Article pp.283-292 du Vol.17 n°5 (1987)

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Evaluation histologique de la pr6sence d'organismes de type Campylobacter dans les gastrites lymphocytaires

L. W A L L E Z , B. W E Y N A N D , J. H A O T

C l i n i q u e s U n i v e r s i t a i r e s S a i n t - L u c U n i v e r s i t ~ C a t h o l i q u e d e L o u v a i n , 1 2 0 0 B r u x e l l e s ( B e l g i q u e )

Histological evaluation for the determination of Campylobacter Type organisms in lymphocytic gastritis

RI~SUMI~

Nous avons recherch6 de mani6re comparative la pr6sence de Campylobacters dans deux s6ries biopsiques r6trospectives comportant chacune 116 observations. La technique utilis6e a 6t6 purement histologique et a comport6 les colorations H.E.S. et argentique de Warthin-Starry. En ce qui concerne la gastrite chronique superficieile et atrophique, nos r6sultats sont similaires ~t ceux de la litt6rature. Dans le cas de la gastrite lymphocytaire, !a pr6sence du Campylobacter est exceptionnelle. Cette 6tude apporte un argument suppl6mentaire en faveur de l'existence de la gastrite lymphocytaire comme entit6 particuli6re.

S U M M A R Y

Two series of retrospective biopsies, each made up of 116 observations, were examined comparatively for the presence of Campylobacter. A purely histological technique was used, utilizing H E S and Warthin-Starry silver stains. For atrophic and superficial chronic gastritis, our results were similar to those described in the literature. In lymphocytic gastritis, the presence of Campylobacter was exceptional. This study corroborates the existence of lymphocytic gastritis as a distinct entity.

I N T R O D U C T I O N

D a n s des p u b l i c a t i o n s r6centes, nous avons d6crit sous le n o m de gastrite h l y m p h o c y t e s une nouvelle entit6 h i s t o p a t h o l o g i q u e caract6ris6e p a r une infiltration l y m p h o c y t a i r e m a r q u 6 e de l'6pith6- lium gastrique [3]. Sa p r 6 s e n t a t i o n e n d o s c o p i q u e et clinique la diff6rencie de la gastrite chronique classique. Elle atteint p r 6 f 6 r e n t i e l l e m e n t la r6gion f u n d i q u e et se m a n i f e s t e p a r trois types de 16sions 616mentaires s o u v e n t associ6es : gros plis 6paissis, n o d u l e s 6rod6s o u n o n , 6rosions planes. D ' u n point de vue clinique, elle p e u t offrir un t a b l e a u de d 6 g r a d a t i o n de l'6tat g6n6ral ofa l ' a n o r e x i e se c o m b i n e tr6s s o u v e n t ~ u n e p e r t e de poids i m p o r - t a n t e et plus r a r e m e n t ~ des ~ed6mes [1, 4-6].

C o m p t e t e n u de l ' i m p o r t a n c e accord6e actuelle- m e n t au C a m p y l o b a c t e r P y l o r i en pathologie gastrique, nous a v o n s conqu le p r 6 s e n t travail dans le but d ' e n 6valuer la p r 6 s e n c e d a n s la gastrite l y m p h o c y t e s .

M A T E R I E L E T M E T H O D E

L e s gastrites h l y m p h o c y t e s , au n o m b r e de 116, o n t 6t6 tir6es au sort dans u n e s6rie de pr6s de 400 o b s e r v a t i o n s diagnostiqu6es au Service d ' A n a - t o m i e P a t h o l o g i q u e des Cliniques U n i v e r s i t a i r e s St L u c e n t r e 1982 et 1986.

C e t y p e de s61ection i m p l i q u e q u e plusieurs o b s e r v a t i o n s puissent p r o v e n i r du m 6 m e p a t i e n t (102 p a t i e n t s p o u r 116 o b s e r v a t i o n s ) . 62 o b s e r v a - tions sont masculines (53 % ) et 54 f6minines (47 % ) .

L a b a s e diagnostique de la gastrite h l y m p h o - cytes est pr6cis6e p a r un c o m p t a g e du n o m b r e de l y m p h o c y t e s intra6pith61iaux de l'6pith61ium de s u r f a c e p a r r a p p o r t aux cellules 6pith61iales qui doit d o n n e r u n e v a l e u r ~>h 30/100, en consid6rant les z o n e s oO ces cellules sont les plus n o m b r e u s e s . P o u r c h a q u e o b s e r v a t i o n , le diagnostic a 6t6 pos6 Tir6s ~i part: Pr J. HAOT, Service d'Anatomie Pathologi-

que, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Bruxelles (Belgique).

Mots cl~s : gastrite lymphocytaire, gastrite varioliforme, Cam- pylobacter Pylori.

Key-words : Campylobacter pylori, lymphocytic gastritis, varioliform gastritis.

