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Friday 4 January 2013

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.


- 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


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


- Depends on etiology
- Dyspepsia in carditis related to H. pylori


- 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)


- 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


- Depends on underlying etiology

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


- 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