A case description of collagenous gastritis concurrent with collagenous colitis: visible endoscopic changes

Introduction

During the past several decades a set of inflammatory diseases of the gastrointestinal tract has been recognized that are characterized by subsurface collagen deposition This set of disorders includes collagenous gastritis, collagenous sprue, and collagenous colitis (1). A survey of the medical literature reveals associations between these entities in enough patients to support the notion that they must be related. Still, there is enough heterogeneity in the clinical presentations and responses to therapy to thwart attempts to unite the collagenous gastroenteritides into one neat family of diseases. Cases of collagen gastritis co-occurring with collagen colitis are rare, we have provided a citation for a similar case.

Case presentation

A 41-year-old woman was admitted with complaints of diarrhea twice daily without blood for the past 10 years. In addition, she complained of epigastric and umbilical pain unrelated to food intake, nausea, heartburn, and flatulence. She reported no alcohol or drug abuse. Her medical history revealed thyroid nodules with normal thyroid function without the presence of autoantibodies. She had no family history of immune-mediated disorders. A year ago, she underwent a colonoscopy, which was normal. Histological examination of biopsies also showed no pathology. Due to 1-month persistent complaints the endoscopy was repeated. Esophagogastroduodenoscopy revealed stage II atrophic gastritis according to OLGA classification. Histological examination indicated Hp-negative gastritis with atrophic changes mainly in the body area, suggesting autoimmune origin.

Esophagogastroduodenoscopy indicated the mucosa is focally hyperemic, diffusely thinned with multiple flat areas of intact mucosa appearing as islands up to 0.5 cm in diameter in the body of the stomach (Figure 1). In the antrum, the mucosa is focally hyperemic and focally thinned with multiple hemorrhagic erosions up to 0.2 cm in diameter distributed around the entire perimeter. Biopsy samples were collected for further examination. The biopsy samples exhibit surface deformation with collagenization of the subepithelial stroma. Picrosirius red staining revealed red staining of the subepithelial deposits (Figure 2). Colonoscopy revealed the mucosa in the transverse, descending, and sigmoid colon is edematous with a whitish tint, with areas of granular appearance; the capillary pattern is blurred and sometimes not visible (Figure 3). In other colon sections, the mucosa is pale pink with a regular capillary pattern. Multifocal biopsies were taken for histological verification. Two fragments in different vials of the mucous membrane of the ascending, transverse, descending, sigmoid, and rectum were taken. The colonic mucosa biopsies show a smooth surface with evenly distributed crypts. There is focal thickening of the subepithelial layer with collagenization (reaching a thickness of up to 28 µm) and an increased density of cellular infiltrate in the lamina propria of the mucosa (Figure 4). Collagen gastritis and microscopic collagen colitis were confirmed. Oral Budesonide 9 mg daily for 8 weeks for treatment with reducing diarrhea, umbilical pain and nausea. The patient goes on maintenance therapy with the lowest effective dose of budesonide: 6 mg daily for 12 months, achieving clinical improvement with the disappearance of diarrhea without any adverse events.

Figure 1 Esophagogastroduodenoscopy. The mucosa is focally hyperemic, diffusely thinned with multiple flat areas of intact mucosa appearing as islands up to 0.5 cm in diameter in the body of the stomach.

Figure 2 Histopathological section of the stomach. Red staining of subepithelial deposits was obtained when stained with picrosirius red. Staining with red picrosirius.

Figure 3 Colonoscopy. The mucosa in descending colon is edematous with a whitish tint throughout, with areas of a granular appearance; the capillary pattern is not visible.

Figure 4 Histopathological section of the colon. Focal thickening of the subepithelial layer with collagenization is observed, reaching a thickness of 28 microns (indicated by an arrow). Staining with hematoxylin and eosin.