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sans aucune discordance entre deux pathologistes examinant les pr6parations de mani~re ind6pen- dante.

Une s6rie t6moin issue du fichier des r6sultats est constitu6e d'observations de gastrites chroniques qualifi6es de mod6r6es ou s6v~res selon la classification de Whitehead [11]. Ces observations sont appari6es h chaque cas de gastrite h lymphocytes (elles suivent ce dernier dans l'ordre s6quen- tiel d'inscription au laboratoire). Les 116 observations proviennent de 116 patients diff6rents. 69 observations sont masculines (59 %) et 47 f6mi- nines ( 4 1 % ) .

Pour chaque observation, nous disposions d'une ou plusieurs biopsies fundiques ou antrales et 6ventuellement de pr616vements bulbaires compl6- mentaires.

Dans la s6rie des gastrites h lymphocytes, pour un total de 567 fragments d'origine gastrique, 386 (68 %) sont de type fundique (187 masculins et 199 f6minins), correspondant ~ 98 observations dont 52 masculines et 46 f6minines, et 181 fragments (32 %) de type antral (120 masculins et 61 f6minins), correspondant h 64 observations dont 36 masculines et 28 f6minines. 57 fragments sont bulbaires (35 masculins et 22 f6minins), pour 29 observations dont 19 masculines et 10 f6minines (Tableau I).

Les fragments biopsiques ont 6t6 fix6s au liquide de Bouin et inclus en paraffine. Les coupes histologiques, de 5 ~m d'6paisseur, ont 6t6 color6es I'H.E.S. et selon la m6thode de Warthin-Starry [10]. Elles ont 6t6 examin6es de mani~re ind6pen- dante par deux pathologistes ne disposant d'aucun renseignement endoscopique ou clinique. Ces der- niers ont recherch6 les Campylobacters en micro- scopie optique conventionnelle en utilisant l'objectif 40 x ~t sec. Ils ont eu recours ~t l'objectif l'immersion d'huile (100 x) pour identifier les germes avec certitude ou lorsque l'examen h plus faible grossissement se r6v61ait n6gatif.

RESUL TATS Probl#mes m~thodologiques Diagnostic des Campylobacters

Les Campylobacters sont des bact6ries spiral6es de quelques ixm de grand axe colorables par l'h6- matoxyline et par l'argent que l'on trouve accol6es au glycocalix des cellules gastriques. Ils apparais- sent en bleu grisgLtre (sale) ~ I'H.E.S. (Figure 1).

TABLEAU I

N O M B R E D ' O B S E R V A T I O N S E T D E F R A G M E N T S BIOPSII~S

Nombre d'observations..

N0mbre d'obs, fundus ..

N0mbre d'obs, antre . . . Nombre d'obs, bulbe . . . Nombre de fragments est0mac

Nombre de fragments fundus

Nombre de fragments antre

Nombre de fragments bulbe

Gastrites lymphocytaires

Total H F

116 62 54

98 52 46

64 36 28

29 19 10

567 307 260

386 187 199

181 120 61

57 35 22

Gastrites t6moins

Total H F

116 69 47

55 31 24

82 54 28

30 19 11

360 217 143

123 63 60

237 154 83

61 40 21

Dans les gastrites t6moins, pour un total de 360 fragments d'origine gastrique, 123 (34 %) sont de type fundique (63 masculins et 60 f6minins), correspondant ~ 55 observations dont 31 masculines et 24 f6minines, et 237 fragments (66 %) de type antral (154 masculins et 83 f6minins), correspondant a 82 observations dont 54 masculines et 28 f6minines. 61 fragments sont bulbaires (40 masculins et 21 f6minins),pour 30 observations dont 19 masculines et 11 f6minines (Tableau I).

Figure 1

De nombreux microorganismes sont visibles a la surface des cellules cryptiques. H.E.S. Immersion. 1 000 x .

Many microorganisms are visible at the surface of pit cells. HES stain.

Oil immersion. 1000 x .

284 V o l u m e 1 7 - N ~ 5 - 1 9 8 7 A c t a E n d o s c o p i c a

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La m6thode argentique de W.S. les r6v~le mieux (Figure 2) ; la pr6cipitation d'argent ~ leur surface les fait apparaitre plus gros et fait ressortir leur forme caract6ristique. D'autre part, leur coloration d'un noir profond tranche mieux sur le fond jau- n~tre de la pr6paration.

Gastrites ~ lymphocytes

L'g~ge des patients varie de 25 h 95 ans, l'age moyen 6tant de 54 ans. On compte 58 hommes (57 %, hge moyen de 53 ans) et 44 femmes (43 %, gLge moyen de 56 ans), soit un sex ratio de 1,32 (Tableau II).

