FOCAL ENHANCED GASTRITIS AND MACROPHAGE MICROAGGREGATES IN THE GASTRIC MUCOSA: potential role in the differential diagnosis between Crohn’s disease and ulcerative colitis

Gastrite focal e microagregados de macrófagos na mucosa gástrica: uso potencial no diagnóstico diferencial entre doença de Crohn e colite ulcerativa

Marcia Henriques de MAGALHÃES-COSTA Beatriz Ribeiro dos REIS Vera Lúcia Antunes CHAGAS Tiago NUNES Heitor Siffert Pereira de SOUZA Cyrla ZALTMAN About the authors

Abstracts

Context and Objectives

Focally enhanced gastritis and macrophage microaggregates are found in the upper gastrointestinal involvement of Crohn’s disease, and may reflect an underlying defective innate immunity. These features, however, are also described in patients with Helicobacter pylori infection. The role of these gastric abnormalities in the diagnosis of Crohn’s disease was assessed in a population with high prevalence of H. pylori infection.

Methods

Thirty-seven Crohn’s disease, 26 ulcerative colitis, and 30 control patients were included. The H. pylori status was evaluated by the rapid urease test and histology. The presence of focally enhanced gastritis and macrophage microaggregates was recorded.

Results

Focally enhanced gastritis was present in 24% of Crohn’s disease patients, 4% of ulcerative colitis patients and 11.5% of controls, presenting an overall sensitivity and specificity for Crohn’s disease of 24% and 88%, respectively. Macrophage microaggregates were found in all groups, but were only detected in ulcerative colitis and controls in association with H. pylori infection, with an overall sensitivity and specificity for Crohn’s disease of 61% and 69%, respectively. In the absence of H. pylori infection, focally enhanced gastritis and macrophage microaggregates were significantly associated with Crohn’s disease (P<0.02 and P = 0.001 respectively).

Conclusions

Focally gastritis and macrophage microaggregates are suggestive of Crohn’s disease only in H. pylori-negative specimens. HEADINGS - Crohn’s disease. Ulcerative colitis. Gastritis. Macrophages. Helicobacter pylori.

Crohn’s disease; Ulcerative colitis; Gastritis; Macrophages; Helicobacter pylori


Contexto e objetivos

Gastrite focal e microagregados de macrófagos são encontradas no acometimento gástrico da doença de Crohn, e podem refletir um defeito subjacente na imunidade inata. Estas características, no entanto, são também descritas em pacientes com infecção por Helicobacter pylori. O papel destas anormalidades gástricas no diagnóstico da doença de Crohn foi avaliada em uma população com alta prevalência de infecção por H. pylori.

Métodos

Trinta e sete pacientes com doença de Crohn, 26 pacientes com colite ulcerativa e 30 pacientes-controle foram incluídos. O status de infecção por H. pylori foi avaliado pelo teste da urease e histologia. A presença de gastrite focal e microagregados de macrófagos foi avaliada.

Resultados

Gastrite focal estava presente em 24% dos pacientes com doença de Crohn, 4% dos indivíduos com colite ulcerativa e 11,5% dos controles, apresentando uma sensibilidade e especificidade para doença de Crohn de 24% e 88%, respectivamente. Microagregados de macrófagos foram encontrados em todos os grupos, mas foram apenas detectados em colite ulcerativa e controles em associação com infecção por H. pylori, com sensibilidade e especificidade para doença de Crohn de 61% e 69%, respectivamente. Na ausência da infecção por H. pylori comprovada, gastrite focal e microagregados de macrófagos foram significativamente associados com doença de Crohn (P<0,02 e P = 0,001, respectivamente).

Conclusões

Gastrite focal e microagregados de macrófagos são sugestivos de doença de Crohn apenas em pacientes com avaliação dignóstica negativa para H. pylori.

Doença de Crohn; Colite ulcerativa; Gastrite; Macrofagos; Helicobacter pylori


INTRODUCTION

Inflammatory bowel diseases (IBD) are comprised of Crohn’s disease (CD) and ulcerative colitis (UC), conditions with distinct clinical, histological and endoscopic features(2323. Podolsky DK. Inflammatory bowel disease. N Engl J Med 2002;347:417-29.). They can, however, share similar genetic, clinical and histopathological features, making it difficult to establish a definitive diagnosis in some individuals. As a result, a subset of patients are labeled as indeterminate colitis or inflammatory bowel disease unclassified (IBDU)(1818. Nikolaus S, Schreiber S. Diagnostics of inflammatory bowel disease. Gastroenterology. 2007;133:1670-89., 3333. Telakis E, Tsironi E. Indeterminate colitis - definition, diagnosis, characteristics and management. Ann Gastroenterol. 2008;21:173-9.).

