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Original Report |
1
Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2
Department of Pathology and Laboratory Medicine, Hospital of the University of
Pennsylvania, Philadelphia, PA 19104.
3
Department of Pathology and Laboratory Medicine, Presbyterian Medical Center,
51 N. 39th St., Philadelphia, PA 19104.
4
Department of Medicine, Presbyterian Medical Center, Philadelphia, PA
19104.
5
Department of Medicine, Hospital of the University of Pennsylvania,
Philadelphia, PA 19104.
Received October 30, 2000;
accepted after revision December 15, 2000.
Address correspondence to M. S. Levine.
Abstract
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CONCLUSION. Lymphoid hyperplasia of the stomach is characterized by distinctive findings on double-contrast upper gastrointestinal tract barium examinations; all five patients had innumerable tiny (1-3 mm in diameter) round frequently umbilicated nodules that carpeted the mucosa of the gastric antrum or antrum and body. Three of these five patients had associated Helicobacter pylori gastritis. The diagnosis of gastric lymphoid hyperplasia, therefore, can be suggested on the basis of the radiographic findings.
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Four patients underwent endoscopy at our university hospital and one at an affiliated area hospital. The endoscopic findings were reviewed. An average of six (range, 3-12) endoscopic biopsy specimens were obtained from the antrum in these five patients. The biopsy specimens were sectioned, stained, and then evaluated for the presence or absence of lymphoid follicles, acute or chronic gastritis, H. pylori, intestinal metaplasia, and tumor. Finally, medical records were reviewed to determine the clinical presentation.
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Radiographic Findings
Double-contrast examinations of the upper gastrointestinal tract revealed
innumerable tiny nodules in the antrum of the stomach in four patients (with
sparing of the distal antrum in one) and in the antrum and body in one. In all
patients, the lesions had a relatively uniform size (1-3 mm), appearing
radiographically as smooth round discrete nodules (etched in white) that
carpeted the mucosa of the antrum or antrum and body (Figs.
1A,
2, and
3A). In all patients, a
variable number of nodules had central umbilications manifested by punctate
collections of barium seen en face in the lesions
(Fig. 3A).
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One patient had mildly enlarged (4 mm in diameter) areae gastricae in the gastric body. No other features of gastritis (including thickened folds, mucosal erosions, or luminal narrowing) and no ulcers or masses were detected in any of these patients.
Endoscopic and Histopathologic Findings
In all five patients, endoscopy revealed a nodular antral mucosa
(Fig. 1B), and endoscopic
biopsy specimens from the gastric antrum revealed lymphoid hyperplasia with
discrete follicles containing germinal centers (Figs.
1C and
3B). Protrusion of the mucosa
overlying these space-occupying follicles presumably accounted for the nodules
seen on double-contrast barium studies
(Fig. 3B). The biopsy specimens
also revealed histologic findings of chronic gastritis, which was graded as
moderate in four patients and mild in one. Stains for H. pylori
confirmed the presence of this organism with typical bacilli in three (60%) of
the five patients (Fig. 1D).
Endoscopic biopsy specimens revealed a focal area of intestinal metaplasia in
one patient, but none had eosinophils, granulomas, or tumor in the antrum.
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In several series, endoscopic biopsy specimens have revealed lymphoid hyperplasia in 53-100% of patients with H. pylori gastritis [6, 8]. Conversely, more than 90% of patients with lymphoid hyperplasia of the stomach are found to have H. pylori gastritis [2]. These data suggest that lymphoid hyperplasia of the stomach may serve as a potential marker for H. pylori gastritis even in the absence of other findings. In our study, we could document the presence of H. pylori in only three (60%) of five patients with lymphoid hyperplasia, possibly because of sampling errors in two patients [9]. Alternatively, the lymphoid aggregates in these two patients may have occurred as a response to other pathogens or environmental factors.