TABLEAU II DONNI~ES GENt~RALES

Nombre de patients Ages extr6mes Age moyen Hommes (%) Age moyen Femmes (%) Age moyen Sex ratio

Gastrites Gastrites

lymphocytaires t6moins 102

25-95 ans 54 ans 58 (57) 53 ans 44 (43) 56 ans 1,32

116 23-86 ans

56 ans 69 (59) 56 ans 47 (41) 54 ans 1,47

Figure 2

Quelques Campylobacters bien mis en evidence par la coloration argentique. Warthin-Starry. Immersion. 1 250 x .

Campylobacter easily visible with silver stain. Warthin-Starry stain. Oil immersion. 1250 x .

Malgr6 la qualit6 sup6rieure des pr6parations argentiques, il n'y a pas de diff6rence significative en ce qui concerne la sensibilit6 des m6thodes de coloration utilis6es. Sauf dans un seul cas, les micro-organismes ont pu 6tre diagnostiqu6s I'H.E.S., lh o~ un examen soigneux des pr6para- tions color6es /~ l'argent avait permis d'en ob- server.

Les micro-organismes sont pr6sents en nombre tr~s variable d'une observation ~ l'autre, pour chaque observation, d'un fragment ~ l'autre, et pour chaque fragment, sont r6partis de mani~re tr~s h6t6rog6ne selon les cryptes examin6es ; une 6tude extrfmement attentive est donc de rigueur.

Dans 9 observations (8 % ; 9 patients diff6- rents), des Campylobacters sont r6v616s dans les biopsies gastriques. I1 s'agit en l'occurrence de 23 biopsies fundiques (6 % des biopsies fundiques ; 8 observations avec muqueuse fundique, soit 8 %) et de 8 biopsies antrales (4 % des biopsies antrales ; 4 observations avec muqueuse antrale, soit 6 %).

On n'a pas observ6 de fragment bulbaire positif.

Les Campylobacters sont pr6sents dans 6 cas masculins (10 % des cas masculins). I1 s'agit de muqueuse fundique dans 19 fragments (10 % des biopsies fundiques masculines ; 5 observations avec muqueuse fundique, soit 10 %) et de muqueuse antrale dans 5 fragments (4 % des biopsies antrales masculines ; 2 observations avec muqueuse antrale, soit 6 %).

Le sexe f6minin est repr6sent6 dans 3 observations (6 % des observations f6minines), pour un total de 4 fragments fundiques (2 % des biopsies fundiques f6minines ; 3 observations avec muqueuse fundique, soit 7 %) et 3 antraux (5 % des biopsies antrales f6minines; 2 observations avec muqueuse antrale, soit 7 %) (Figures 3 et 4).

I1 n'y a pas de corr61ation apparente entre l'intensit6 de l'infiltration lymphocytaire intra6pi- th61iale, celle de l'atteinte choriale et la pr6sence du Campylobacter.

Gastrites t~moins

L'~ge des patients varie de 23 h 86 ans, l'hge moyen 6tant de 56 ans. On compte 69 hommes (59 %, ~ge moyen de 56 ans) et 47 femmes ( 4 1 % , hge moyen de 54 ans), soit un sex ratio de 1,47 (Tableau II).

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muqueuse fundique, soit 55 %) sont porteuses de

Campylobacters

ainsi que 117 biopsies antrales (49 % des biopsies antrales ; 49 observations avec muqueuse antrale, soit 60 %). 8 fragments bulbaires sont positifs (13 % des biopsies bulbaires ; 6 observations avec muqueuse bulbaire, soit 20 %).

Figure 3

Pourcentages de fragments positifs.

Dans 67 observations (58 %, 67 patients diff6- rents), on a pu d6montrer la pr6sence de

Campy- lobacters

dans les biopsies gastriques. Exprim6s selon les fragments de muqueuse, les r6sultats indiquent que 65 biopsies fundiques (53 % des biopsies fundiques ; 30 observations avec

Figure 4

Pourcentages d'observations positives.

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Les Campylobacters sont prdsents chez 40 patients du sexe masculin (58 % des hommes). O n les trouve dans 32 des f r a g m e n t s de m u q u e u s e fundique ( 5 1 % des biopsies fundiques mascu- l i n e s ; 16 observations avec m u q u e u s e fundique, soit 52 % ) , dans 81 f r a g m e n t s de m u q u e u s e antrale (53 % des biopsies antrales masculines ; 32 observations avec m u q u e u s e antrale, soit 59 % ) et dans 5 fragments de m u q u e u s e bulbaire (13 % des biopsies bulbaires masculines ; 4 observations, soit 2 1 % ) .

L e sexe f6minin est r e p r d s e n t d dans 27 observations (57 % des f e m m e s ) , p o u r un total de 33 fragments fundiques (55 % des biopsies fundiques f6minines ; 14 observations, soit 58 % ) , 36 antraux (45 % des biopsies antrales f6minines ; 17 observations, soit 60 % ) et 3 bulbaires (14 % des biopsies bulbaires f6minines ; 2 observations, soit 18 ~ (Figures 3 et 4).

