An Unusual Cause of Recurrent Gastric Perforations and Upper GI Bleeding: 2541

This is a 32 year old Jewish female seen in our clinic for chronic anemia. She had h/o recurrent gastric ulcers and upper GI bleeds, but no other GI or constitutional symptoms. Growing up in Israel, she had two spontaneous gastric perforations. She was extensively evaluated-H. Pylori testing was +ve twice previously and treated appropriately. No h/o NSAID use. Physical exam was unremarkable. She had mild normocytic anemia with normal iron studies and B12 levels. Autoimmune workup was negative, as was work-up for Celiac disease and Zollinger Ellison syndrome. EGD at our center showed diffuse moderate mucosal changes with granularity and nodularity in entire stomach and multiple fundic gland polyps; no active bleeding; normal duodenum and esophagus. Multiple random biopsies from stomach revealed chronic active gastritis with patchy inflammation and pit/epithelial damage. Lamina propria had mature lymphocytes with areas of increased eosinophils and plasma cells. There was an expanded patchy layer of irregular collagen under the superficial epithelium with entrapped vessels/lymphatics and inflammatory cells, indicative of collagenous gastritis (CG). Biopsies from duodenum showed focal mild intraepithelial lymphocytosis. H. Pylori staining was negative. Jejunum was normal. She was started on PPIs, ferrous sulphate and probiotics with improvement of her symptoms. CG is a rare disease (˜300 cases reported so far in literature) similar in pathogenesis to collagenous colitis. Adults with CG usually present with chronic watery diarrhea but our patient had recurrent UGI bleeding and chronic anemia. Etiology is largely unknown but often linked to autoimmune and other GI diseases. Diagnosis is based on histology (sub-epithelial collagen deposition, intraepithelial lymphocytosis, lymphoplasmacytic infiltrate in lamina propria with entrapped capillaries, and superficial epithelial damage). Treatment strategies like PPIs, H2 -blockers, steroids etc. have been tried but not well established. Adults have chronic persistent histological disease with intermittent clinical relapses but no increased mortality or significant clinical deterioration. In view of debilitating symptoms and potential complications like perforation/ bleeding, further studies to understand this condition and develop effective treatment strategies are warranted. In conclusion, we recommend that Gastroenterologists and Pathologists be aware of this rare cause of upper GI bleeding and gastric perforation.Figure: EGD showing diffuse mucosal granularity and nodularity in stomach.Figure: Pathology slide illustrating subepithelial collagen deposition and chronic inflammatory changes.