Significant gastroduodenal involvement occurs in between 0.5% to 4% of all patients with CD and is usually associated with distal small bowel or colonic disease(1313. Isaacs KL. Upper gastrointestinal tract endoscopy in inflammatory bowel disease. Gastrointest Endosc Clin N Am. 2002;12:451-62, vii., 2424. Reynolds HL Jr, Stellato TA. Crohn’s disease of the foregut. Surg Clin North Am 2001;81:117-35, viii.). The most recognized criteria for gastric CD include the presence of histological evidence of gastric non-caseating granulomatous inflammation, after the exclusion of other granulomatous diseases; or the presence of an established intestinal CD diagnosis with diffuse gastric inflammation compatible with CD(1313. Isaacs KL. Upper gastrointestinal tract endoscopy in inflammatory bowel disease. Gastrointest Endosc Clin N Am. 2002;12:451-62, vii., 1919. Nugent FW, Roy MA. Duodenal Crohn’s disease: an analysis of 89 cases. Am J Gastroenterol. 1989;84:249-254.). It is estimated that up to 50% of all patients with established intestinal CD also have histological alterations in the gastric mucosa despite the absence of symptoms or radiological abnormalities(55. Castellaneta SP, Afzal NA, Greenberg M et al. Diagnostic role of upper gastrointestinal endoscopy in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2004;39:257-61., 2828. Rutgeerts P, Onette E, Vantrappen G, Geboes K, Broeckaert L, Talloen L. Crohn’s disease of the stomach and duodenum: A clinical study with emphasis on the value of endoscopy and endoscopic biopsies. Endoscopy. 1980;12:288-94.).

Endoscopic evaluation with biopsies of the stomach is the gold standard for the diagnosis of gastric CD(2828. Rutgeerts P, Onette E, Vantrappen G, Geboes K, Broeckaert L, Talloen L. Crohn’s disease of the stomach and duodenum: A clinical study with emphasis on the value of endoscopy and endoscopic biopsies. Endoscopy. 1980;12:288-94.). These endoscopic characteristics, however, are non-specific and usually have a patchy distribution, including mucosal friability, erythema, nodular mucosa (cobblestoning), ulcerations and thickened folds(1414. Kefalas CH. Gastroduodenal Crohn’s disease. Proc (Bayl Univ Med Cent) 2003;16:147-51.). Even the most characteristic CD histological finding, the non-caseating granuloma, lacks specificity as granulomas can also be found in other granulomatous conditions(3434. van Hogezand RA, Witte AM, Veenendaal RA, Wagtmans MJ, Lamers CB. Proximal Crohn’s disease: review of the clinicopathologic features and therapy. Inflamm Bowel Dis. 2001;7:328-37.). The most frequent histological abnormality in gastric CD is the presence of H. pylori (Hp)- negative focally enhanced gastritis (FEG) which is found in almost 80% of patients with known intestinal CD(99. Halme L, Karkkainen P, Rautelin H, Kosunen TU, Sipponen P. High frequency of helicobacter negative gastritis in patients with Crohn’s disease. Gut. 1996;38:379-83., 1313. Isaacs KL. Upper gastrointestinal tract endoscopy in inflammatory bowel disease. Gastrointest Endosc Clin N Am. 2002;12:451-62, vii.).

FEG consists predominantly of macrophages and lymphocytes associated with macrophage microaggregates (MMs) found in the non-inflamed gastroduodenal mucosa(2020. Oberhuber G, Puspok A, Oesterreicher C et al. Focally enhanced gastritis: a frequent type of gastritis in patients with Crohn’s disease. Gastroenterology. 1997;112:698-706., 2222. Petrolla AA, Katz JA, Xin W. The clinical significance of focal enhanced gastritis in adults with isolated ileitis of the terminal ileum. J Gastroenterol. 2008;43:524-30.). Nevertheless, the presence of Hp infection can also generate a similar pattern of gastritis(1010. Herz R, Schaube J, Meining A, Stolte M. Gastritis associated with Crohn disease can be masked by Helicobacter pylori gastritis. Scand J Gastroenterol. 1999;34:471-3.). It is important, therefore, to rule-out the effect of these bacteria if an association is to be established between FEG and CD. The presence of MMs in non-inflamed normal gastric mucosa, however, is characteristic of CD, regardless of the presence of FEG(3737. Yao K, Yao T, Iwashita A, Matsui T, Kamachi S. Microaggregate of immunostained macrophages in noninflamed gastroduodenal mucosa: a new useful histological marker for differentiating Crohn’s colitis from ulcerative colitis. Am J Gastroenterol. 2000;95:1967-73.).

