Interpretation of gastric

biopsy
Speaker: Dr. Shefali Gupta
Guide: Col. Satyanarayana
 HEADS
INTRODUCTION
NORMAL HISTOLOGY
BIOPSY SITES
ENDOSCOPIC IMAGES
CLASSIFICATION & GRADING OF GASTRITIS
ROLE OF H. pylori
OVERVIEW OF TYPES OF GASTRITIS
OTHER PATHOLOGICAL CONDITIONS
 THE STOMACH
Unequal dilatation of the
foregut
11 th thoracic vertebra to
right of 1st lumbar
vertebra
4 parts
Cardia : microscopically
indistinct zone immediately
distal to the gastro
esophageal junction
Fundus : lies above a line
drawn horizontally through
GE junction
Body : proximal 2/3
Pyloric antrum : distal third
leading to pyloric sphincter
MICROSCOPIC APPEARANCE
SURFACE (FOVEOLAR)
EPITHELIUM
of total thickness of body
mucosa
Single layer of tall
columnar mucus secreting
cells with basal nuclei
cover surface papillae &
line the gastric pits.
Mucin is neutral
glycoprotein ( so stain with
PAS but not with alcian
blue )
 ANTRAL & PYLORIC
REGIONS
Gastric pits are deeper &
branched
Glands shorter & less
tightly packed
Simple & branched coiled
tubules composed of mucin
secreting cells
The deep zone consists of
glands coiled & split up
into lobules by thin
prolongations of the
muscularis mucosae MM
 INTERMEDIATE ( TRANSITIONAL) ZONE
not more than 10 mm wide. Broadest along
the lesser curvature
Disappearance of pepsinogen secreting cells
Diminution in the thickness & branching of the
glands in the deeper zone
 FUNDIC & BODY
MUCOSA
Gastric crypts
( pits,foveolae) lined
by surface epithelium
comprise 25% of the
total thickness
Deeper zone 75%
consists of straight
tubules arranged
perpendicularly to the
surface
Specialised cells
present.
 Mucus neck cells
Form the regenerative zone
Lie in the upper part of the tubule
Low columnar & not interdigitate freely with
membrane of adjacent cells
Do not contain microvillous alkaline
phosphatase or aminopeptidase
Mucin content neutral
 Acid secreting (parietal,
oxyntic) cells
25 35 m diameter,
central nucleus ,
eosinophilic cytoplasm
Secrete intrinsic factor &
blood group substances
Appear to arise from
downward migration of
mucus neck cells
Have high content of
succinate , lactate
dehydrogenase & NAD
tetrazolium reductase
 Pepsinogen secreting ( chief ) cells
Less numerous
Mainly deeper part of tubules
Cuboidal or low columnar
Apical surface bear short irregular microvilli &
surface glycocalyx
 ENDOCRINE CELLS
Widely & patchily distributed throughout
stomach
On H & E , oval or pyamidal cells in
glandular layer wedged between basement
membrane of the glands & epithelial cells
Enterochromaffin like cells or
argentaffin cells
present in lower part of glands
Reduce silver salts without exposure to a
reducing substances & show positive diazo
reaction
Studies on rats suggest that it contain
decarboxylases & can convert
5 hydroxy tryptophan to 5 HT ;
Ldopa to dopamine & histidine to histamine
implicating them in the control of acid
secretion
 BIOPSY SITES
Five biopsy specimens

2 antrum within 2-3 cm
from pylorus
1 from distal lesser
curvature
distal greater curvature
Corpus 8 cm from
cardia
Incisura angularis
 SPECIAL STAINS-
H &E
Modified Giemsa
Warthin starry
Alcian blue
Periodic acid schiff (PAS ) stain
Genta stain
 ENDOSCOPIC Biopsy
Endo : within & skopein : to view
1880 Rudolf Schindler introduced.
Rigid flexirigid (1920) flexible
optical axis (1980) fibreoptic
biopsy
Procedural contraindications:
Uncooperative
Medical c.ind ( recent M.I )
Surg c.ind. ( G.I.perforation / gastric varices)
 INSTRUMENTS
Std. cupped forceps
 BIOPSY HANDLING
Dry rapidly : quick
 Normal appearance of gastric fundus
 Image of fundus of stomach
 Antrum with the pylorus
 Image of pylorus which
continuosly opens & closes
 Normal
 ROLE OF HELICOBACTER
Formely referred to as C.pylori
Gram ve,spiral flagellate
Measures about 3.5 in length & 0.5 in
width.
Selectively located on the surface &
lumina of gastric pits within mucus gel
layer
Helicobacter pylori
 GRADING THE
MORPHOLOGICAL VARIABLES
(UPDATED SYDNEY SYSTEM)
GRADED VARIABLES
H.pylori density
Polymorphonuclear neutrophil activity
Chronic inflammation
Glandular atrophy
Intestinal metaplasia
 NON-GRADED VARIABLES
surface epithelial demage, mucous depletion&
erosions
Lymphoid follicles
Foveolar hyperplasia
Pseudo pyloric metaplasia
Pancreatic ( acinar) metaplasia
Endocrine cell hyperplasia
 CLASSIFICATION- CHR.
TYPE
GASTRITIS
ETIOLOGICAL GASTRITIS
FACTORS SYNONYMS
NON H..pylori Superficial
Diffuse antral gastritis
ATROPIC Chronic antral gastritis
Interstitial-follicular

