Treatment of Cobblestone Gastric Mucosa on Endoscopy
The primary treatment for cobblestone gastric mucosa depends on the underlying etiology: if associated with inflammatory bowel disease (particularly Crohn's disease), initiate immunosuppressive therapy targeting mucosal healing; if associated with long-term proton pump inhibitor (PPI) use, discontinue or reduce PPI therapy and monitor for resolution.
Differential Diagnosis and Initial Assessment
The cobblestone appearance in the stomach requires careful differentiation between distinct etiologies:
Crohn's disease: Cobblestone mucosa represents a classic endoscopic finding in gastric Crohn's disease, characterized by raised nodules with or without ulceration 1. This pattern results from longitudinal ulcers intersecting with transverse ulcers, creating islands of edematous mucosa 1.
PPI-induced changes: Long-term PPI use (≥6 months) can cause gastric cobblestone-like lesions (GCLLs) in 35% of patients, particularly in those without atrophic gastritis 2. These lesions result from parietal cell hyperplasia and fundic gland cysts 2, 3.
Collagenous gastroduodenitis: Rare entity presenting with cobblestone appearance and subepithelial collagen deposition 4.
Diagnostic Workup
Obtain multiple biopsies from the cobblestone areas and surrounding mucosa to establish the definitive diagnosis 1, 5:
Take biopsies from at least six segments (if involving multiple areas): targeted biopsies from cobblestone lesions plus random biopsies from body and antrum in separately labeled jars 1, 5.
Histopathology will differentiate between inflammatory bowel disease (granulomas, transmural inflammation), PPI-induced changes (parietal cell hyperplasia, fundic gland cysts), or collagenous gastritis (subepithelial collagen bands) 4, 2.
Assess for Helicobacter pylori infection, as this should be treated if present regardless of the underlying cause 5.
Treatment Based on Etiology
For Crohn's Disease-Related Cobblestone Mucosa
Initiate immunosuppressive therapy with the goal of achieving mucosal healing 1:
Anti-TNFα agents are particularly effective for achieving long-term mucosal healing in inflammatory bowel disease 1.
Endoscopic reassessment should be performed to monitor treatment response, as mucosal healing correlates with improved long-term outcomes 1.
Consider endoscopic reassessment in cases of relapse, refractoriness, or new symptoms 1.
For PPI-Induced Cobblestone Lesions
Discontinue or reduce PPI therapy if clinically feasible 2:
GCLLs occur more frequently in patients without atrophic gastritis and are associated with parietal cell hyperplasia 2.
The clinical significance of these lesions remains uncertain, but they should be monitored with follow-up endoscopy 2.
Endoscopic ultrasonography may show thickened gastric second layer with small a-echoic lesions corresponding to oxyntic gland dilatations 3.
For Collagenous Gastroduodenitis
Treat symptomatically with H2-blockers or PPIs for symptom control 4:
Regular endoscopic monitoring is recommended due to the rarity of this condition and uncertain long-term prognosis 4.
Biopsies should be obtained from multiple sites, as collagen deposition may be patchy 4.
Common Pitfalls to Avoid
Failing to obtain adequate biopsies: The endoscopic appearance alone cannot distinguish between etiologies; histopathology is essential 1, 2.
Overlooking PPI history: Always inquire about duration of PPI use, as this is an increasingly recognized cause of cobblestone gastric mucosa 2.
Assuming benign nature without follow-up: Even PPI-induced lesions require monitoring, and Crohn's disease requires aggressive treatment to prevent complications 1, 2.
Not assessing for H. pylori: This should be evaluated in all cases of gastric mucosal abnormalities 5.
Follow-up Strategy
For inflammatory bowel disease: Repeat endoscopy at 6-12 months to assess mucosal healing and guide treatment decisions 1.
For PPI-induced changes: Consider repeat endoscopy after PPI discontinuation or dose reduction to document resolution 2.
For collagenous gastroduodenitis: Regular monitoring with endoscopy and biopsies to assess disease progression 4.