In Brazil, there is a high prevalence of Hp infection(2525. Rocha GA, Queiroz DM, Mendes EN et al. Indirect immunofluorescence determination of the frequency of anti-H. pylori antibodies in Brazilian blood donors. Braz J Med Biol Res. 1992;25:683-9., 3232. Souto FJ, Fontes CJ, Rocha GA, de Oliveira AM, Mendes EN, Queiroz DM. Prevalence of Helicobacter pylori infection in a rural area of the state of Mato Grosso, Brazil. Mem Inst Oswaldo Cruz. 1998;93:171-4.) and since Hp is associated with several of the histological features recognized in gastric CD, its presence could play a confounding role in the histological diagnosis of IBD patients with gastric involvement. The aim of this study was to determine the clinical utility of the diagnosis of FEG and MMs in the gastric mucosa in an IBD population with an expected high prevalence of Hp infection.

METHODS

Ethical considerations

The study protocol was approved by the Ethical Committee of the HUCFF-UFRJ. All subjects gave their informed consent prior to their inclusion in the study.

Study population

Sixty-three consecutive patients with IBD, 37 CD and 26 UC patients were recruited at the gastroenterology outpatient unit of the HUCFF-UFRJ. The diagnosis of IBD was confirmed by standard radiological, endoscopic and histological features. CD and UC patients were classified with respect to disease characteristics according to the Montreal Classification(2929. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006;55:749-53.). Inflammation was assessed using the Crohn’s disease activity index (CDAI)(22. Best WR, Becktel JM, Singleton JW, Kern F, Jr. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology. 1976;70:439-44.) and the Lichtiger Index(1515. Lichtiger S, Present DH, Kornbluth A et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med. 1994;330:1841-5.).

Thirty consecutive control patients with dyspeptic symptoms and a normal gastrointestinal endoscopy were also enrolled at the Endoscopy Unit. One patient with intestinal metaplasia and atrophic gastritis was excluded as these histological findings are associated with a higher histological score and could be misinterpreted as a more intense inflammation according to the Updated Sydney System(77. Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol. 1996;20:1161-81.). In addition, gastric metaplasia and atrophy can underestimate the presence of Hp infection(1111. Hirschl AM, Makristathis A. Methods to detect Helicobacter pylori: from culture to molecular biology. Helicobacter. 2007;12 Suppl 2:6-11.).

None of the IBD patients or controls had received any antibiotics, non-steroidal anti-inflammatory drugs, bismuth compounds, H2-receptor antagonists, proton pump inhibitors or chemotherapy for at least 6 months prior to study inclusion. Bleeding disorders, use of anticoagulant agents, and diagnosis of other granulomatous diseases were also considered exclusion criteria.

Endoscopy setting and mucosal specimens

Patients and controls underwent a blinded upper gastrointestinal video-endoscopy and received conscious sedation with midazolam and meperidine. Four gastric biopsies were obtained from the gastric body and antrum with standard biopsy forceps. Hp infection was determined by positive rapid urease test and histological analysis, as demonstrated by previous studies(11. Al-Fadda M, Powe J, Rezeig M, Al NM, Alrajhi AA, Baynton R. Comparison of carbon-14-urea breath test and rapid urease test with gastric biopsy for identification of Helicobacter pylori. Ann Saudi Med. 2000;20:170-2.). Patients were defined as Hp-negative when both tests were negative. Two controls, three CD and one UC patients with only one of the two methods confirming Hp infection were excluded.

Histological analysis

Formalin-fixed gastric sections were stained with hematoxylin and eosin for the evaluation of microscopic lesions and with Giemsa for Hp detection. Histological inflammation was evaluated by two independent blinded pathologists according to the Updated Sydney System(44. Burger-Kentischer A, Goebel H, Seiler R et al. Expression of macrophage migration inhibitory factor in different stages of human atherosclerosis. Circulation. 2002;105:1561-66., 77. Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol. 1996;20:1161-81., 1212. Hoi AY, Iskander MN, Morand EF. Macrophage migration inhibitory factor: a therapeutic target across inflammatory diseases. Inflamm Allergy Drug Targets. 2007;6:183-90.). In this score, parameters were inflammation (mononuclear leukocyte infiltration), gastritis activity (neutrophil infiltration), Hp density, the presence of atrophy and intestinal metaplasia. All parameters were graded as absent (0), mild (1), moderate (2), or severe (3). FEG was defined when at least one gland, or foveola, was infiltrated by lymphocytes, monocytes and neutrophils surrounded by normal gastric mucosa, as described by Oberhuber et al.(2020. Oberhuber G, Puspok A, Oesterreicher C et al. Focally enhanced gastritis: a frequent type of gastritis in patients with Crohn’s disease. Gastroenterology. 1997;112:698-706.). Three patients, one of each group, were excluded, as the gastric samples were inadequate for analysis.