In a previous report in the radiology literature, a single case of lymphoid hyperplasia of the stomach was manifested on a double-contrast barium study by diffuse nodularity of the gastric antrum and fundus in a 7-year-old girl with H. pylori gastritis [5]. Before the discovery of H. pylori, two cases of gastric lymphoid hyperplasia were also reported in adults in whom graded-compression images from single-contrast barium studies revealed small umbilicated nodules in the stomach [10]. In our study, however, lymphoid hyperplasia of the stomach was characterized by distinctive findings on double-contrast upper gastrointestinal tract examinations in five adult patients; all five had innumerable tiny (1-3 mm in diameter) round frequently umbilicated nodules that carpeted the mucosa of the gastric antrum or antrum and body (Figs. 1A, 2, and 3A). The radiographic findings in patients with lymphoid hyperplasia of the stomach, therefore, are similar to those of lymphoid hyperplasia of the small bowel or colon.
The distal involvement of the stomach in our patients correlates with histopathologic data showing that these lymphoid follicles most commonly occur in the antrum [8]. Although one of our patients had enlarged areae gastricae, none had other radiographic findings associated with H. pylori gastritis, such as thickened gastric folds [11]. Thus, lymphoid hyperplasia may be detected as the only sign of H. pylori gastritis on double-contrast barium studies.
In the past, the failure to diagnose lymphoid hyperplasia of the stomach on double-contrast upper gastrointestinal tract examinations has probably been related to a lack of familiarity with this condition. However, we also believe that lymphoid hyperplasia can be shown on double-contrast images only when these lymphoid follicles are large enough to cause macroscopic protrusion of the overlying mucosa. As a result, this finding may be detected on barium studies only in patients with severe forms of lymphoid hyperplasia in the stomach.
Gastric MALT lymphoma is the major consideration in the differential diagnosis of a nodular antral mucosa in patients with H. pylori gastritis. In a previous study, gastric MALT lymphoma was manifested on double-contrast barium studies by multiple round variably sized (2-7 mm in diameter) often confluent nodules with poorly defined borders [1]. In contrast, the nodules of gastric lymphoid hyperplasia have more discrete borders, a more uniform size, and, not infrequently, central umbilications. Furthermore, MALT lymphoma may be associated with other radiographic findings, including malignant-appearing gastric ulcers, thickened lobulated folds, and polypoid mass lesions [1]. We, therefore, believe that it usually is possible to differentiate the nodules of lymphoid hyperplasia from those of gastric MALT lymphoma on the basis of the radiographic findings. This differentiation has important implications for treatment of patients, because low-grade gastric MALT lymphoma may undergo complete regression by eradicating H. pylori from the stomach with antibiotics and antisecretory agents [12], whereas untreated MALT lymphoma may progress to more high-grade forms of lymphoma [13]. If the radiographic findings are equivocal, endoscopic biopsy specimens should be obtained for a more definitive diagnosis.
Lymphoid hyperplasia of the stomach should also be distinguished from enlarged areae gastricae, another finding associated with H. pylori gastritis [11]. However, enlarged areae gastricae have a more polygonal or angulated configuration, producing a sharply marginated reticular network, and they do not contain central umbilications. Other unusual neoplastic lesions such as leukemic infiltrates or even polyposis syndromes involving the stomach may also be manifested on double-contrast studies by multiple small nodules, but the nodules tend to have a more variable size and a more sporadic distribution. Thus, it should also be possible to differentiate these conditions from lymphoid hyperplasia of the stomach on radiographic criteria.
In summary, lymphoid hyperplasia of the stomach is characterized by distinctive findings on double-contrast upper gastrointestinal tract examinations; all five of our patients had innumerable tiny (1-3 mm in diameter) round frequently umbilicated nodules that carpeted the mucosa of the gastric antrum or antrum and body. Three of these five patients had associated H. pylori gastritis. The diagnosis of gastric lymphoid hyperplasia, therefore, can be suggested on the basis of the radiographic findings.
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  S. E. Rubesin, M. S. Levine, and I. Laufer Double-Contrast Upper Gastrointestinal Radiography: A Pattern Approach for Diseases of the Stomach Radiology, January 1, 2008; 246(1): 33 - 48. [Abstract] [Full Text] [PDF]
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 M. S. Levine Invited Commentary RadioGraphics, November 1, 2001; 21(6): 1502 - 1504. [Full Text] [PDF]
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