ATROPIC
AUTO Autoimmunity TYPE A
Diffuse corporal
IMMUNE Pernicious anaemia
associated

MULTIFOCAL H.Pylori Type B

Environmental
ATROPIC Dietary Metaplastic

Environmental factors
SPECIAL
CHEMICAL Bile,NSAIDS Reflux,reactive,NSAIDS
TYPE C

RADIATION Radiation injury

LYMPHOCYTIC Idiopathic ? Celiac disease
Gluten,drug associated
? H.pylori
NON- Crohn s
INFECTIOS ,sarcioidosis,
1.GRANULOMA wegners
TOUS granulomatosis
2.EOSINOPHILI Food sensitivity
C GASTRITIS ? allergies
OTHERS
 INTESTINAL METAPLASIA
Whether intestinalised epithelium within
gastric mucosa represent a congenital
heterotopia or an acquired metaplasia ?
Represent conversion of gastric type mucosa
to a mucosa resembling intestine.
Epithelium includes eosinophilic enterocytes
with well developed brush border & goblet
cells secreting acid mucins
Paneth cell occupy crypt base
 Endocrine cells appropiate to s. intestine
identified immunocytochemically.
Enzyme histochemical studies
demonstrate brush border enzymes
dissacharides, alkaline phosphatase ,
 MAJOR TYPES OF INTESTINAL
METAPLASIA
FEATURE TYPE I TYPE II B
(COMPLETE) (INCOMPLETE)
Absorptive cells many -
Paneth cells + rare
Goblet mucous few many
cells

Stains for:
sialomucins + +
sulfomucin - +

Asso. with ca - +
 GRANULOMATOUS
GASTRITIS
Diagnosis of last resort
Granulomas in gastric
mucosa seen in
Crohns disease
Sarcoidosis
Tuberculosis
Histoplamosis
Reaction to foreign
material
May be part of immune
mediated vasculitis
syndrome / gastric
lymphoma .
 EOSINOPHILIC GASTRITIS
Manifestation of a generalised involvement of
the alimentary tract by an allergic reaction
Eosinophils must be the dominant cell type
with little or no increase in other inflammatory
cell types
Focal increase in eosinophils may be seen in
crohns disease & parasitic diseases
Diagnosed with greater confidence when
history of allergic disease & peripheral blood
eosinophilia.
GASTRIC TUBERCULOSIS
 ROLE OF HELICOBACTER
Formely referred to as C.pylori
Measures about 3.5 in length & 0.5 in
width.
Selectively located on the surface &
lumina of gastric pits
INFECTIVE GASTRITIS

Cytomegalic virus inclusions

CROHN S DISEASE
CROHN DISEASE OF THE STOMACH
FOOD GRANULOMA IN PERIGASTIC TISSUES
GIST
ZOLLINGER-ELLISON
SYNDROME
GASTRINOMA
REGENERATIVE POLYP
ENDOCRINE CELL TUMORS

CARCINOID
HETEROTOPIAS
CARCINOMA OF THE STOMACH
GASTRIC CARCINOMA
ADENOCARCINOMA

MILD DYSPLASIA
SEVERE DYSPLASIA
GASTRIC LYMPHOMA
MALIGNANT LYMPHOMA
 REFERENCES
Si Chun Ming. Pathology of gastointestinal
tract.2nd edn. Williams & Wilkins 1992
Richard Whitehead. Mucosal biopsy of the
gastrointestinal tract. 4th edn.1990
Day DW, Dixon DF. Biopsy pathology of the
oesophagus, stomach and Duodenum. London
chapman & hall medical 1995 :156
B.C. Morson, Gastrointestinal pathology. Harvey
Miller press. 1988
Basil C. Morson. Morson & Dawsons
gastrointestinal pathology. 3rd edn.1990
NORMAL HISTOLOGY

NORMAL GASTIC ANTRUM

BODY AND FUNDIC MUCOSA
DIVERTICULUM
KAPOSI SARCOMA
GRANULOMATOUS GASTRITIS