N o t r e g r o u p e dtant f o r m d en a p p a r i e m e n t avec les gastrites l y m p h o c y t a i r e s c o m p o r t e 67 % de gastrites 6volutives et 33 % ne m o n t r a n t pas de signe d'dvolutivitd.

Etude statistique

L ' i m p o r t a n c e n u m d r i q u e des sdries p e r m e t de c o m p a r e r e n t r e elles les sdries de gastrites lymphocytaires et tdmoins p a r le test de c o m p a r a i s o n de deux pourcentages. Q u e l'on c o m p a r e les pourcentages calculds sur le n o m b r e de fragments biopsiques ou sur le n o m b r e d ' o b s e r v a t i o n s , l'dcart r6duit est tr6s i m p o r t a n t , aussi bien en site fundique qu'antral. L e degr6 de signification est tr6s 61ev6 dans t o u s l e s cas avec un p < 10 -l~ (Tableau III).

TABLEAU III I~TUDE STATISTIQUE

TEST DE C O M P A R A I S O N D E D E U X P O U R C E N T A G E S

Valeurs compar6es

% fragments fundiques + .

% fragments antraux + . .

% obs. fundiques +

% obs. antrales +

Ecart rdduit 12,080

9,948 6,442 6,745

p < x x < 10 -l~

x < 10 10 x < 10 -1~

x < 10 -1~

< 0,05 si dcart rdduit > 2.

D I S C U S S I O N

D a n s le prdsent travail, n o u s avons recherchd la prdsence du Campylobacter dans la m u q u e u s e gastrique en nous basant sur des t e c h n i q u e s p u r e m e n t histologiques, soit apr6s c o l o r a t i o n de routine I ' H . E . S . , soit en utilisant u n e coloration argentique plus sophistiqude de Warthin-Starry. Les rdsultats fournis p a r les d e u x m d t h o d e s de colora-

tion sont strictement c o m p a r a b l e s si l'on p r e n d la p r d c a u t i o n d'utiliser un o b j e c t i f ~ i m m e r s i o n p o u r l'identification pr6cise des germes.

I1 apparait d ' a u t r e part certain h l ' h e u r e actuelle que les rdsultats des e x a m e n s histologiques sont fiables et en excellente corrdlation avec la culture du g e r m e [2]. C o m m e n o t r e 6 t u d e 6tait rdtrospec- tive, nous n ' a v o n s pu e f f e c t u e r a u c u n contr61e bactdriologique ; n6anmoins, nos rdsultats p e u v e n t se c o m p a r e r h ceux de la littdrature p u i s q u e nous avons o b t e n u des chiffres de 50 ~ 60 % d e positi- vit6 dans la sdrie contr61e de gastrites c h r o n i q u e s

<< banales >> moddr6es o u sdv6res. O n t r o u v e dans la littdrature rdcente des chiffres plus dlev6s mais il s'agit t o u j o u r s de gastrites dvolutives [8]. N o t r e sdrie c o m p o r t a n t par son type de sdlection un p o u r c e n t a g e de gastrites n o n dvolutives, nos chiffres p e u v e n t se c o m p a r e r avec les sdries similaires de la litt6rature [9].

L a gastrite l y m p h o c y t a i r e se signale p o u r ce crit6re p a r un c o m p o r t e m e n t t o t a l e m e n t diff6rent des gastrites habituelles puisque l'on n ' y o b s e r v e le Campylobacter que dans un tr6s faible p o u r c e n t a g e de cas.

Bien que nous ne disposions que d ' u n e sdrie plus restreinte p o u r les biopsies bulbaires, on o b s e r v e la m 6 m e diff6rence e n t r e les gastrites t6moins et les gastrites l y m p h o c y t a i r e s puisque 20 % des observations effectudes en site bulbaire et p r o v e n a n t de patients souffrant de gastrite b a n a l e sont positives p o u r le Campylobacter, alors que nous ne r e n c o n t r o n s a u c u n cas positif dans la s6rie des gastrites lymphocytaires.

Ces observations v i e n n e n t ~i l'appui de nos r e c h e r c h e s antdrieures qui ont isol6 la gastrite lym- p h o c y t a i r e et ont m o n t r d qu'il s'agissait d ' u n e entit6 n e t t e m e n t diff6rente des gastrites r e n c o n - tr6es h a b i t u e l l e m e n t .

Q u e signifie ce c o m p o r t e m e n t diff6rent ~ l'dgard du Campylobacter ? Si l'on a d m e t q u e ce d e r n i e r j o u e un r61e d t i o p a t h o g d n i q u e dans les gastrites banales, tel ne parait pas 6tre le cas dans la gastrite l y m p h o c y t a i r e p u i s q u ' o n ne l'y r e n c o n t r e qu'assez r a r e m e n t , ~ un taux bien inf6rieur ~ celui q u e certains ont rencontr6 dans des m u q u e u s e s h i s t o l o g i q u e m e n t normales. I1 s'agirait d6s lors d ' u n e association fortuite excluant t o u t ~ fait un r61e du Campylobacter.

