Background

Gastro-Oesophageal Reflux Disease (GORD) is a common condition that can lead to complications including gastric ulcers. While most gastric ulcers heal with appropriate treatment, persistent non-healing ulcers raise concerns for further underlying pathology. Rarely, benign conditions such as gastric lymphocytic phlebitis may cause refractory ulcers. Understanding this rare condition is important for guiding clinical decision-making and avoiding over-treatment.

Case Presentation

A female in her 70s presented with ongoing symptoms of gastro-oesophageal reflux despite maximal proton pump inhibitor therapy. Her medical history included hypertension and hypothyroidism. She was a former smoker with no history of alcohol consumption. An initial gastroscopy performed 18 months earlier revealed a gastric ulcer, with biopsies showing inflammation without malignancy. A concurrent Helicobacter pylori infection was treated and Uncommon Cause of Refractory Gastric Ulcer: Lymphocytic Phlebitis eradicated. Follow-up gastroscopy showed a healing ulcer with only scar present at the ulcer site, but a later surveillance gastroscopy revealed ulcer recurrence. Despite increased acid suppression therapy, the ulcer persisted, and histopathology raised concerns for possible lymphoma. Imaging revealed thickening of the gastric wall and regional lymphadenopathy, further raising suspicion for malignancy. The patient was presented with two options: continued surveillance or surgery. She opted for a distal gastrectomy with Roux-en-Y reconstruction and lymphadenectomy. Gross examination of the resected specimen showed a 35mm ulcer, and histopathology demonstrated gastric lymphocytic phlebitis.

Investigations

Initial gastroscopies revealed a persistent ulcer in the gastric body, with biopsies showing no malignancy. Imaging with CT and endoscopic ultrasound revealed thickening of the gastric wall and regional lymphadenopathy. Endoscopic ultrasound confirmed submucosal thickening with inflammation, but malignancy was not definitively excluded. Histopathological examination of the resected specimen showed patchy lymphocytic and eosinophilic infiltration around blood vessels in the gastric submucosa and subserosa, consistent with gastric lymphocytic phlebitis. No evidence of malignancy was found.

Differential Diagnosis

The initial differential diagnosis included Helicobacter pylori infection, drug-induced ulceration, and malignancy, particularly lymphoma. Biopsies and imaging raised concerns for B-cell proliferation, but repeated surveillance and biopsy failed to confirm malignancy. Ultimately, the diagnosis of gastric lymphocytic phlebitis was made based on histopathology after resection.

Treatment

The patient was treated initially with maximal acid suppression therapy, including proton pump inhibitors and histamine receptor antagonists. However, the ulcer persisted, and concerns for malignancy led to the decision to perform a distal gastrectomy with Roux-en-Y reconstruction and lymphadenectomy. Surgery provided both a diagnostic and therapeutic solution, with the final histology confirming benign lymphocytic phlebitis.

Outcome And Follow-Up

Postoperatively, the patient had an uneventful recovery. She showed no signs of systemic vasculitis or other complications. Follow-up at 6 months showed no recurrence of symptoms, and surveillance endoscopy showed no new ulcer formation. The patient was able to return to her normal daily activities.

Discussion

Gastric lymphocytic phlebitis is an exceedingly rare benign condition that presents with chronic gastric ulcers. The rarity of this condition, combined with the more common causes of persistent gastric ulcers (such as malignancy or infection), makes the diagnosis Uncommon Cause of Refractory Gastric Ulcer: Lymphocytic Phlebitis challenging. In this case, the persistent ulcer, refractory to treatment, raised concerns for malignancy, leading to the decision to proceed with surgery. Histologically, gastric lymphocytic phlebitis is characterized by lymphocytic and eosinophilic infiltration around the gastric blood vessels. It is crucial to differentiate this localized condition from systemic vasculitis, which would require different management. This case supports previous literature suggesting that gastric lymphocytic phlebitis is a localized process without systemic involvement. A review of similar published cases reveals that gastric lymphocytic phlebitis is very rarely diagnosed, often discovered incidentally following gastrectomy. No standard treatment guidelines exist, and surgical resection is generally curative, as seen in this case.

Learning Points

1. Persistent gastric ulcers refractory to standard treatment should prompt consideration of both benign and malignant causes.
2. Gastric lymphocytic phlebitis is a rare, benign condition that can mimic malignancy but has a good prognosis after surgical resection.
3. Thorough histopathological examination is essential in diagnosing rare conditions like lymphocytic phlebitis.
4. Clinicians should be aware of this rare diagnosis when evaluating non-healing ulcers, to avoid unnecessary aggressive treatments.