Gastrointestinal Mucosal Changes in Syphilitic Gastritis
Syphilitic gastritis presents with distinctive mucosal changes including thickened, friable mucosa with nodular appearance, diffuse inflammatory infiltration rich in plasmocytes, and ulcerative lesions that can mimic neoplastic disease. 1
Endoscopic Findings
Syphilitic gastritis has several characteristic endoscopic features:
- Diminished gastric expandability
- Diffuse mucosal lesions extending from cardia to pylorus
- Thickened and friable gastric mucosa
- Nodular mucosal appearance
- Ulcerative lesions throughout the stomach 1
- Pale appearance of gastric mucosa (similar to other forms of atrophic gastritis) 2
- Increased visibility of submucosal vasculature due to mucosal thinning 2
- Appearance that can mimic linitis plastica (leather bottle stomach) 3
Histopathological Findings
The key histopathological features include:
- Dense inflammatory infiltration rich in plasmocytes 1
- Presence of Treponema pallidum spirochetes (identifiable with silver staining or immunohistochemistry) 3
- Positive immunohistochemical tests for Treponema pallidum and CD138 1
- Loss of gastric glands (atrophic changes) similar to other forms of atrophic gastritis 2
- Inflammatory changes that can involve any layer of the stomach wall
Clinical Significance and Diagnostic Challenges
Syphilitic gastritis is particularly important to recognize because:
It can mimic more serious conditions including gastric carcinoma, lymphoma, or plastic linitis 1
The presentation is often nonspecific with symptoms including:
- Epigastric pain
- Nausea
- Anorexia
- Weight loss
- Early satiety
- Occasionally melena or hematochezia 4
Diagnosis requires a high index of suspicion, especially in:
- HIV-infected individuals 3
- Patients with risk factors for sexually transmitted infections
- Cases with unusual or treatment-resistant gastric symptoms
Diagnostic Approach
For accurate diagnosis of syphilitic gastritis:
- Endoscopy with multiple biopsies from affected areas is essential
- Silver staining techniques (Warthin-Starry or Steiner) should be used to identify spirochetes
- Serological testing for syphilis (VDRL, RPR, and treponemal-specific tests) should be performed 1
- Immunohistochemical staining for Treponema pallidum provides definitive identification 1
Treatment Considerations
Treatment of syphilitic gastritis follows standard syphilis treatment protocols:
- Benzathine penicillin G 2.4 million units IM in a single dose for primary, secondary, and early latent syphilis 5
- For late latent syphilis or latent syphilis of unknown duration: benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM at 1-week intervals 5
- Alternative treatments for penicillin-allergic patients include doxycycline 100 mg orally twice daily for 14 days 5
- Treatment typically leads to resolution of gastric symptoms and endoscopic abnormalities 1
Important Pitfalls to Avoid
- Misdiagnosis as gastric malignancy, leading to unnecessary extensive surgery
- Failure to consider syphilis in the differential diagnosis of unusual gastritis patterns
- Inadequate biopsy sampling that may miss diagnostic areas
- Relying solely on routine H&E staining without special stains for spirochetes
- Failure to test for HIV in patients with confirmed syphilitic gastritis, as coinfection is common
Recognizing the distinctive mucosal changes of syphilitic gastritis is crucial for accurate diagnosis and appropriate treatment of this rare but increasingly reported condition.