L a prdsence de Campylobacters dans les m u q u e u s e s strictement n o r m a l e s a y a n t dtd contes- tde p a r d ' a u c u n s (8), o n p o u r r a i t c e p e n d a n t se d e m a n d e r si les cas o/1 nous avons o b s e r v d l'association d ' u n e gastrite l y m p h o c y t a i r e et d e Campy- lobacters ne constitueraient pas u n e intrication des d e u x types de maladie, ~ savoir la gastrite lymphocytaire et la gastrite c h r o n i q u e << b a n a l e >>. Plaide c o n t r e c e t t e derni6re h y p o t h 6 s e le fait q u e nous n ' a v o n s pas observd de diff6rence histologique essentielle e n t r e les gastrites l y m p h o c y t a i r e s avec ou sans Campylobacter.

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On pourrait aussi supposer q u ' u n tableau incluant le Campylobacter repr6sente un des modes d'6volution de la gastrite lymphocytaire qui, apr6s une dur6e particuli6rement longue, se transformerait en gastrite ,, banale , . Va ~ l'encon- tre de cette hypoth6se le fait que dans notre exp6rience, un nombre non n6gligeable de gastrites lymphocytaires gu6rissent apr6s une 6volu- tion de un h trois ans alors que les gastrites chroniques ne paraissent pas gu6rir sans traite- ment.

U n e derni6re hypoth~se serait 6 v i d e m m e n t que la gastrite lymphocytaire repr6sente une r6action immunitaire ~ l'6gard du Campylobacter; compte t e n u du fait que ce dernier se d6veloppe pr6f6ren- tiellement dans l'antre gastrique, on expliquerait alors real la localisation essentiellement fundique de la gastrite lymphocytaire.

On pourrait encore proposer une explication t o t a l e m e n t diff6rente de nos r6sultats m e t t a n t l'ac-

cent sur le r61e protecteur du mucus. O n sait depuis les travaux de L a m b e r t et col. [7] que dans la gastrite varioliforme, qui est une des formes de la gastrite lymphocytaire, le mucus gastrique pr6- sente une qualit6 et une abondance particuli6res l'observation endoscopique. D ' a u t r e part, dans nos observations, il y a peu de modifications des cellules mucos6cr6tantes dans ce type de gastrite.

Ceci signifierait que la qualit6 du mucus dans la gastrite lymphocytaire est telle que l'estomac se d6fend bien contre une invasion par le Campylo- bacter.

C O N C L U S I O N

Quelle que soit l'hypoth6se expliquant la raret6 du C . L . O . dans la gastrite lymphocytaire, cette 6tude p e r m e t d'6toffer les caract6ristiques origi- nales de cette derni6re par rapport h la cohorte des gastrites chroniques banales.

R E F E R E N C E S

1. D E L O S M . , J O U R E T - M O U R I N A . , W A L L E Z L., WIL- L E T T E M . , M A I N G U E T P., H A O T J. - - Evolution d ' u n e sdrie de gastrites caract6risdes p a r une infiltration lymphocytaire intradpithdliale. Acta Endoscopica, 1986, 16, 185-188.

2. G O O D W l N C.S., A R M S T R O N G J . A . , M A R S H A L L B.J.

- - Campylobacter pyloridis, gastritis, and peptic ulceration.

J Clin Pathol, 1986, 39, 353-365.

3. H A O T J., W A L L E Z L., J O U R E T - M O U R I N A . , H A R D Y N. - - La gastrite ~ h i y m p h o c y t e s , . U n e nouvelle entit6 ? Acta Endoscopica, 1985, 15, 187-188.

4. H A O T J., D E L O S M., W A L L E Z L., H A R D Y N., LEN- Z E N B . , J O U R E T - M O U R I N A . - - Les lymphocytes in- tra6pith61iaux e n pathologie gastrique inflammatoire. Acta Endoscopica, 1986, 16, 61-67.

5. H A O T J., J O U R E T - M O U R I N A . , D E L O S M., W A L - L E Z L., M E L A N G E M . , D E G A L O C S Y C . , B O E M E R F., W l L L E T I ' E M., M A I N G U E T P. - - E t u d e anatomocli- nique d ' u n e s6rie de gastrites c h r o n i q u e s caractdrisdes par une infiltration lymphocytaire intradpithdliale. Acta En- doscopica, 1986, 16, 69-74.

6. H A O T J., H A M I C H I L., M A I N G U E T P., W A L L E Z L.

- - Lymphocytic gastritis : a n e w described entity. A retrospective e n d o s c o p i c and histologic study. Gut (soumis pour publication).

