carditis

Definition: Inflammation in proximal stomach immediately distal to anatomic GE junction; Generally refers to inflammation in proximal stomach immediately distal to anatomic gastroesophageal (GE) junction.

Etiology

 Helicobacter pylori
 Gastroesophageal reflux disease (GERD)

• Role of GERD in carditis is controversial
• Cardia-type mucosa at GE junction in GERD patients is likely to be esophageal in location

 Autoimmune gastritis
 Varices
 gastric antral vascular ectasia

Site

 Definition of "cardia" is controversial. Generally regarded as area ≤ 1.0 cm immediately distal to GE junction

Presentation

 Depends on etiology
 Dyspepsia in carditis related to H. pylori

Macroscopy

 Carditis related to H. pylori truly gastric in location
 GERD-related carditis likely to be metaplastic epithelium in distal esophagus

 Cardia

• Endoscopic definition: Gastric mucosa immediately distal to anatomic GE junction
• Pathologic definition: Columnar mucosa with mucus glands (cardia) or mucus glands with admixed parietal cells (oxyntocardia)

Microscopy

 Predominantly lymphoplasmacytic infiltration of lamina propria
 Neutrophilic infiltration in H. pylori-related cases
 Erosion, ulcer, or intestinal metaplasia may be present
 Cases with intestinal metaplasia need to be distinguished from Barrett esophagus
 Inflammation

• Lymphoplasmacytic infiltration of lamina propria
• Neutrophilic infiltration in H. pylori-related cases
• Variable eosinophils

 Erosion
 Ulcer
 Active esophagitis in adjacent squamous epithelium suggests GERD as likely etiology
 Intestinal metaplasia

• Represents metaplastic response to chronic inflammation
• Coexistent antral intestinal metaplasia in patients with H. pylori-associated carditis
• Intestinal metaplasia at GEJ in GERD patients more likely to be ultrashort Barrett esophagus

 Endocrine cell hyperplasia in autoimmune gastritis-related cases (AMAG)

Differential diagnosis

 Ultrashort Segment Barrett Esophagus (BE)

• Needs to be distinguished from carditis with intestinal metaplasia (CIM)
• Clinically important distinction
• Carditis with intestinal metaplasia is H. pylori related and does not substantially increase risk of subsequent dysplasia or cancer
• Risk of dysplasia and cancer increased in BE patients; periodic endoscopic surveillance and biopsy are indicated
• Correlation with site of biopsy important in distinguishing BE from CIM
• Several morphological features favor diagnosis of BE
  • Presence of esophageal glands or ducts
  • Multilayered epithelium
  • Diffuse intestinal metaplasia
  • Metaplastic crypts buried underneath squamous mucosa

 Morphologic findings need to be correlated with site of biopsy
 Cardia-type mucosa may be associated with H. pylori infection and gastric location
 Similar mucosa in GERD patients represents columnar metaplasia of distal esophagus

Treatment

 Depends on underlying etiology

• Antibiotic therapy for H. pylori carditis patients
• Proton pump inhibitor therapy in GERD patients

References

 Cestari R et al: The pathology of gastric cardia: a prospective, endoscopic, and morphologic study. Am J Surg Pathol. 31(5):706-10, 2007

 Srivastava A et al: Morphologic features are useful in distinguishing Barrett esophagus from carditis with intestinal metaplasia. Am J Surg Pathol. 31(11):1733-41, 2007

 Gulmann C et al: ’Cardiac-type’ (mucinous) mucosa and carditis are both associated with Helicobacter pylori-related gastritis. Eur J Gastroenterol Hepatol. 16(1):69-74, 2004

 Zentilin P et al: Carditis in patients with gastro-oesophageal reflux disease: results of a controlled study based on both endoscopy and 24-h oesophageal pH monitoring. Aliment Pharmacol Ther. 19(12):1285-92, 2004

 Wieczorek TJ et al: Pathologic features of reflux and Helicobacter pylori-associated carditis: a comparative study. Am J Surg Pathol. 27(7):960-8, 2003

 Goldblum JR et al: Helicobacter pylori infection, not gastroesophageal reflux, is the major cause of inflammation and intestinal metaplasia of gastric cardiac mucosa. Am J Gastroenterol. 97(2):302-11, 2002

 Der R et al: Carditis: a manifestation of gastroesophageal reflux disease. Am J Surg Pathol. 25(2):245-52, 2001

 Sharma P et al: Helicobacter pylori eradication dramatically improves inflammation in the gastric cardia. Am J Gastroenterol. 95(11):3107-11, 2000