Immunohistochemistry

Tissue samples were immediately embedded in Tissue-Tek O.C.T. compound (Miles Scientific Laboratories Ltd, Naperville, IL) and snap-frozen in isopentane in a liquid nitrogen bath. Samples were then stored at -80 °C until processing, and cut into 6-µm section in a cryostat maintained at -20°C. Tissue sections were air-dried and fixed for 10 min in a 1:1 solution of chloroform-acetone. Immunologic assessment of the intestinal mucosa was made using indirect immunoperoxidase technique using the primary mouse monoclonal antibody anti-CD68 (1:100) (Dako A/S, Glostrup, Denmark). Briefly, frozen sections were immersed in 0.3% hydrogen peroxide in methanol for 20 min to block endogenous peroxidase activity. After being rinsed in phosphate buffered saline (PBS) containing 0.5% Tween 20 for 10 min, tissue sections were incubated with normal horse serum + BSA 0.1% + Triton 0.1% in PBS solution at room temperature in a humidified chamber for 30 min. Subsequently, sections were incubated overnight with the respective primary monoclonal antibody in a humidified chamber at 4oC. Following, the sections were incubated with secondary biotinylated antibody and then with horseradish peroxidase-conjugated streptavidin (LSAB-DAKO® kit) (Dako A/S, Glostrup, Denmark), both for 20 min at room temperature. Sections were then washed in PBS, and developed using 3,3-diaminobenzidine tetrahydrochloride (Dako A/S, Glostrup, Denmark). Preparations were lightly counterstained in Harris’s hematoxylin, dehydrated, and mounted in Permount (Fisher Scientific, Pittsburgh, PA, USA). As a negative control, the treatment with the primary antibody was omitted.

Quantitative assessment

Quantitative analysis of tissue sections (under light microscopy at × 400 magnification) and images were captured using a computer-assisted image analyzer (Image-Pro Plus Version 4.1 for Windows, Media Cybernetics, LP, Silver Spring, MD, USA). Any epithelial and lamina propria cells exhibiting identifiable reactivity distinct from the background were regarded as positive. In the immunoperoxidase studies, percentages of different cell subsets were defined by the number of immunoreactive cells in relation to total cell count (immunoreactive and non-immunoreactive cells) in the lamina propria per millimeter squared (counted in at least five different areas or average sum areas of 0.625 mm² per section). The presence of five to ten CD68-positive cells in close contact, relatively losing their own limits in subepithelial or lamina propria layers were recorded as macrophage microaggregates, according to Yao et al.(3737. Yao K, Yao T, Iwashita A, Matsui T, Kamachi S. Microaggregate of immunostained macrophages in noninflamed gastroduodenal mucosa: a new useful histological marker for differentiating Crohn’s colitis from ulcerative colitis. Am J Gastroenterol. 2000;95:1967-73.).

Statistical analysis

Statistical analysis was performed using SPSS for windows (version 11.0, SPSS Inc, 1989-1999, USA). Fisher exact test and Yates’ corrected chi-square were used to test the association between variables. Statistical differences among the experimental groups were evaluated with one-way ANOVA-test in which pair-wise multiple comparisons were carried out using the Dunnett’s T3 test. Correlations between densities of positive cells measured by immunohistochemistry were assessed using Spearman rank correlation coefficient. Values were expressed as means ± SEM. FEG and MM-related sensitivity and specificity with positive and negative predictive values for CD diagnosis were calculated. The level of significance was set at P<0.05.

RESULTS

Sample characteristics

Clinical and demographic characteristics of the 57 patients with IBD enrolled in this study (33 CD, 24 UC) are summarized in Table 1. Of the 26 control individuals, 14 were female and 8 were male, and the median age was 42 years old (range: 18-67). Age and gender did not differ significantly among the groups. Disease activity, duration, age at diagnosis, location, and clinical behavior were not associated with any endoscopic, histological, or immunohistochemical finding. Upper gastrointestinal symptoms such as epigastric pain, fullness, heartburn and nausea were present in 45% (95% CI: 0.28-0.63) and 42% (95% CI: 0.20-0.63) of CD and UC patients, respectively, with no correlation with any of the analyzed variables in this study. In terms of treatment, neither the use of steroids nor 5-ASA derivates showed any significant correlation with the densities of macrophages.