All procedures performed in this case were in accordance with the ethical standards of the institution and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Collagenous gastroenteritis is a complex of inflammatory phenomena from the gastrointestinal tract, including collagenous gastritis, collagenous colitis and collagenous sprue (1). Their histological similarities are so pronounced that it is reasonable to infer a shared etiology or pathogenesis. Collagenous gastritis is a rare disease characterized by subepithelial deposition of collagen bands with a thickness exceeding 10 microns and infiltration of inflammatory mononuclear cells into the mucosal layer (2). Collagenous colitis is a major histological subtype of microscopic colitis (3). The prevalence of collagen gastritis is 13 per 100,000 esophagogastroduodenoscopies (4). The overall prevalence of microscopic colitis is 119 cases per 100,000 population, with collagen colitis accounting for 50.1 cases per 100,000 people per year (3). Based on previous case reports, two separate clinical and pathological models have been identified, including; children and young people whose disease is limited to the gastric mucosa and the main manifestation is anemia. The second group is adult patients with chronic diarrhea (5). In this group of patients, various areas are affected, including the mucous membrane of the stomach and colon; therefore, the patient’s condition depends on the area of the affected gastrointestinal tract (1). In our case, we are talking about an adult patient. Associations with autoimmune disorders such as thyroiditis and coeliac disease are frequently reported, but conclusive immunological evidence is lacking (1). Women over 60 years old have a higher risk of developing collagen colitis, and smoking further increases this risk. The pathogenesis of collagen gastritis and collagen colitis is complex and multifactorial, involving luminal factors, immune dysregulation, and genetic predisposition (3). As for the clinical manifestations, various symptoms are noticeable, from abdominal pain and gastrointestinal bleeding (associated with gastritis) to chronic diarrhea (associated with colitis) (2). In collagenous gastritis, endoscopic findings may include nodularity of the stomach body; however, this does not occur in all cases (5,6). Diagnosis relies on histological examination of multiple mucosal biopsy samples taken from affected areas (1). According to several authors, no correlation has been observed between the thickness of the deposits and the clinical severity of the condition (7). Collagenous colitis does not increase the risk of colorectal cancer or adenoma. A special surveillance colonoscopy program is not recommended (3). We would like to emphasize that in our observation, the patient with combined autoimmune gastrointestinal pathology demonstrated a favorable response to corticosteroid treatment, which was not reported in the studies of several other authors (7). Currently, simultaneous cases of collagenous gastritis and collagenous colitis are rare. To better understand the nature of this disease and develop effective therapeutic strategies, gathering and analyzing additional similar cases is essential.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-1009/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this case were in accordance with the ethical standards of the institution and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Ziaei H, Boghratian A, Sohrabi M, Zare Mehrjardi A, Zamani F. Concurrent Collagenous Gastritis and Collagenous Colitis: A Case Presentation and Review of the Literature. Middle East J Dig Dis 2022;14:131-5. [Crossref] [PubMed]
2. Kamimura K, Kobayashi M, Sato Y, Aoyagi Y, Terai S. Collagenous gastritis World J Gastrointest Endosc 2015;7:265-73. Review. [Crossref] [PubMed]
3. Miehlke S, Guagnozzi D, Zabana Y, Tontini GE, Kanstrup Fiehn AM, Wildt S, et al. European guidelines on microscopic colitis: United European Gastroenterology and European Microscopic Colitis Group statements and recommendations. United European Gastroenterol J 2021;9:13-37. [Crossref] [PubMed]
4. Genta RM, Turner KO, Morgan CJ, Sonnenberg A. Collagenous gastritis: Epidemiology and clinical associations. Dig Liver Dis 2021;53:1136-40. [Crossref] [PubMed]
5. Matta J, Alex G, Cameron DJS, Chow CW, Hardikar W, Heine RG. Pediatric Collagenous Gastritis and Colitis: A Case Series and Review of the Literature. J Pediatr Gastroenterol Nutr 2018;67:328-34. [Crossref] [PubMed]
6. Wu C, Wang L, Zhang L, Ni Y, Wang Z, Qu Y. A case of collagenous gastritis and literature review: A case report. Medicine (Baltimore) 2023;102:e33868. [Crossref] [PubMed]
7. Arredondo Montero J, Peñafiel-Freire DM, Carracedo Vega E, Antona G, de Oliveira Gomes AS, Bronte Anaut M. Pediatric Collagenous Gastritis: A Case Series With Clinical, Endoscopic and Histopathological Correlation. Clin Pediatr (Phila) 2024;63:599-603. [Crossref] [PubMed]