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doi:10.1111/jgh.12896
E D U C AT I O N A N D I M A G I N G
Gastrointestinal: Endoscopic findings of collagenous gastroenterocolitis with protein-losing enteropathy
Figure 2 Esophagogastroduodenoscopy with indigo carmine dye spraying reveals nodular mucosa of the gastric antrum (a) and multiple short and linear scratches along the transverse axis in the gastric body (b). Balloon-assisted endoscopy reveals multiple erosions in the jejunum (c) and in the ileum (d).
Figure 1 Colonoscopy reveals distorted hypervascularity throughout colon (a). Histological examination of the biopsy from colon shows a thickened subepithelial collagen band and inflammatory infiltrate in the lamina propria (H&E; original magnification x 200) (b).
An 88-year-old Japanese woman visited our hospital in May 2012, with a complaint of water diarrhea for a duration of 3 months and edema of the lower extremities. She had a prior history of gastroduodenal ulcers, which was managed by Helicobacter pylori eradication therapy in February 2011. Physical examination revealed no abnormalities except for edema of the lower extremities. Abnormal laboratory test results were as follows: total serum proteins, 4.5 g/dl (normal, 6.5–8.0); serum albumin, 1.3 g/dl (normal, 3.8–5.1); leukocyte counts, 10310 /μl (normal, 3040–9640); hemoglobin levels, 10.6 g/dl (normal, 10.8–14.9); C-reactive protein, 6.21 mg/dl (normal, 0.10–0.18). Both serum IgG antibody to H. pylori and stool culture were negative. Colonoscopy revealed minimally distorted hypervascularity throughout the colon except for the sigmoid colon and the rectum (Fig. 1a). Histological examination of the multiple biopsy specimens from colonic mucosa except for sigmoid colon and rectum revealed a thickened subepithelial collagen band and inflammatory infiltrate in the lamina propria (Fig. 1b). Esophagogastroduodenoscopy using indigo-carmine dye spraying clearly revealed nodular mucosa of the gastric antrum (Fig. 2a) and multiple short and linear scratches along the transverse axis in the gastric body (Fig. 2b). Endoscopic images of the esophagus
and the duodenum were normal. Balloon-assisted endoscopy revealed multiple erosions with normal intervening mucosa in the jejunum (Fig. 2c) and in the ileum (Fig. 2d). Histology of the multiple biopsies obtained from the stomach, the duodenum, the jejunum, and the ileum confirmed collagen band in the subepithelial layer. Her serum was negative for antibodies to antiendomysial and anti-tissue transglutaminase. n technetium-99m human serum albumin scintigraphy, protein leakage into the gastrointestinal tract was verified. Furthermore, alpha-1 antitrypsin test showed that the clearance was 22.1 mL/day (normal, ≤13). Based on these findings, we diagnosed the patient as collagenous gastroenterocolitis with protein-losing enteropathy. We treated the patient by oral prednisolone with an initial dose of 50 mg/day. The medication resulted in prompt resolution of diarrhea and edema. We subsequently tapered the dose to 10 mg/day without any exacerbation of diarrhea and edema. Although there have been cases of collagenous gastroenterocolitis reported in the literature, the endoscopic findings have been scarcely documented. In those cases, erythema and petechiae in the stomach, erythema in the duodenum, and increased vascularity, edema, and erythema in the colon have been observed. Our case suggests that less severe endoscopic findings such as scratches in the stomach and erosions in the small bowel may be characteristic of collagenous gastroenterocolitis. Contributed by S Kochi,* K Kurahara,* T Matsumoto,† K Kawasaki,* Y Oshiro,‡ M Tokumoto,* A Saka* and T Fuchigami* Divisions of *Gastroenterology and ‡Pathology, Matsuyama Red Cross Hospital, Ehime, and †Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Journal of Gastroenterology and Hepatology 30 (2015) 967 © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
967
doi:10.1111/jgh.12896
E D U C AT I O N A N D I M A G I N G
Gastrointestinal: Endoscopic findings of collagenous gastroenterocolitis with protein-losing enteropathy
Figure 2 Esophagogastroduodenoscopy with indigo carmine dye spraying reveals nodular mucosa of the gastric antrum (a) and multiple short and linear scratches along the transverse axis in the gastric body (b). Balloon-assisted endoscopy reveals multiple erosions in the jejunum (c) and in the ileum (d).
Figure 1 Colonoscopy reveals distorted hypervascularity throughout colon (a). Histological examination of the biopsy from colon shows a thickened subepithelial collagen band and inflammatory infiltrate in the lamina propria (H&E; original magnification x 200) (b).
An 88-year-old Japanese woman visited our hospital in May 2012, with a complaint of water diarrhea for a duration of 3 months and edema of the lower extremities. She had a prior history of gastroduodenal ulcers, which was managed by Helicobacter pylori eradication therapy in February 2011. Physical examination revealed no abnormalities except for edema of the lower extremities. Abnormal laboratory test results were as follows: total serum proteins, 4.5 g/dl (normal, 6.5–8.0); serum albumin, 1.3 g/dl (normal, 3.8–5.1); leukocyte counts, 10310 /μl (normal, 3040–9640); hemoglobin levels, 10.6 g/dl (normal, 10.8–14.9); C-reactive protein, 6.21 mg/dl (normal, 0.10–0.18). Both serum IgG antibody to H. pylori and stool culture were negative. Colonoscopy revealed minimally distorted hypervascularity throughout the colon except for the sigmoid colon and the rectum (Fig. 1a). Histological examination of the multiple biopsy specimens from colonic mucosa except for sigmoid colon and rectum revealed a thickened subepithelial collagen band and inflammatory infiltrate in the lamina propria (Fig. 1b). Esophagogastroduodenoscopy using indigo-carmine dye spraying clearly revealed nodular mucosa of the gastric antrum (Fig. 2a) and multiple short and linear scratches along the transverse axis in the gastric body (Fig. 2b). Endoscopic images of the esophagus
and the duodenum were normal. Balloon-assisted endoscopy revealed multiple erosions with normal intervening mucosa in the jejunum (Fig. 2c) and in the ileum (Fig. 2d). Histology of the multiple biopsies obtained from the stomach, the duodenum, the jejunum, and the ileum confirmed collagen band in the subepithelial layer. Her serum was negative for antibodies to antiendomysial and anti-tissue transglutaminase. n technetium-99m human serum albumin scintigraphy, protein leakage into the gastrointestinal tract was verified. Furthermore, alpha-1 antitrypsin test showed that the clearance was 22.1 mL/day (normal, ≤13). Based on these findings, we diagnosed the patient as collagenous gastroenterocolitis with protein-losing enteropathy. We treated the patient by oral prednisolone with an initial dose of 50 mg/day. The medication resulted in prompt resolution of diarrhea and edema. We subsequently tapered the dose to 10 mg/day without any exacerbation of diarrhea and edema. Although there have been cases of collagenous gastroenterocolitis reported in the literature, the endoscopic findings have been scarcely documented. In those cases, erythema and petechiae in the stomach, erythema in the duodenum, and increased vascularity, edema, and erythema in the colon have been observed. Our case suggests that less severe endoscopic findings such as scratches in the stomach and erosions in the small bowel may be characteristic of collagenous gastroenterocolitis. Contributed by S Kochi,* K Kurahara,* T Matsumoto,† K Kawasaki,* Y Oshiro,‡ M Tokumoto,* A Saka* and T Fuchigami* Divisions of *Gastroenterology and ‡Pathology, Matsuyama Red Cross Hospital, Ehime, and †Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Journal of Gastroenterology and Hepatology 30 (2015) 967 © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
967
