A gastric biopsy shows reactive chemical gastropathy with inflammation and edema on endoscopy. What is the most likely diagnosis?

Reactive Chemical Gastropathy: NSAID-Induced or Bile Reflux Injury

The histologic finding of reactive chemical gastropathy with inflammation and edema most strongly suggests NSAID-induced gastropathy or bile reflux gastropathy (duodenogastric reflux). These are the two most common causes of this specific histopathologic pattern.

Key Diagnostic Features

The constellation of findings you describe represents the classic triad of reactive/chemical gastropathy 1, 2:

• Foveolar hyperplasia (elongation of gastric pits)
• Smooth muscle fibers extending into the lamina propria between glands
• Vascular congestion and edema with capillary dilatation
• Minimal inflammatory cell infiltration (distinguishing it from H. pylori gastritis)

Most Likely Etiologies

Primary Considerations:

1. NSAID Use - The most common cause in clinical practice 3, 4

   • Includes aspirin, ibuprofen, naproxen, and other NSAIDs
   • Can occur with both regular and intermittent use
   • May present with or without symptoms

2. Bile Reflux (Duodenogastric Reflux) 1, 4

   • Occurs after gastric surgery (Billroth procedures, pyloroplasty)
   • Can occur with pyloric dysfunction
   • Bile acids cause direct chemical injury to gastric mucosa

3. Alcohol - Less common but documented cause 4

Critical Clinical Correlation Needed

You must obtain the following information to narrow the diagnosis:

• Medication history: Current or recent NSAID use (including over-the-counter aspirin)
• Surgical history: Any prior gastric or biliary surgery
• Alcohol consumption: Heavy or chronic use
• H. pylori status: Should be negative or minimal inflammation if truly reactive gastropathy 2

Important Diagnostic Pitfalls

The presence of "inflammation" in your description requires clarification 1, 2:

• True reactive gastropathy has minimal inflammatory cells (neutrophils, lymphocytes, plasma cells)
• If significant inflammatory infiltrate is present, consider:
  • Mixed pattern: Reactive gastropathy + H. pylori infection 4
  • Other causes: Autoimmune gastritis, eosinophilic gastritis
  • The edema and vascular congestion you describe are part of reactive changes, not true inflammation

Associations to Consider

Reactive gastropathy shows significant associations with 5:

• Barrett's esophagus (OR 1.21)
• Duodenitis (OR 1.36)
• Microscopic colitis (OR 1.50)
• These suggest systemic NSAID effects or reflux-related injury throughout the GI tract

Next Steps for Definitive Diagnosis

1. Review medication list - Stop NSAIDs if identified
2. Confirm H. pylori status - Should be negative in pure reactive gastropathy 2
3. Assess for bile reflux - Particularly if post-surgical patient
4. Consider endoscopic findings - Subepithelial hemorrhages, erosions, or ulcers support NSAID injury 3

Bottom line: In the absence of prior gastric surgery, NSAID-induced gastropathy is by far the most common diagnosis for this histologic pattern 3, 4. The treatment is cessation of the offending agent and acid suppression if erosions or ulcers are present.