A 55-year-old man was referred to our general gastroenterology clinic by colleagues from the renal transplant unit for evaluation of persistent epigastric abdominal pain and nausea that had been present for the past 6 months and had started to interfere with his quality of life.
The patient’s past medical history included allogeneic renal transplantation 3 years prior, secondary to progressive hypertensive kidney disease. His current immunosuppression regimen was mycophenolate mofetil, cyclosporine, everolimus and steroids, while his hypertension was being controlled with nebivolol. The only other drug taken on a regular basis was oral iron supplementation to manage mild hypochromic anaemia. His symptoms had failed to resolve with a proton pump inhibitor (PPI) trial administered by a gastroenterologist in private practice. He had also undergone noninvasive testing (urea breath test) for the presence of Helicobacter pyloriinfection, with the result being negative. He denied weight loss, vomiting, changes in bowel habit, fever or any other accompanying symptoms in the same time period as his main complaints. No significant information was elicited from his family or regarding his social history (including travels and sexual behaviour).
Physical examination findings were unremarkable. The patient had recently undergone blood tests that revealed no significant changes from his previous baseline values. In view of the above symptoms and history an upper gastrointestinal endoscopy was scheduled and performed. The endoscopic findings included erythema with small erosions of the gastric mucosa. Multiple biopsy samples were obtained from areas with findings and also from macroscopically normal mucosa. Histological findings are shown in figure 1.
Figure 1 | Histological findings in the stomach of the case patient. Haematoxylin and eosin (H&E) staining. Magnification x400.
Case Question 1
WHAT IS THE HISTOLOGICAL DIAGNOSIS?
A. MALT lymphoma
B. H. pylori-associated chronic gastritis
C. Granulomatous gastritis
D. Gastric adenocarcinoma
E. Collagenous gastritis
Case Question 2
IN VIEW OF THE PAST HISTORY OF THIS PATIENT, WHAT WAS THE UNDERLYING CAUSE OF THE SYMPTOMS OBSERVED?
B. Granulomatosis with polyangiitis
C. Crohn’s disease
F. A drug-induced reaction
G. Helicobacter pyloriinfection
H. Whipple’s disease
Case Question 3
HOW SHOULD WE PROCEED REGARDING THE MANAGEMENT OF THIS PATIENT?
A. Acid suppression with PPIs
B. Investigate other possible causes
C. Stop iron supplementation and take repeat biopsy samples
D. Stop iron supplementation and investigate other possible causes