7. L A M B E R T R . , B U G N O N B., M O U L I G N I E R B., A N D R E C. - - A s p e c t s e n d o s c o p i q u e s de la gastrite varioliforme diffuse. Endoscopie Dig, 1977, 2, 81-86.

8. R A T H B O N E B.J., W Y A T T J.L., W O R S L E Y B . W . , T R E J D O S I E W l C Z L . K . , H E A T L E Y R . V . , L O S O W S K Y M.S. - - I m m u n e response to Campylobacter Pyloridis.

Lancet, i, 1217.

9. R O L L A S S O N T . P . , S T O N E J., R H O D E S J.M. - - Spiral organisms in e n d o s c o p i c biopsies o f the h u m a n stomach. J Clin Pathol, 1984, 37, 23-26.

10. W A R T H I N A . S . , S T A R R Y A . C . - - A m o r e rapid and improved m e t h o d o f d e m o n s t r a t i n g spirochaetes in tissues.

American Journal o f Syphilis, 1920, 4, 97.

11. W H I T E H E A D R. - - Mucosal biopsy o f the gastrointesti- nal tract. Third Edition. W.B. Saunders C o m p a n y . 1985.

I N T R O D U C T I O N

In recent publications, we described a new pathological entity, characterized by marked lym- phocytic infiltration, under the name o f lymphocytic gastritis [3]. Its endoscopic and clinical aspects differentiate it f r o m classical chronic gastritis. Prefe- rential attack o f the fundic region is typical, as are the three types o f often-associated basic lesions :

large thickened folds, nodules, eroded or not, and flat erosions. From a clinical point o f view, symp- tomatology can be a degradation o f general health, where anorexia is very often combined with weight loss, and more rarely, edema [1, 4-6].

Considering the emphasis currently placed on Campylobacter Pylori in gastric pathology, we designed the present study to evaluate its presence in lymphocytic gastritis.

288 V o l u m e 17 - N ~ 5 - 1987 Acta Endoscopica

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MATERIAL AND METHODS

116 lymphocytic gastritis cases were randomly selected from a series o f almost 400 observations diagnosed by the Pathology Department o f the St.

Luc University Clinic between 1982 and 1986.

A n implication o f this selection method is that more than one observation can come from the same patient (102 patients for 116 observations), 62 observations were f r o m male subjects (53 %), while 54 were from women (47 %).

The diagnosis basis o f lymphocytic gastritis is determined by a count o f intraepithelial lymphocy- tes in the surface epithelium compared to the number of epithelial cells, which must be a value

>- 30/100, considering the zones where the cells are most numerous. For each observation, there was no disagreement between the diagnoses of two pathologists examining each preparation indepen- dently.

A control series, taken f r o m the result file, was made up o f chronic gastritis cases classified as moderate or severe according to Whitehead's classification [11]. These observations were paired with each lymphocytic gastritis case (the chronic gastritis case following the proceeding lymphocytic gastritis case in the sequence o f laboratory registra- tion were paired together). The 116 observations came from 116 different patients. 69 observations were from male subjects (59 %), while 47 were f r o m women ( 4 1 % ) .

One or more fundic or antral biopsies were available for each observation, sometimes accom- panied by additional bulbar samples.

In the lymphocytic gastritis series, out o f a total of 567 gastric origin fragments, 386 (68 %) were of fundic type (187 f r o m men and 199 from women), corresponding to 98 observations of 52 men and 46 women. 181 fragments ( 3 2 %) were of antral type (120 from men and 61 f r o m women), correspon- ding to 64 observations o f 36 men and 28 women.

57 fragments were bulbar (35 from men and 22 f r o m women, f o r 29 observations of 19 men an 10

women (Table 1).

In the control gastritis series, out of a total of 360 gastric origin fragments, 123 (34 %) were of fundic type (63 f r o m men and 60 from women), corresponding to 55 observations of 31 men and 24 women. 237 fragments (66 %) were o f antral type (154 from men and 83 f r o m women), correspon- ding to 82 observations o f 54 men and 28 women.

61 fragments were bulbar (40 from men and 21 f r o m women, f o r 30 observations of 19 men and 11

women (Table I).

The biopsy fragments were fixed with Bouin's liquid and embedded in paraffin. 5 ~m histological slices were stained with H E S (hematoxylin-eosin- saffron) and by Warthin-Starry's method [10]. They were independently examined by two pathologists, who had no access to endoscopic or clinical data.

TABLE I

N U M B E R O F O B S E R V A T I O N S A N D B I O P S Y F R A G M E N T S

N u m b e r o f observations

No. of f u n d u s obs.

No. of a n t r u m obs.

No. of b u l b o b s . . . N u m b e r o f s t o m a c h f r a g m e n t s

No. of f u n d u s frgs.

No. of a n t r u m frags.

No. of b u l b f r g s . . .

