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 Table of Contents  
CASE STUDY
Year : 2016  |  Volume : 14  |  Issue : 3  |  Page : 146-147

Idiopathic granulomatous gastritis with severe gastrointestinal bleeding


Department of General Surgery, Ataturk State Hospital, Balikesir, Turkey

Date of Submission21-Jul-2016
Date of Acceptance05-Dec-2016
Date of Web Publication15-Feb-2017

Correspondence Address:
Nazim Gures
Balikesir Ataturk State Hospital General Surgery Department, Balikesir, 10100
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-1693.200150

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  Abstract 

A 54-year-old woman presented at the emergency service with acute gastrointestinal bleeding. Her haemoglobin level was 6.5 mg/dl and she had hypovolemic shock symptoms. Emergency endoscopy showed a severely bleeding area near the cardia but no open vessel was visualized. As the bleeding could not be stopped by endoscopic intervention and another nonbleeding multiple erosive focus was seen close to the pylorus laparotomy, total gastrectomy was performed. The patient was discharged on postoperative day 6 without any complication. Interestingly, the pathologic examination of the bleeding lesion revealed a granulomatous inflammation. Additional searches to determine the source of the granulomatous inflammation (tuberculosis, Helicobacter pylori, Crohn’s disease, etc.) yielded negative results; hence, the case was classified as idiopathic granulomatous gastritis.

Keywords: bleeding, gastritis, granulomatous, idiopathic


How to cite this article:
Gures N, Erol M. Idiopathic granulomatous gastritis with severe gastrointestinal bleeding. Al-Azhar Assiut Med J 2016;14:146-7

How to cite this URL:
Gures N, Erol M. Idiopathic granulomatous gastritis with severe gastrointestinal bleeding. Al-Azhar Assiut Med J [serial online] 2016 [cited 2017 Oct 17];14:146-7. Available from: http://www.azmj.eg.net/text.asp?2016/14/3/146/200150


  Introduction Top


Gastritis can be classified as infectious, noninfectious, and idiopathic [1]. First described by Fahimi et al. [2], idiopathic granulomatous gastritis (IGG) is a rare condition. Tuberculosis, syphilis, and mycosis can be infectious; sarcoidosis, Crohn’s disease, vasculitis, some malignancies, and foreign bodies can be noninfectious reasons of granulomatous lesions [3],[4] To confirm IGG, infectious and noninfectious etiologies should be excluded [5].

Acute gastrointestinal bleeding is a life-threatening condition with high mortality and morbidity [6]. Here, we would like to present an extremely rare case of acute gastrointestinal bleeding due to IGG.


  Case report Top


A 54-year-old woman complaining of haematemesis, fatigue and dizziness was referred to the emergency department. She had no particular complaints other than hypertension and some vague gastrointestinal symptoms in anamnesis. The patient’s blood pressure was 70/30 mmHg and haemoglobin level was 6.5 mg/dl. Emergency room ultrasonography revealed nothing. After starting fluid and blood resuscitation the patient was taken to the endoscopy unit. On endoscopy, a bleeding, ulcerous and nodular 2×2 cm lesion neighbouring the cardia was seen, but haemostasis attempts failed. In addition, multiple erosive lesions were viewed in the antrum. The endoscope hardly passed to the bulbus duodeni. Open laparotomy was decided to be performed. On the basis of the multiple erosions in the antrum and suspicion of pyloric stricture in addition to the bleeding ulcer in the cardia, total gastrectomy was decided. The patient was discharged on postoperative day six without any complication.

Pathologic examination of the specimen revealed granuloma formations ([Figure 1] and [Figure 2]) in the different parts of the gastric mucosa, including the main bleeding lesion. A narrowed gastric outlet was also seen ([Figure 3]).
Figure 1 Granuloma formation. Haematoxylin and eosin stain, ×10.

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Figure 2 Granuloma formation. Haematoxylin and eosin stain, ×20.

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Figure 3 Postoperative stomach specimen.

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After recovery, the patient was investigated for other causes of granulomatous diseases. Infectious (including Helicobacter pylori) or noninfectious reasons were searched for and no aetiological factor could be identified. Thus, the case was regarded as IGG.


