3 year-old, Male, Mixed Breed, Canine

This case was discussed in virtual Abdominal Rounds with Donald E. Thrall DVM, PhD, DACVR in, December 2020.

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History:  History of vomiting and diarrhea, both with blood.  Also has history of eating non-food items.

Imaging:  Lateral and ventrodorsal radiographs of the abdomen were acquired (Figure 1).

Findings:

  • The stomach is normally sized and contains gas.  The gastric rugae are enlarged and increased in conspicuity.
  • The small intestine is normal in size and contains a small amount of gas and fluid.  In some areas the intraluminal gas is fragmented into small bubbles.
  • The abdomen has a tucked appearance with poor serosal contrast, consistent with minimal abdominal fat.

Conclusions:

  • The appearance of the small intestine is nonspecific but enteritis or malabsorption disorders can result in the presence of multiple small intraluminal gas bubbles.
  • The size and conspicuity of the rugal folds are consistent with an infiltrative disease such as lymphoma.  The appearance is also consistent with the rare condition of giant hypertrophic gastritis, also known as Menetrier disease.

Discussion: 

A definitive diagnosis was not obtained in this patient and the radiographic appearance of the stomach could be due to an infiltrative disease, such as lymphoma.  Lymphoma could also be the cause of the appearance of the small intestine.  However, the similarity of the appearance of the stomach and the condition of giant hypertrophic gastritis is noteworthy and provides an opportunity to review the specifics of that disease.

In people, Menetrier disease is a rare disorder characterized by massive overgrowth of mucous cells in the gastric mucosa, resulting in large gastric folds.  The cause is unknown.  The abnormal gastric mucosa often results in increased loss of albumin, which can lead to hypoalbuminemia.  The diagnosis of Menetrier disease is suspected based on the radiographic appearance of the gastric mucosa, but is proven only by biopsy.  There is no universally effective treatment.  Strategies include anticholinergic drugs, acid suppression and antibiotic therapy against H pylori infection.  Cetuximab, an epidermal growth factor receptor, has been successful in some patients.  In severe cases, partial or total gastrectomy may be needed.* Giant hypertrophic gastritis occurs in dogs and several clinical reports are available.  A 4 yr old castrated male Jack Russell terrier had a 2 mo. history of vomiting, anorexia, and weight loss. Abdominal radiographs and ultrasound supported gastric outflow obstruction. At gastrotomy there was a large, narrowly based mass originating from the mucosa of the gastric body that protruded through the pylorus into the duodenum. A partial gastrectomy was performed.  Giant hypertrophic gastritis was diagnosed histopathologically. In this dog, surgical excision of the affected gastric tissue provided complete resolution of clinical signs. Twelve mo. following surgery, no recurrence of either vomiting or weight loss had been noted and the dog was clinically normal. 1

An 11-year-old, male Old English sheepdog had weight loss and intermittent vomiting of 1 month duration. A cranioventral abdominal mass, anemia, hypoproteinemia, and hypoalbuminemia were the prominent abnormal findings. Imaging studies identified a remarkably thickened gastric wall with multilobulated folds protruding into the gastric lumen. Gastrotomy revealed the presence of giant cerebriform rugal folds arising from the fundus and body of the stomach. Pronounced gastric glandular hyperplasia and lack of evidence of cellular atypia were suggestive of giant hypertrophic gastritis. The dog was treated with prednisolone, cimetidine, and hyoscine butylbromide, only to experience a short-term remission. 2

Chronic hypertrophic gastritis was described in a 7-year-old Boxer dog. This gastritis resembled Menetrier’s disease in man. The dog was emaciated, lethargic, vomiting and had a poor appetite over a 4-month period. There was anemia and at a later stage of the disease, a hypoalbuminemia. On gastroscopic examination the gastric rugae were enlarged with numerous small hemorrhages. Radiographically, the stomach had a marked folding, primarily at the greater curvature. The transit of contrast medium from the stomach into the duodenum was delayed. Histopathologicaly, there was gland cell hyperplasia in the body as well as the pylorus, foveolar hyperplasia and, in the fundus and in the body near the greater curvature, folding of the muscularis mucosa and the submucosa. 3

One cat with abnormalities similar to Menetrier disease has also been reported.  A 3.5-year-old domestic shorthair cat had a 6 month history of weight loss and polyphagia. There was a markedly reduced body condition score (2/9) a mild non-regenerative anaemia, stress leukogram, hypoalbuminemia, azotaemia, hypokalemia, and total hypocalcemia.  Sonographically there was marked thickening of the gastric mucosa in the fundus, body and pylorus; the most dorsal portion of the fundus was spared. The thickened mucosa contained multiple small, anechoic cyst-like structures. The gastric submucosa, muscularis and serosa appeared normal. Histopathologically there was mucosal hypertrophy and markedly dilated gastric glands. The findings of hypoproteinaemia, gastric ultrasonographic changes and histopathology results share several similarities to Ménétrier disease.

The condition of giant hypertrophic gastritis should be considered in patients where enlarged gastric rugal folds are identified.

References:

  1. Vaughn DP, Syrcle J, Cooley J.  Canine giant hypertrophic gastritis treated successfully with partial gastrectomy.  J Am Anim Hosp Assoc 2014; 50:62-66.
  2. Rallis TS et al.  Giant hypertrophic gastritis (Menetrier’s-like disease) in an Old English sheepdog.  J Am Anim Hosp Assoc 2007; 43:122-127.
  3. Van deg Gaag I, Happe RP, Wolvekamp WT.  A boxer dog with chronic hypertrophic gastritis resembling Menetrier’s disease in man.  Vet Pathol 1976;13:172-185.
  4. Barker EN, Holdsworth AS, Hibbert A, et al.  Hyperplastic and fibrosing gastropathy resembling Menetrier disease in a cat.  JFMS Open Rep 2019; 5: 2055116919861248.

Photo by Dominik QN on Unsplash

3 comments

  1. Hello everyone and thank you for sharing.

    We can see variable intestinal dilations with gas content and the presence of gas bubbles in the form of tears.

    The diameter of the serosa to the serosa is greater than the height of the central part of the body of the L2 and the small intestine / L5 ratio is greater than 2.4 = mechanical ileus with occlusion.

    Foreign body (in fabric) -Intususception
    Intestinal mass (intrinsic or extrinsic).

    Additional exams:

    redo the X-rays with barium or gastrografin (if there is any doubt about perforation)

    Ultrasound

    Thank you

  2. Both the radiographs are of diagnostic quality. There is a generalised lack of detail. The stomach is gas-filled with small amount of soft-tissue opacity material in the pylorus. From the VD view the pylorus is gas-filled and dilated. The small intestines are gas-filled and heterogeneously mildly dilated, but not more than 1.6 times the DV size of L5. There are several small gas bubbles in the left mesogastrium. The colon is gas-filled, normal in size and the descendent part is dislocated to the right from midline.
    The liver seems to be normal. The remaining abdominal organs can not be evaluated due to the lack of serosal detail.
    My top differential diagnosis is a linear foreign body stucked within the pylorus. Another differential diagnosis to consider is severe gastroenteritis.
    The loss of serosal detail could be due to the cachexy, but a small amount of free fluid can’t be excluded.
    The next step should be the abdominal ultrasound.

  3. Gas distended stomach and colon, concern for some loss of serosal detail in caudal abdomen, fluid and gas in the small intestines
    I would recommend repeat fasted radiographs in 8 – 12 hours or an abdominal ultrasound if available to determine cause of clinical signs.

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