Non-neoplastic Gastrointestinal Diseases: Surgical Pathology of Gastritis

Non-neoplastic Gastrointestinal Diseases: Surgical Pathology of Gastritis

Diagnosing gastritis among non-neoplastic gastrointestinal conditions presents challenges due to its diverse subtypes (chronic and acute). Precise diagnosis by a skilled pathologist is crucial for effective treatment decisions. Modern surgical pathology techniques enhance accuracy in diagnosing gastritis based on detailed knowledge of causes and symptoms.


Establishing a diagnosis of gastritis within non-neoplastic gastrointestinal conditions can pose significant challenges. Gastritis, the disease characterized by the inflammation of the gastric mucosa can be divided into two main subtypes – chronic and acute. These subtypes can further be divided into more subtypes. Accurate diagnosis paves the way for informed decisions and optimal treatment choices. So, if the diagnosis isn’t precisely set, the treatment cannot be successful. The best surgical pathologist knows the minutest of details including the causes, and the symptoms. It isn’t unusual to apply certain techniques in modern surgical pathology practice to set up the diagnosis more precisely. In this article, we will explore the intricacies involved in diagnosing gastritis, shedding light on the various types that patients may encounter.

Non-neoplastic Disorders of the Gastrointestinal Tract

The alimentary tract serves as a host to many diseases. When it comes to a non-neoplastic group of disorders, surgical pathology, and conventional histochemistry continue to play an important role in setting up the diagnosis. They are especially critical to specific infectious diseases such as Helicobacter gastritis, Whipple disease, intestinal tuberculosis, diverse forms of mycobacteriosis, and amebiasis.

Use of Histochemistry

In these cases, histochemistry is used in the characterization of structural gastrointestinal (GI) disorders. They include mucosal metaplasias, amyloidosis, glycogenic acanthosis of the esophagus, lymphocytic-collagenous colitis, gastric neuroendocrine hyperplasia, and pill gastritis. The diseases of the GI tract tend to involve the mucosa and submucosa of the gut preferentially and that represents an interface with the outside environment. Many enteric disorders have their origins in the contents of the gut lumen, such as microbes or toxins.

Pathogenic Organisms and Alimentary Tract Diseases

Certain organisms like Mycobacterium tuberculosis are consistently pathogenic. Others exist as components of the normal GI flora and only trigger disease in specific circumstances, such as when immune surveillance is compromised. Infections are the most common cause of alimentary tract disease internationally, other disorders in that system are caused by mucosal damage from ischemia or toxic injury.

Diagnosis of Gastritis

Gastritis can be defined as a group of diseases characterized by inflammation of the gastric mucosa. Surgical pathologists who evaluate a gastric biopsy for gastritis need to find the cause of gastritis because that will direct the therapeutic measures. If the biopsy shows chronic gastritis, you should pose the following questions:

  • Are there features of chronic gastritis present? If there is a lymphatic and plasmatic inflammatory reaction present, it indicates chronic gastritis.
  • Are there neutrophils in the mucosa? The presence of neutrophils can indicate active gastritis.
  • Is there Helicobacter?
  • Is there glandular atrophy present?
  • Is intestinal metaplasia present?
  • What is the topography of lesions (predominantly in the oxyntic mucosa of the body and fundus, predominantly in the antrum, or involving both locations)?
  • Are there special features such as granulomas, foveolar hyperplasia, or viral inclusions?
  • What ancillary studies are indicated, and what are the results?

Uncommon Forms of Gastric Injuries

In your routine clinical practice, you may encounter uncommon forms of gastritis and a wide range of gastric injuries. The most encountered rare forms of gastritis are lymphocytic and collagenous gastritis and graft versus host disease. In addition to these conditions, you may also come across less prevalent ailments including eosinophilic gastritis, granulomatous gastritis, focally enhanced gastritis, and certain types of hypertrophic gastropathy.

Types of Chronic Gastritis

Gastritis disease can be largely divided into two groups. These groups can further be divided into more subtypes. The two major groups are infectious and noninfectious gastritis which could be chronic or acute.

Infectious Gastritis

The most common cause of infectious gastritis is Helicobacter pylori. Other forms of infectious gastritis involve Helicobacter heilmannii (associated gastritis), and granulomatous gastritis associated with gastric infections in mycobacteriosis. There are also syphilis, histoplasmosis, mucormycosis, South American blastomycosis, anisakiasis or anisakiasis, chronic gastritis associated with parasitic infections, and viral infections like cytomegalovirus and herpesvirus infections.

Noninfectious Gastritis

Noninfectious gastritis is associated with autoimmune gastritis, reactive or chemical gastropathy usually related to chronic bile reflux or non-steroidal anti-inflammatory drug (NSAID) intake, and uremic gastropathy. It is also associated with noninfectious granulomatous gastritis, lymphocytic gastritis, including gastritis associated with celiac disease, eosinophilic gastritis, radiation injury to the stomach, graft-versus-host disease, ischemic gastritis, and gastritis secondary to chemotherapy. Many cases of gastritis are of undetermined cause and present as chronic, inactive gastritis with various degrees of severity.