TABLE 1.
Demographic and clinical characteristics of the patients with inflammatory bowel disease

H. pylori status and endoscopic findings

Regarding the prevalence of Hp, no significant difference was found among the study groups, with 50% (13/26) of controls, 54.5% (18/33) of CD, and 62.5% (15/24) of UC patients being infected. The majority of the IBD patients had either a completely normal endoscopic examination, or the presence of nonspecific gastric findings, Table 2. In the IBD Hp-positive population, endoscopic gastric abnormalities were comparable in CD (23%) and UC (27%) patients. However, in the Hp-negative IBD population, gastric lesions occurred significantly more in CD (47%) than in UC patients (22%, P = 0.03, Table 2).

TABLE 2.
Upper gastrointestinal endoscopic findings in inflammatory bowel disease patients with respect to their Hp infection status

Histopathological findings

In all groups, the presence of Hp was associated with more inflammation demonstrated by higher histopathological scores. The median histopathological scores of control, CD and UC increased significantly from 1 (0-3), 2 (1-4) and 1 (0-3) in Hp-negative biopsies, to 6 (4-8), 5 (2-8) and 6 (4-8) in Hp-positive specimens, respectively (P = 0.008). When analyzing Hp-negative IBD patients, no significant difference in the histological scores was found between CD and UC (P = 0.26).

Focally enhanced gastritis (FEG)

FEG was detected in 24% (8/33) of CD patients, in 4.2% (1/24) of UC patients and 11.5% (3/26), of controls, regardless of Hp status. In UC and controls, FEG exclusively occurred in the presence of Hp infection (Figure 1). This histological finding had an overall sensitivity and specificity for CD of 24% and 88%, respectively. In the Hp-negative population, FEG had a sensitivity of 33% and specificity of 100%, with a NPV of 100% (Table 3).

FIGURE 1.
H&E staining of the antral gastric mucosa showing a focal inflammatory infiltrate surrounding a gland in a patient with Crohn’s disease (CD). (Original magnification ×100) (A). Detail of the previous picture, showing the cellular infiltrate composed of mononuclear cells (Original magnification ×400) (B). Differential presence of focal gastritis in patients with CD, ulcerative colitis (UC), and controls, in relation to H. pylori (Hp) infection, was analyzed using chi-square. * P = 0.014, as compared with H. pylori-negative control and UC patients (C).

TABLE 3.
Predictive power of FEG, MM, and FEG+MM, with or without Hp infection, as diagnostic markers to distinguish CD from UC.

Macrophage microaggregates (MMs)

Macrophages were diffusely distributed in the gastric mucosa in 57% of specimens, or formed focal subepithelial and lamina propria MMs in 43% of the specimens (Figure 2A). Although MMs were found in all groups, in controls and UC patients they were almost exclusively associated with the presence of Hp. Of the 36 specimens showing MMs, 24 (67%) were Hp-positive and no significant difference was found among the groups (P = 0.7). In contrast, of the 12 Hp-negative specimens presenting MMs, 10 were associated with CD, 1 was a control, and the other was a UC patient. In the absence of Hp infection, a strong positive association was found between the presence of MM and CD (P = 0.001, Figure 2B). This histological finding had an overall sensitivity and specificity for CD of 61% and 69%, respectively. In the Hp-negative population, MMs had a sensitivity of 67% and specificity of 89% (Table 3). In addition, the predictive power for the presence of both FEG and MMs, with or without Hp infection, as a diagnostic marker to distinguish CD from UC is also showed in Table 3.

FIGURE 2.
Detection of CD68-positive macrophage microaggregates (MM) in the gastric mucosa of a patient with Crohn’s disease (CD). The panel shows dark brown immunohistochemical staining for CD68 in mononuclear cells of the gastric lamina propria of a tissue section from a patient with CD (Original magnification ×1000) (A). Differential presence of macrophage microaggregates (MM) in the gastric mucosa of patients with CD, ulcerative colitis (UC), and controls, in relation to H. pylori (Hp) infection, was analyzed using chi-square. * P = 0.001, as compared with H. pylori-negative control and UC patients (B).

Macrophages (CD68+ cells)

In addition to the labeling and identification of MMs, CD68+ cells (macrophages) were also analyzed according to cell density within the lamina propria of antral biopsies in all study groups. A higher CD68+ cell density was associated with Hp infection (P=0.001). Although Hp-positive CD patients demonstrated a higher CD68+ cell density (16.4±1.4%) compared to controls (10.5 ±1.6%; P = 0.031), no significant difference was detected compared to UC patients (14.6 ± 1.7%, Figure 2). Among Hp-negative patients, CD68+ cell density was not significantly different between UC (13.1±2.4%), CD (11.1±1.7%), and controls (7.8±2.0%).

