Copyright 2012 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Endoscopic and Histological Gastric Lesions in Children With Celiac Disease: Mucosal Involvement Is Not Only Confined to the Duodenum  Raffaella Nenna, y Fabio Massimo Magliocca, z Claudio Tiberti,  Gerarda Mastrogiorgio,  Laura Petrarca,  Maurizio Mennini,  Federica Lucantoni,  Rita Pia Lara Luparia, and  Margherita Bonamico ABSTRACT Objectives: Lymphocytic gastritis (LG) has been reported in patients with celiac disease (CD). The aim of the present study was to evaluate gastric mucosa involvement in celiac children and gastroenterological controls (GC). Methods: In a retrospective study on 226 patients with CD (82 M; median age: 5.7years) at diagnosis and 154 GC (66 M; median age: 7.4 years), the evaluation of gastric and duodenal mucosa was performed. CD was diagnosed according to the North America Society for Pediatric Gastroenterology, Hepatology, and Nutrition criteria. Gastric lesions were classified according to Updated Sydney System. Anti-gastric parietal cell antibodies (GPCA) were assayed by enzyme-linked immunosorbent assay. Results: A total of 21.2% and 7% of patients with CD showed chronic superficial gastritis (CSG) and LG, respectively. Helicobacter pylori (Hp) infection was found in 6 (2.7%) children with CD (66.7% had CSG, 16.7% LG, and 16.7% interstitial gastritis). CSG was present in 21.4% of controls. No control subject showed LG. Hp infection was found in 24 (15.6%) children with GC (91.7% had CSG). Among patients with CSG, Hp infection was more frequent in controls than in celiac children (P < 0.0001). Ten of 90 patients with CD and 1 of 29 controls were positive for GPCA. Conclusions: Gastritis is a common finding in children with CD and adolescents. In celiac subjects, CSG is the most frequently detected. Our data suggest the hypothesis that LG may be related to a longer exposure to gluten. The presence of GPCA may suggest the presence of an underlying autoimmune process. Key Words: anti-gastric parietal cell antibodies, celiac disease, gastric mucosa, gastritis (JPGN 2012;55: 728–732) C eliac disease (CD) is a chronic autoimmune enteropathy caused by the ingestion of gluten, a component of wheat, barley, and rye, which affects genetically susceptible individuals and is characterized by typical lesions of the duodenal mucosa. Recent studies revealed that CD affects >1% of the general population, both in Europe (1,2) and in North America (3). CD can appear with gastrointestinal symptoms (typical form), in patients with iron-deficiency anemia, dermatitis herpeti- formis, headaches, recurrent aphthous stomatitis (atypical form), or be asymptomatic (silent form). Several long-term complications, such as autoimmune disorders (4,5), osteoporosis (6), infertility (7,8), malignancy (9), or a refractory CD, have also been described. Anti-gliadin (AGA), anti-endomysium (EMA), and anti- human transglutaminase antibodies (tTG Ab) can be used as a screening method. The demonstration of histological changes of the small bowel mucosa, evaluated according to the Marsh classification as modified by Oberhuber et al (10), is the criterion standard for CD diagnosis. In CD, an involvement of the gastric mucosa was also described (11–16), particularly lymphocytic gastritis (LG), a form of gastritis of uncertain pathogenesis, reported for the first time by Haot et al (17). According to Sydney Updated System (18), LG was ranked among the special forms of gastritis and is histologically characterized by mature lymphocytes infiltrating the surface and foveolar epithelium (>25 lymphocytes/100 cells), in conjunction with a variable increase in chronic inflammatory cells in the lamina propria of the gastric mucosa. It has been shown that the number of intraepithelial lymphocytes (IEL) in the gastric mucosa of celiac patients is significantly higher than in controls, regardless of the diagnosis of LG and, that this number can decrease in patients with gluten-free diet (11). The aim of our study was to perform a global evaluation of gastric mucosa in a large series of children and adolescents with CD and in gastroenterological controls (GC). METHODS Patients In this retrospective study, a total of 380 patients (148 boys, age range 11 months–19 years, median age 6.3 years), who under- went upper endoscopy for several gastrointestinal complaints, were evaluated. These patients were divided into 2 groups according to the diagnosis: 1. A total of 226 celiac children and adolescents (82 boys, age range 11 months – 19 years, median age 5.7 years) at gluten- containing diet 2. A total of 154 children with GC (66 boys, age range 1 – 18 years, median age 7.4 years) who underwent endoscopy because of poor growth, chronic abdominal pain, gastroesophageal reflux, Received May 29, 2012; accepted June 21, 2012. From the  Department of Pediatrics, the y Department of Experimental Medicine and Pathology, and the z Department of Internal Medicine and Medical Specialties, ‘‘Sapienza’’ University of Rome, Rome, Italy. Address correspondence and reprint requests to Dr Raffaella Nenna, Department of Pediatrics, ‘‘Sapienza’’ University of Rome, Viale Regina Elena 324, 00161 Rome, Italy (e-mail: raffaella.nenna@ uniroma1.it). The authors report no conflicts of interest. Copyright # 2012 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0b013e318266aa9e ORIGINAL ARTICLE:GASTROENTEROLOGY 728 JPGN  Volume 55, Number 6, December 2012