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Gastric Intestinal Metaplasia by Craig E. Litz, M.D.
Gastric Intestinal Metaplasia by Craig E. Litz, M.D.
Gastric intestinal (goblet cell) metaplasia (GIM), originally described in the 19th century, is defined as the presence of intestinal type cells in the gastric mucosa.1 This definition specifically excludes intestinal metaplasia of columnar epithelium in the esophagus (Barrett’s esophagus). Normally, the gastric mucosal epithelium is composed of 5 cell types: mucous neck and columnar cells which are
Fig. 1 – Normal gastric body mucosa showing mucous cells (black arrow),
mucous neck cells (white arrow), basophilic chief cells (blue arrow) and
eosinophilic parietal cells (red arrow). Hematoxylin and Eosin (H and E), 100X.
located throughout the stomach; and parietal, chief, and endocrine cells which are found in the fundus and body (fig.1). GIM is a relatively common abnormality that usually occurs in the setting of chronic inflammation and is distinguished by the presence of goblet cells, cells in which the cytoplasmic membrane and nucleus are distorted by large vacuoles of acidic (intestinal) mucin on hematoxylin and eosin stained sections (fig. 2A, black arrow).1 Goblet cells may be confirmed by Alcian Blue/PAS cytochemical stains. The Alcian Blue stains the acid mucin of goblet cells blue while the PAS stains all mucin red (fig. 2B, black and white arrows, respectively). GIM typically begins at the junction of the gastric antrum and corpus as foci that may appear endoscopically as small nodules. These foci eventually fuse and extend distally to involve the entire antrum and proximally to involve the entire lesser curvature. It may also extend in finger-like processes to the proximal oxyntic mucosa on the anterior and posterior walls of the gastric body. In contrast, GIM associated with pernicious anemia is limited to the oxyntic mucosa and spares the antrum.2 Several investigators have proposed the concept of "complete" and "incomplete"
Fig. 2A and 2B – Gastric mucosa showing goblet cell (intestinal) metaplasia
stained with H and E (A) and Alcian Blue/PAS (B). Goblet cells (black
arrows) show clear cytoplasmic vacuole that displaces the nucleus on H and E
(Panel A) and stains blue with Alcian Blue/PAS (Panel B). Gastric mucous cells
are identified in both stain preparations by the white arrows. 100X.
gastric intestinal metaplasia.3,5 Completely metaplastic epithelium is composed of intestinal goblet and absorptive cells; incomplete metaplasia consists of a mixture of goblet cells and mucin secreting gastric cells. Further subclassification has been proposed based on whether the mucin produced in the metaplastic epithelium is colonic (sulfomucin; type III) or small bowel (sialomucin) in nature and whether there is glandular distortion accompanying the metaplasia.5 Unfortunately, criteria for classifying intestinal metaplasia have been confusing and sometimes vague not allowing practical application. No consensus exists regarding the diagnostic reproducibility of the various subclasses of gastric intestinal metaplasia.1,6,7
As a result, the clinical significance of gastric intestinal metaplasia in biopsy material is debated. It is generally agreed that:
1) Intestinal metaplasia is a common finding in biopsy material. In one large study, 244 of 1041 (23%) endoscopic biopsy specimens contained intestinal metaplasia of one type or the other.5
In summary, while patients with extensive GIM show an increased risk for gastric carcinoma, the value of subtyping GIM in assigning carcinoma risk in any given patient awaits better designed prospective studies with easily applied, reproducible criteria for pathologists.
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