DISCUSSION

The diagnosis of IBD is not always straightforward and frequently represents a clinical challenge. In a recent review, Yantiss and Odze described the existence of 5% to 15% of indeterminate colitis among IBD patients(3636. Yantiss RK, Odze RD. Diagnostic difficulties in inflammatory bowel disease pathology. Histopathology. 2006;48:116-32.). The non-classifiable IBD represents the most noticeable expression of the diagnostic overlap between CD and UC and changes in the diagnosis over time, mostly from UC to CD, are not uncommon and may impact treatment and prognosis. In this regard, before performing colectomy with ileal pouch-anal anastomosis in severe UC patients, is advisable to definitely exclude CD due to the increased risk of surgical complications, disease recurrence and pouch failure if a diagnosis of CD is later recognized(2727. Romano C, Famiani A, Gallizzi R, Comito D, Ferrau’ V, Rossi P. Indeterminate colitis: a distinctive clinical pattern of inflammatory bowel disease in children. Pediatrics. 2008;122:e1278-e81.).

Even though gastric CD can have suggestive features that can help in the diagnosis, they are not pathognomonic. In this regard, many histological characteristics found in gastric CD are also associated with Hp infection and this infection can constitute a confounding factor. Accordingly, FEG, for instance, has been observed in the gastric mucosa of Hp-positive non-IBD subjects(2121. Parente F, Cucino C, Bollani S, et al. Focal gastric inflammatory infiltrates in inflammatory bowel diseases: prevalence, immunohistochemical characteristics, and diagnostic role. Am J Gastroenterol. 2000;95:705-11.). In our study, therefore, the accuracy of gastric features associated with CD is for the first time evaluated in a population with high prevalence of Hp infection.

As expected in a country with high prevalence of Hp, the infection ratio in the IBD subjects was higher than previously published(1616. Luther J, Dave M, Higgins PD, Kao JY. Association between Helicobacter pylori infection and inflammatory bowel disease: a meta-analysis and systematic review of the literature. Inflamm Bowel Dis. 2010;16:1077-84.) and not lower than in controls. In fact, there were no differences in Hp prevalence among the study groups. Similarly, there were no differences with respect to endoscopic gastric abnormalities and level of histological inflammation when CD and UC patients were compared. Of note, when the Hp-negative IBD population was analyzed, CD patients had more gastric lesions than UC.

FEG has been considered a characteristic histological finding of CD with a variable prevalence (46%-73%) depending on the method employed and the population studied(2020. Oberhuber G, Puspok A, Oesterreicher C et al. Focally enhanced gastritis: a frequent type of gastritis in patients with Crohn’s disease. Gastroenterology. 1997;112:698-706., 3030. Sharif F, McDermott M, Dillon M et al. Focally enhanced gastritis in children with Crohn’s disease and ulcerative colitis. Am J Gastroenterol. 2002;97:1415-20.). In this study, FEG was exclusively associated with CD when Hp infection was ruled out. This finding suggests that in a population with a high prevalence of Hp, the presence of FEG in gastric samples is not necessarily consistent with CD diagnosis, but it can be a discriminatory diagnostic tool in Hp-negative IBD patients, reaching a PPV of 100% in this setting. In keeping with these results, studies which had not taken into consideration Hp infection have observed that FEG had a low positive predictive value for the diagnosis of CD(3535. Xin W, Greenson JK. The clinical significance of focally enhanced gastritis. Am J Surg Pathol. 2004;28:1347-51.), being not capable of distinguishing between patients with CD and UC(1717. McHugh JB, Gopal P, Greenson JK. The clinical significance of focally enhanced gastritis in children. Am J Surg Pathol. 2013;37:295-9.).

In accordance with the present study, several other investigators have found a higher prevalence of FEG in CD, particularly in children(2626. Roka K, Roma E, Stefanaki K, Panayotou I, Kopsidas G, Chouliaras G. The value of focally enhanced gastritis in the diagnosis of pediatric inflammatory bowel diseases. J Crohns Colitis. 2013;7:797-802.), younger patients(3131. Sonnenberg A, Melton SD, Genta RM. Frequent occurrence of gastritis and duodenitis in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2011;17:39-44.), or in association with colorectal CD(66. Danelius M, Ost A, Lapidus AB. Inflammatory bowel disease-related lesions in the duodenal and gastric mucosa. Scand J Gastroenterol. 2009;44:441-5.). FEG is characterized by a focal infiltration of T-cells and macrophages(88. Furusu H, Murase K, Nishida Y et al. Accumulation of mast cells and macrophages in focal active gastritis of patients with Crohn’s disease. Hepatogastroenterology. 2002;49:639-43., 2020. Oberhuber G, Puspok A, Oesterreicher C et al. Focally enhanced gastritis: a frequent type of gastritis in patients with Crohn’s disease. Gastroenterology. 1997;112:698-706.) and it is likely that this accumulation of inflammatory cells may also constitute the basis for the formation of MMs, described in the gastroduodenal mucosa of CD patients(3737. Yao K, Yao T, Iwashita A, Matsui T, Kamachi S. Microaggregate of immunostained macrophages in noninflamed gastroduodenal mucosa: a new useful histological marker for differentiating Crohn’s colitis from ulcerative colitis. Am J Gastroenterol. 2000;95:1967-73.). Although MMs were observed in all patient groups, their identification by immunohistochemical staining predominated in CD patients. The remarkable presence of MMs in CD gastric specimens suggests an abnormal and specific distribution of macrophages even in non-inflamed mucosa of these patients. Importantly, as FEG, the presence of MMs in the gastric mucosa was associated with CD diagnosis only in Hp-negative individuals.

