S6332 Collagenous Gastritis: A Therapeutically Challenging Case

Introduction: Collagenous gastritis (CG) is part of a disease spectrum called collagenous gastroenteritidis which includes CG, collagenous sprue and collagenous colitis (CC). These diseases share the same histological characteristics of deposition of collagen bands in the subepithelium, thicker than 10 µm, along with mononuclear cells infiltration in the lamina propria. Although, CC is common, CG and collagenous sprue remain rare, and there are no clear guidelines for the treatment. Case Description/Methods: Fifty-seven-year-old lady with past medical history of iron deficiency anemia, Reynaud, Sjogren, hypothyroidism, CC and CG. She was diagnosed with CC and CG after having chronic abdominal pain with early satiety and weight loss for several years. She was treated with Budesonide 9 mg with complete resolution of her symptoms. It was then tapered to 3 mg daily, but the patient stopped the medication. Her symptoms progressively worsened with the as-needed use of budesonide. Budesonide slurry 9 mg was started with partial response. Given the lack of response to Budesonide and continuous weight loss, we started Prednisone 40 mg daily which resulted in weight gain and complete resolution of her symptoms. Given the good response to steroids and to prevent the side effects of long term use of Prednisone, we decided to taper steroids and start Azathioprine at 50 mg daily. She had recurrence of her abdominal pain once she was off steroids. Azathioprine was increased to 150 mg without control of her symptoms. Prednisone 40 mg daily was re-introduced with azathioprine with a plan to start her on adalimumab. Discussion: The pathogenesis of CG remains unknown. Clinical presentation is various and includes abdominal pain, anemia, nausea, vomiting, weight loss, gastric perforation, constipation or diarrhea. Endoscopically, CG was characterized by nodular mucosa. Histologically, there is deposition of collagen in the subepithelium with thickness more than 10 µm. There are no clear guidelines for the treatment of CG and no randomized controlled trials have been done to investigate the best treatment option. Various degree of response has been reported to gluten and lactose free diet, avoiding ARBs, high dose proton pump inhibitors, glucocorticoids, thiopurines and anti-tumor necrosis factor. We describe here a case of CG that was very challenging to treat. she had an appropriate response to budesonide that was subsequently lost, either due to non-compliance or loss of effect. Her symptoms completely resolved with prednisone.