  Discussion Top


A search of the scientific databases shows that IGG is a very rare disease. As most of the granulomatous lesions of the stomach are associated with systemic granulomatous diseases (sarcoidosis, Crohn’s disease, tuberculosis, vasculitis, etc.) or foreign bodies [5],[7] careful examination is necessary. In fact, it was even questioned in the literature whether a disease could be classified as IGG [7]. H. pylori is one of the main causes of gastric granulomas [8] but H. pylori was not detected in our patient’s tissues, although H. pylori is a common infectious agent worldwide and highly prevalent in the Turkish population [9].

Transmural, noncaseating granulomatous inflammation is the major histopathological feature of IGG [3]. In our case, several noncaseating granulomatous lesions were observed in pathologic sections taken from different parts of the stomach. The main bleeding lesion was diagnosed as a granuloma as well. We did not encounter a case in the literature of an IGG with severe bleeding. Thus, this case can be regarded as an extremely rare example of gastrointestinal bleeding.

Pyloric narrowness was probably the result of granulomatous diseases; Spinzi et al. [10] reported a similar case of IGG with gastric outlet obstruction.


  Conclusion Top


IGG should be contemplated as a rare cause of granulomatous lesions in the stomach. IGG may also be a reason for acute upper gastrointestinal bleeding.

Acknowledgements

Nazim Gures contributed in manuscript preparation, definition of intellectual content, literature search and clinical studies. Mustafa Erol contributed in manuscript preparation, literature search, clinical studies and data acquisition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Imbe K, Irisawa A, Shibukawa G, Abe Y, Saito A, Hoshi K et al. Idiopathic granulomatous gastritis diagnosed with endoscopic ultrasound-guided fine-needle aspiration: report of a case. Endosc Int Open 2014; 2:E259–E261.  Back to cited text no. 1
    
2.
Fahimi HD, Deren JJ, Gottlieb LS, Zamcheck N. Isolated granulomatous gastritis: it’s relationship to disseminated sarcoidosis and regional enteritis. Gastroenterology 1963; 45:161–175.  Back to cited text no. 2
    
3.
Niitsu H, Tanabe K, Tokumoto N, Suzuki T, Tanaka A, Arihiro K, Ohdan H. Idiopathic granulomatous gastritis resembling a gastrointestinal stromal tumor. Case Rep Gastroenterol 2012; 6:502–509.  Back to cited text no. 3
    
4.
Caso F, Galozzi P, Costa L, Sfriso P, Cantarini L, Punzi L. Autoinflammatory granulomatous diseases: from Blau syndrome and early-onset sarcoidosis to NOD2-mediated disease and Crohn’s disease. RMD Open 2015; 1:e000097.  Back to cited text no. 4
    
5.
Shapiro JL, Goldblum JR, Petras RE. A clinicopathologic study of 42 patients with granulomatous gastritis. Is there really an “idiopathic” granulomatous gastritis? Am J Surg Pathol 1996; 20:462–470.  Back to cited text no. 5
    
6.
Nable JV, Graham AC. Gastrointestinal bleeding. Emerg Med Clin North Am 2016; 34:309–325.  Back to cited text no. 6
    
7.
Sandmeier D, Bouzourene H. Does idiopathic granulomatous gastritis exist? Histopathology 2005; 46:352–353.  Back to cited text no. 7
    
8.
Yamasaki T, Nebiki H, Kurai O. A case of isolated granulomatous gastritis that spontaneously resolved without Helicobacter pylori eradication. Clin J Gastroenterol 2009; 2:17–21.  Back to cited text no. 8
    
9.
Koklu H, Koklu S, Cinar H. Helicobacter pylori and metabolic syndrome. Turk J Gastroenterol 2016; 27:201.  Back to cited text no. 9
    
10.
Spinzi G, Meucci G, Radaelli F, Sangiovanni A, Terruzzi V, Minoli G. Granulomatous gastritis presenting as gastric outlet obstruction: a case report. Ital J Gastroenterol Hepatol 1998; 30:410–413.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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