In the current paper, the impact of the different therapies on the prevalence of FEG and macrophage density was also evaluated. It has been previously suggested that a higher intestinal macrophage density might be associated with intestinal inflammation in CD and that macrophage migration to the inflamed areas could be decreased by 5-ASA therapy(33. Brogden RN, Sorkin EM. Mesalazine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in chronic inflammatory bowel disease. Drugs. 1989;38:500-23.). In our study, however, there was no correlation between any medical treatment and FEG, or CD68+ cell density.

In conclusion, the histological gastric abnormalities found in Hp-positive IBD individuals are non-specific. In Hp-negative specimens, FEG and MMs are associated with the diagnosis of CD. Importantly, these histological abnormalities can be found even in endoscopically normal mucosa without any macroscopic lesions.

ACKNOWLEDGEMENTS

The authors would like to thank Cesônia de Assis Martinusso for her assistance with the histologic and immunohistochemical experiments and data collection, Claudio José de Almeida Tortori for his role in patients’ selection, data collection and statistical analysis, Kalil Madi for the histologic and immunohistochemical experiments and interpretation of pathology studies, Morgana Teixeira Lima Castelo-Branco for her assistance in data interpretation and for performing a critical review of the manuscript and Celeste Elia for her important contribution to the early study design.

REFERENCES

  • 1
    Al-Fadda M, Powe J, Rezeig M, Al NM, Alrajhi AA, Baynton R. Comparison of carbon-14-urea breath test and rapid urease test with gastric biopsy for identification of Helicobacter pylori. Ann Saudi Med. 2000;20:170-2.
  • 2
    Best WR, Becktel JM, Singleton JW, Kern F, Jr. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology. 1976;70:439-44.
  • 3
    Brogden RN, Sorkin EM. Mesalazine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in chronic inflammatory bowel disease. Drugs. 1989;38:500-23.
  • 4
    Burger-Kentischer A, Goebel H, Seiler R et al. Expression of macrophage migration inhibitory factor in different stages of human atherosclerosis. Circulation. 2002;105:1561-66.
  • 5
    Castellaneta SP, Afzal NA, Greenberg M et al. Diagnostic role of upper gastrointestinal endoscopy in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2004;39:257-61.
  • 6
    Danelius M, Ost A, Lapidus AB. Inflammatory bowel disease-related lesions in the duodenal and gastric mucosa. Scand J Gastroenterol. 2009;44:441-5.
  • 7
    Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol. 1996;20:1161-81.
  • 8
    Furusu H, Murase K, Nishida Y et al. Accumulation of mast cells and macrophages in focal active gastritis of patients with Crohn’s disease. Hepatogastroenterology. 2002;49:639-43.
  • 9
    Halme L, Karkkainen P, Rautelin H, Kosunen TU, Sipponen P. High frequency of helicobacter negative gastritis in patients with Crohn’s disease. Gut. 1996;38:379-83.
  • 10
    Herz R, Schaube J, Meining A, Stolte M. Gastritis associated with Crohn disease can be masked by Helicobacter pylori gastritis. Scand J Gastroenterol. 1999;34:471-3.
  • 11
    Hirschl AM, Makristathis A. Methods to detect Helicobacter pylori: from culture to molecular biology. Helicobacter. 2007;12 Suppl 2:6-11.
  • 12
    Hoi AY, Iskander MN, Morand EF. Macrophage migration inhibitory factor: a therapeutic target across inflammatory diseases. Inflamm Allergy Drug Targets. 2007;6:183-90.
  • 13
    Isaacs KL. Upper gastrointestinal tract endoscopy in inflammatory bowel disease. Gastrointest Endosc Clin N Am. 2002;12:451-62, vii.
  • 14
    Kefalas CH. Gastroduodenal Crohn’s disease. Proc (Bayl Univ Med Cent) 2003;16:147-51.
  • 15
    Lichtiger S, Present DH, Kornbluth A et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med. 1994;330:1841-5.
  • 16
