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Surgical Pathology Criteria

Helicobacter Gastritis


  • Gastric infection by Helicobacter sp.

Alternate / Historic Names

  • Campylobacter pylori – old name for H pylori
  • Gastrospirillum hominis – old name for H heilmanni

Diagnostic Criteria

  • Helicobacter species
    • H pylori
      • Most common Helicobacter to infect humans by far
      • Small curved rods
      • Frequently in chain of two, resembling a seagull
      • May become coccoid, especially after treatment
    • H heilmanni
      • Primarily affects domestic cats
        • Occasionally infects humans
      • Much larger than H pylori
      • Clearly visible spirochete structure on light microscopy
    • Others are rarer in western populations
  • Primarily localized to surface and gland necks
  • Present in mucus or attached to the surface of epithelial cells
  • Less frequently attached to parietal and chief cells
  • Primarily involves gastric antrum
    • May extend to body and cardia
    • Loose organisms may wash into duodenum or involve gastric surface metaplasia in duodenum
  • Helicobacter is the most common cause of chronic active gastritis
  • Intraepithelial neutrophils in surface and gland necks
    • Moderate to marked lympho-plasmacytoid infiltrate in superior lamina propria
    • Basal lymphoid hyperplasia
  • Long-standing cases may produce multifocal atrophic gastritis
  • Patchy process
    • Destruction of glands
    • Lamina propria fibrosis
    • Intestinal metaplasia
  • May involve all regions of the stomach
  • Active inflammation may resolve
    • Helicobacter may become difficult to identify
    • Non-atrophic areas may revert to normal
  • Acute inflammation in surface epithelium and gland necks should prompt close examination and, if necessary, a special stain for Helicobacter
    • In untreated cases:
      • 70-80% organisms easily found on H&E
      • 10-25% require careful search on H&E
      • 10-20% require special stain
        • Alcian Yellow, Giemsa, Dif-Quik, Steiner and Steiner
        • Immunohistochemical stains are easier to interpret
    • We perform a special stain if the H&E is negative for the following:
      • All pediatric cases with a clinical suspicion of Helicobacter
      • All pediatric and adult cases with active chronic gastritis
      • All cases with a question of Helicobacter refractory to treatment
      • Gastroesophageal junction specimens with acute inflammation of the gastric type mucosa, unless biopsies of the stomach are available for examination
      • Gastric biopsies with moderate to severe inactive chronic gastritis only if any of the following are present:
        • Lymphocytic duodenitis
        • Lymphoid follicles
        • History of treated Helicobacter
        • Ulcers or neoplasm
          • Better to stain adjacent mucosa than the actual neoplasm

    Robert V Rouse MD
    Department of Pathology
    Stanford University School of Medicine
    Stanford CA 94305-5342

    Original posting / last update: 9/9/09 ; 1/19/14

Differential Diagnosis

  • Occasionally mixed bacterial flora are identified in the bed of an ulcer or as contaminants washed into the stomach from the oral cavity
    • Lacks the uniform appearance of Helicobacter
    • Lacks the intimate association with the epithelial cell surface
  • Occasionally after treatment Helicobacter may appear almost spherical
    • Recognizable by intimate association with the epithelial cell surface or presence of a few organisms with typical appearance
    • Immunhistochemistry should be positive

Classification / Lists

Gastritis / Gastropathy


  • Associated disorders
    • Duodenal ulcer
    • Gastric ulcer
    • Gastric adenocarcinoma
    • Gastric extranodal marginal zone B cell lymphoma


  • Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
  • Owen DA. Gastritis and carditis. Mod Pathol. 2003 Apr;16(4):325-41.
  • Batts KP, Ketover S, Kakar S, Krasinskas AM, Mitchell KA, Wilcox R, Westerhoff M, Rank J, Gibson J, Mattia AR, Cummings OW, Davison JM, Naini BV, Dry SM, Yantiss RK; Rodger C Haggitt Gastrointestinal Pathology Society. Appropriate use of special stains for identifying Helicobacter pylori: Recommendations from the Rodger C. Haggitt Gastrointestinal Pathology Society. Am J Surg Pathol. 2013 Nov;37(11):e12-22.
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