Lymphocytic gast riti~, T o t a l M W

116 62 54

98 52 46

64 36 28

29 19 10

567 307 260

386 187 199

181 120 61

57 35 22

C o n t r o l gastritis T o t a l M W

116 69 47

55 31 24

82 54 28

30 19 11

360 217 143

123 63 60

237 154 83

61 40 21

The pathologists searched the samples for Campy- lobacter by conventional light microscopy, using dry 40x objectives. They used oil immersion objec- tives (lOOx) for definitive microorganism identifica- tion or when the examination at lower magnifica- tion was negative.

RESULTS Methodological problems Campylobacter diagnosis

Campylobacter are spiral bacteria, a f e w ixm on the long axis, which can be stained with hematoxy- lin and silver, and which are f o u n d attached to the glycocalyx o f gastric cells. They appear a grey (dirty) blue with H E S (Fig. 1). Using the Warthin- Starry silver method, they are much more visible.

Silver precipitate on their surface makes them appear larger, and highlights their characteristic shape. Also, their dark black stain contrasts better with the yellowish background o f the preparation.

Despite the better quality on the silver prepara- tions, there is no significant difference between the sensitivity of the two methods. With the exception o f one case, it was possible to diagnose the micio- organisms using HES, when careful examination o f silver stained preparations had revealed their pre- sence.

The number o f microorganisms present varied widely f r o m one observation to another. For each observation, it varied between fragments, and within fragments, distribution was heterogeneous according to the gastric pits examined. Careful examination is therefore required.

Lymphocytic Gastritis Series

Patients were between 25 to 90 years old, with an average age o f 54 years. There were 58 men

(8)

(57 %, average age 53 years) and 44 women (43 %, average age 56 years) making a sex ratio o f 1.32 (Table 11).

TABLE II G E N E R A L D A T A

Number of patients Age limits

Average age Men (%) Average age Women (%) Average age Sex ratio

Lymphocytic Control gastritis gastritis

102 25-95 years

54 years

58 (57)

53 years 44 (43) 56 years 1,32

116 23-86 years

56 years 69 (59) 56 years

47 (41) 54 years

1,47

In 9 observations (8 %, 9 different patients) Campylobacter were f o u n d in gastric biopsies.

They occured in 23 fundic biopsies (6 % o f the fundic biopsies ; 8 observations with fundic mucosa, or 8 %) and in 8 antral biopsies (4 % o f the antral biopsies ; 4 observations with antral mucosa, or 6 %). No positive bulbar fragments were observed.

Campylobacter were present in 6 male patients (10 % of male cases). They were f o u n d in the fundic mucosa o f 19 fragments (10 % o f male fundic biopsies ; 5 observations with fundic mucosa, or 10 %), and in the antral mucosa of 5 fragments (4 % o f male antral biopsies ; 2 observa-

tions with antral mucosa, or 6 %).

Campylobacter were present in 3 female patient observations (6 % o f female observations), for a total o f 4 fundic fragments (2 % o f female fundic biopsies ; 3 observations with fundic mucosa, or 7 %) and 3 antral fragments (5 % o f female antral biopsies ; 2 observations with antral mucosa, or 7 %) (Fig. 3 and 4).

There is no apparent correlation between the intensity o f intraepithelial lymphocytic infiltration, lamina propria invasion, and the presence o f Cam- pylobacter.

Control Gastritis Series

Patients were between 23 to 86 years old, with an average age o f 56 years. There were 69 men (59 %, average age 56 years) and 47 women ( 4 1 % , average age 54 years) making a sex ratio o f 1.47 (Table 11).

In 67 observations (58 %, 67 different patients), the presence o f Campylobacter was demonstrated in gastric biopsies. Expressed as a function o f mucosa fragments, the results indicated that 65 fundic biop- sies (53 % o f the fundic biopsies ; 30 observations with fundic mucosa, or 55 %) were Campylobacter

Figure 3

Percent of positive fragments.

carriers, as were 117 antral biopsies (49 % o f the antral biopsies ; 49 observations with antral mucosa, or 60 %). 8 bulbar fragments were posi- tive (13 % o f the bulbar biopsies ; 6 observations with bulbar mucosa, or 20 %).

Campylobacter were present in 40 male patients (58 % of male cases). They were f o u n d in 32

(9)

Campylobacter were present in 27 female patient observations (57 % of female cases). They were found in 33 fundic mucosa fragments (55 % of female fundic biopsies ; 14 observations, or 58 %), 36 antral mucosa fragments (45 % of female antral biopsies ; 17 observations, or 60 %), and in 3 bulbar mucosa fragments (14 % of female bulbar biopsies ; 2 observations, or 18 %) (Fig. 3 and 4).

Our group formed by lymphocytic gastritis pair- ing showed 67 % << active ,> gastritis, while 33 % did not show signs of activity.