    Luther J, Dave M, Higgins PD, Kao JY. Association between Helicobacter pylori infection and inflammatory bowel disease: a meta-analysis and systematic review of the literature. Inflamm Bowel Dis. 2010;16:1077-84.
  • 17
    McHugh JB, Gopal P, Greenson JK. The clinical significance of focally enhanced gastritis in children. Am J Surg Pathol. 2013;37:295-9.
  • 18
    Nikolaus S, Schreiber S. Diagnostics of inflammatory bowel disease. Gastroenterology. 2007;133:1670-89.
  • 19
    Nugent FW, Roy MA. Duodenal Crohn’s disease: an analysis of 89 cases. Am J Gastroenterol. 1989;84:249-254.
  • 20
    Oberhuber G, Puspok A, Oesterreicher C et al. Focally enhanced gastritis: a frequent type of gastritis in patients with Crohn’s disease. Gastroenterology. 1997;112:698-706.
  • 21
    Parente F, Cucino C, Bollani S, et al. Focal gastric inflammatory infiltrates in inflammatory bowel diseases: prevalence, immunohistochemical characteristics, and diagnostic role. Am J Gastroenterol. 2000;95:705-11.
  • 22
    Petrolla AA, Katz JA, Xin W. The clinical significance of focal enhanced gastritis in adults with isolated ileitis of the terminal ileum. J Gastroenterol. 2008;43:524-30.
  • 23
    Podolsky DK. Inflammatory bowel disease. N Engl J Med 2002;347:417-29.
  • 24
    Reynolds HL Jr, Stellato TA. Crohn’s disease of the foregut. Surg Clin North Am 2001;81:117-35, viii.
  • 25
    Rocha GA, Queiroz DM, Mendes EN et al. Indirect immunofluorescence determination of the frequency of anti-H. pylori antibodies in Brazilian blood donors. Braz J Med Biol Res. 1992;25:683-9.
  • 26
    Roka K, Roma E, Stefanaki K, Panayotou I, Kopsidas G, Chouliaras G. The value of focally enhanced gastritis in the diagnosis of pediatric inflammatory bowel diseases. J Crohns Colitis. 2013;7:797-802.
  • 27
    Romano C, Famiani A, Gallizzi R, Comito D, Ferrau’ V, Rossi P. Indeterminate colitis: a distinctive clinical pattern of inflammatory bowel disease in children. Pediatrics. 2008;122:e1278-e81.
  • 28
    Rutgeerts P, Onette E, Vantrappen G, Geboes K, Broeckaert L, Talloen L. Crohn’s disease of the stomach and duodenum: A clinical study with emphasis on the value of endoscopy and endoscopic biopsies. Endoscopy. 1980;12:288-94.
  • 29
    Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006;55:749-53.
  • 30
    Sharif F, McDermott M, Dillon M et al. Focally enhanced gastritis in children with Crohn’s disease and ulcerative colitis. Am J Gastroenterol. 2002;97:1415-20.
  • 31
    Sonnenberg A, Melton SD, Genta RM. Frequent occurrence of gastritis and duodenitis in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2011;17:39-44.
  • 32
    Souto FJ, Fontes CJ, Rocha GA, de Oliveira AM, Mendes EN, Queiroz DM. Prevalence of Helicobacter pylori infection in a rural area of the state of Mato Grosso, Brazil. Mem Inst Oswaldo Cruz. 1998;93:171-4.
  • 33
    Telakis E, Tsironi E. Indeterminate colitis - definition, diagnosis, characteristics and management. Ann Gastroenterol. 2008;21:173-9.
  • 34
    van Hogezand RA, Witte AM, Veenendaal RA, Wagtmans MJ, Lamers CB. Proximal Crohn’s disease: review of the clinicopathologic features and therapy. Inflamm Bowel Dis. 2001;7:328-37.
  • 35
    Xin W, Greenson JK. The clinical significance of focally enhanced gastritis. Am J Surg Pathol. 2004;28:1347-51.
  • 36
    Yantiss RK, Odze RD. Diagnostic difficulties in inflammatory bowel disease pathology. Histopathology. 2006;48:116-32.
  • 37
    Yao K, Yao T, Iwashita A, Matsui T, Kamachi S. Microaggregate of immunostained macrophages in noninflamed gastroduodenal mucosa: a new useful histological marker for differentiating Crohn’s colitis from ulcerative colitis. Am J Gastroenterol. 2000;95:1967-73.

  • Financial support: CNPq and FAPERJ.

Publication Dates

  • Publication in this collection
    Oct-Dec 2014

History

  • Received
    13 Mar 2014
  • Accepted
    17 June 2014
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