endoscopists the and is therefore to allow for of used for are gastritis, gastritis is from or is gastric are accurate of are thick folds or not folds or because and are not findings. It is also important to in the stomach accurately. 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