Types of Acute Gastritis

Numerous forms of gastritis initially manifest as acute conditions, often progressing to chronic gastritis due to persistent injury or resulting complications. Acute gastritis is associated with long-term intake of aspirin and other NSAIDs and bile reflux into the stomach, excessive alcohol consumption, heavy smoking, cancer chemotherapeutic drugs and radiation, acids, and alkali in suicide attempts, uremia, severe stress, ischemia and shock, systemic infections, mechanical trauma, such as intubation associated mucosal lesions, and viral infections. The various types of acute gastritis are:

Helicobacter Pylori-associated Chronic Gastritis

Helicobacter (H) pylori infection is associated with the histologic pattern of active and chronic gastriti, and reflects the presence of neutrophils and mononuclear cells in the mucosa. It can manifest as pangastritis involving the area from the pylorus to the gastric body and cardio, or it may predominantly involve the antrum. When large numbers of H pylori are present in the mucosa, the identification of typical organisms is generally possible on H&E stains.

Crohn's Disease-associated Gastritis

The characteristic features of Crohn’s disease-associated gastritis are the presence of patchy, acute inflammation with possible gastric pit or glandular abscesses, commonly with a background with lymphoid aggregates. One of the studies showed the presence of gastritis in patients with Crohn’s disease as a focally enhanced gastritis, characterized by a small collection of lymphocytes and histiocytes surrounding a small group of gastric foveolae or glands, often with infiltrates of neutrophils. In severe cases, there can be an inflammation of lamina propria.

Atrophic Gastritis

Interobserver variability is significant, especially in the evaluation of antral atrophy. If there is an H pylori gastritis, the infection should be eradicated before atrophy is evaluated. When marked inflammation is present, a diagnosis for indefinite atrophy may be offered, especially if there is no intestinal metaplasia.

Autoimmune Atrophic Gastritis

This is caused by antiparietal cells and anti-intrinsic factor antibodies and presents as a chronic gastritis with oxyntic cell injury, and glandular atrophy that is essentially restricted to the oxyntic mucosa of the gastric body and fundus. This is a relatively rare disease but represents the most frequent cause of pernicious anemia in temperate climates. Patients with pernicious anemia were reported to have at least a 2.9 times higher risk of developing gastric adenocarcinoma.

Lymphocytic Gastritis

It is characterized by marked infiltration of the gastric surface and foveolar epithelium by T lymphocytes and by chronic inflammation in the lamina propria. A diagnosis can be rendered when 30 or more lymphocytes per 100 consecutive epithelial cells are observed. Although this disease can occur in children, it typically becomes apparent during late adulthood, with an average age of diagnosis around 50 years.

Chronic, Reactive (Chemical) Gastropathy

This disease is highly prevalent in modern clinical practice. The mucosal changes are usually more prominent in the prepyloric region, but they can also extend to involve the oxyntic mucosa. The usual causes involve chronic bile reflux and long-term NSAID intake. This type of gastritis is usually found in patients with partial gastrectomy.

Cytomegalovirus Gastritis

Patients with compromised immune systems commonly exhibit this stomach infection. Characteristic features of this condition include intranuclear eosinophilic inclusions and smaller intracytoplasmic inclusions within enlarged cells. Viral inclusions can be seen in the gastric epithelial cells. Severe activity may lead to mucosal ulceration.

Ask Questions to Understand the Biopsies

Gastritis is one of the most common non-neoplastic gastrointestinal diseases. Often, a limited list of questions can be helpful for you to evaluate the histopathology of gastric biopsies. That can lead to a pattern of answers that correspond to a specific diagnosis of the most common types of gastritis. If the biopsy site is unfamiliar, immunohistochemical stains for synaptophysin and gastrin can help determine the biopsy location, permitting a specific diagnosis of atrophic gastritis type.


Gastritis disease is one of the most common non-neoplastic gastrointestinal diseases. The surgical pathology of gastrointestinal diseases often includes setting up the diagnosis with H&E stains. Gastritis encompasses various types characterized by distinct symptoms and diverse underlying causes. Accurate diagnosis holds paramount significance in the field of surgical pathology when dealing with gastritis. A well-established diagnosis not only facilitates informed decision-making regarding subsequent treatment but also enhances the overall effectiveness and success of the treatment itself.  When establishing an accurate diagnosis of gastritis, the utilization of “additional” information, such as detailed knowledge of the case can greatly streamline the workflow and expedite the attainment of results with improved efficiency. The utilization of appropriate technical solutions, such as PreciPoint’s digital equipment and software, holds immense significance, as it ensures the delivery of high-quality treatment by employing top-notch equipment and technology.