Statistical Analysis

The size o f the series allows compar&on between the lymphocytic gastritis series and control series by the percentage comparison test. Whether the com- par&ons are based on the percentages calculated from the number of fragments or the number of observations, the standard error & very important, both at fundic and antral sites. The degree of significance is very high in all cases, with p < 10 -1r

(Table III).

TABLE I l l S T A T I S T I C A L S T U D Y P E R C E N T A G E C O M P A R I S O N T E S T

V a l u e s c o m p a r e d

% f u n d i c frgs. +

% a n t r a l f i g s . +

% f u n d i c o b s . +

% a n t r a l o b s . +

S t a n d a r d e r r o r ( S E )

12,080 9 . 9 4 8 6 . 4 4 2 6 . 7 4 5

p < x

x < 10 .i.

x < 10 io x < 10 )o x < 10 to p < 0,05 if the standard error > 2.

Figure 4

Percent of positive observations.

fundic mucosa fragments ( 5 1 % of male fundic biopsies ; 16 observations with fundic mucosa, or 52 %), 81 antral mucosa fragments (53 % of male antral biopsies ; 32 observations with antral mucosa, or 59 %) and in 5 bulbar mucosa frag- ments (13 % of male bulbar biopsies ; 2 observa- tions, or 2 1 % ) .

DISCUSSION

In the present study, we determined the presence of Campylobacter in gastric mucosa using purely histological techniques, either after routine H E S staining, or by using a more sophisticated silver stain developed by Warthin-Starry. The results fur- nished by both staining methods are strictly com- parable, if care is taken to use and oil immersion lens for precise microorganism identification.

It also seems certain that current histological examination results are reliable and correlate excel- lently with microorganism cell cultures [2]. Since our study was retrospective, bacteriological verifica- tion was impossible. However, our results can be compared to those of the literature, since we obtained figures o f between 50 and 60 % positive findings in the control series of <, common ,> mo- derate or severe chronic gastritis cases. Higher figures can be f o u n d in recent literature, but they

(10)

always involve active gastritis

[8].

A s our series, by its type of selection, includes a percentage of quiescent gastritis cases, our series can be com- pared to similar series in the literature

[9].

Lymphocytic gastritis differs, for this criterion, by its completely different behavior from usual gas- tritis:

Campylobacter

is observed in only a small percentage of cases.

Although we only had a smaller series of bulbar biopsies available, the same difference between con- trol gastritis and lymphocytic gastritis was observed: 20 % of the bulbar site observations from patients suffering from common gastritis were

Campylobacter

positive, while no positive cases were observed in the lymphocytic gastritis series.

This observation supports our earlier research, which isolated lymphocytic gastritis and showed that it is a clearly distinct entity from commonly found gastritis.

What does this difference in behavior toward

Campylobacter

signify ? Granted that

Campylobac- ter

plays an etiopathic role in common gastritis, the same cannot be said for lymphocytic gastritis, since they are found but rarely, and at much lower counts than have been f o u n d in histologically nor- mal mucosae. Their presence then appears to be a fortuitous association, excluding any role for

Cam-

pylobacter.

While no one contests the presence of

Campy- lobacter

in strictly normal mucosae

[8],

their pre- sence in the cases we observed of associated lym- phocytic gastritis and

Campylobacter

might be construed as a mixture o f the two diseases : both lymphocytic gastritis and ~ common ~ gastritis. The fact that we observed no essential histological differences between lymphocytic gastritis with or without

Campylobacter

argues against this hy- pothesis.

Another possibility would be a clinicopathologi- cal schema including

Campylobacter,

where one evolutionary mode of lymphocytic gastritis would be its transformation, after a particularly long period of time, to ~ common ~ gastritis. This hypothesis has not been borne out by our expe- rience : after a general course of one to three years, a significant number of lymphocytic gastritis cases recover, while chronic gastritis cases do not appear to heal without treatment.

A final, hypothesis would be that lymphocytic gastritis represents an immunological reaction to

Campylobacter.

Considering

Campylobacter's

pre- ferential development in the gastric antrum, it

would be difficult to explain the essentially fundic localization of lymphocytic gastritis.

A completely different explanation of our results could be made, emphasizing the protective role of mucus. It has been known, since the publication of the study by Lambert et al.

[7],

that in varioliform gastritis, which is one of the forms of lymphocytic gastritis, gastric mucus shows a particular quality and abundance under endoscopic observation.

Moreover, in our observations, there were few modifications of mucus secreting cells in this type of gastritis. This would mean that mucus quality in lymphocytic gastritis is such that the stomach is well-defended from

Campylobacter

invasion.

CONCLUSION

Whatever the hypothesis explaining the rarity of

Campylobacter

in lymphocytic gastritis, this study substantiates the specificity o f lymphocytic gastritis characteristics in comparison to the mass of com- mon chronic gastritis.

292

Volume 17 - N ~ 5 - 1987 Acta Endoscopica