Helicobacter pylori Gastritis Presenting as an Umbilicated Polypoidal Lesion

Keywords

dyspepsia - gastritis - Helicobacter pylori - umbilicated nodule

Introduction

Helicobacter pylori infection is a common cause of dyspepsia. Endoscopic findings suggestive of H. pylori infection include mucosal atrophy, diffuse redness, spotty redness, mucosal swelling, ulcerations, and nodularity. Chronic H. pylori infection can lead to lymphoid hyperplasia of the stomach, which is a benign condition characterized histologically by an increase in the size and number of lymphoid follicles. It appears endoscopically as a nodule or rarely as an umbilicated polypoid lesion. We report a case of dyspepsia who presented with epigastric pain and post-prandial abdominal fullness that did not respond to proton-pump inhibitors (PPIs). Gastroscopy revealed an umbilicated polypoidal lesion in the antrum, which turned out to be H. pylori-associated chronic active gastritis.

Case Details

A 42-years-old gentleman with no known comorbidities presented with epigastric pain and post-prandial abdominal fullness for 1 year. He did not have any red flag signs. There was history of taking over-the-counter PPIs on and off with symptomatic improvement. He was hemodynamically stable at the time of examination and his physical examination was unremarkable. Routine blood investigations including complete blood counts, liver function tests, renal function test, thyroid profile, and glycated hemoglobin were normal. Stool H. pylori antigen test was negative. He underwent gastroscopy, which revealed a 1.5 cm × 1 cm elevated umbilicated lesion, with a central depression in the antrum close to the pylorus ([Fig. 1]) along with mild antral and body hyperemia with regular arrangement of collecting venules in the body and fundus. Possibilities of subepithelial lesion with central depression or pancreatic rest were kept in mind. Biopsy was taken from the depressed area of the lesion. Histopathology of the biopsy specimen showed moderate to marked chronic active gastritis with numerous H. pylori ([Fig. 2]). He was treated with clarithromycin-based triple therapy. Repeat gastroscopy after 8 weeks showed near disappearance of the antral lesion ([Fig. 3]).

Fig. 1 Umbilicated antral lesion at index endoscopy.

Fig. 2 Hematoxylin and eosin (H&E) section showing moderate to marked chronic active gastritis with numerous H. pylori (high power).

Fig. 3 Follow-up endoscopy after triple regimen therapy.

Discussion

Dyspepsia is a constellation of symptoms referable to the gastroduodenal region of the upper gastrointestinal tract. It includes pain or burning in the epigastrium, early satiety, and fullness during or after a meal.[1] Nonresponding dyspepsia is the most common indication for gastroscopy in real-world practice. Most common endoscopic finding in patients presenting with dyspepsia are gastritis and esophagitis.[2] Dyspeptic individuals are more likely to be H. pylori seropositive than asymptomatic individuals.[3] About 50% of the world's population is a carrier of H. pylori.[4] In developing countries, as many as 80% residents carry H. pylori in their gastric mucosa but only around 10 to 20% of infected individuals become symptomatic. The most common symptom of H. pylori infection is dyspepsia.[5] The prevalence of H. pylori infection in adult dyspeptic patients in India has been reported as 32.9%.[6] Common endoscopic features suggestive of H. pylori infection includes sticky mucus, mucosal atrophy, diffuse redness, spotty redness, mucosal swelling, and nodularity.[7] Chronic H. pylori infection of gastric mucosa leads to lymphoid hyperplasia with discrete follicles containing germinal centers and they appear endoscopically as nodules. Sometimes, this lymphoid hyperplasia can present as umbilicated polypoid lesions.[8] Most common differentials for umbilicated lesions in the stomach are pancreatic rests, neuroendocrine tumours (NETs), ulcerated gastrointestinal stromal tumor, or lymphoma.

In our patient, we initially thought that the elevated umbilicated lesion could be a neuroendocrine tumor or a pancreatic rest. However, histopathology sprung a surprise and it turned out to be chronic active H. pylori gastritis, which responded well to H. pylori triple therapy regimen.

• References

• 1 Talley NJ, Ford AC. Functional dyspepsia. N Engl J Med 2015; 373 (19) 1853-1863
• 2 Srinivas Y, Prasad PK, Sai ND. Prevalence and impact of Helicobacter pylori in dyspepsia. Int Surg J 2016; 3 (01) 305-309
• 3 Aminde JA, Dedino GA, Ngwasiri CA, Ombaku KS, Mahop Makon CA, Aminde LN. Helicobacter pylori infection among patients presenting with dyspepsia at a primary care setting in Cameroon: seroprevalence, five-year trend and predictors. BMC Infect Dis 2019; 19 (01) 30
• 4 Oki S, Takeda T, Hojo M. et al. Comparative study of Helicobacter pylori-infected gastritis in Okinawa and Tokyo based on the Kyoto classification of gastritis. J Clin Med 2022; 11 (19) 5739
• 5 Tanni NN, Ahmed S, Anwar S. et al. Endoscopic and histopathological findings in adult dyspeptic patients, and their association with Helicobacter pylori infection in Dhaka, Bangladesh. IJID Reg 2021; 2: 30-34
• 6 Badi A, Naushad VA, Purayil NK. et al. Endoscopic findings in patients with uninvestigated dyspepsia: a retrospective study from Qatar. Cureus 2020; 12 (10) e11166
• 7 Zhao J, Xu S, Gao Y. et al. Accuracy of endoscopic diagnosis of Helicobacter pylori based on the Kyoto classification of gastritis: a multicenter study. Front Oncol 2020; 10: 599218
• 8 Bahk YW, Ahn JS, Choi HJ. Lymphoid hyperplasia of the stomach presenting as umbilicated polypoid lesions. Report of two cases. Radiology 1971; 100 (02) 277-280