An incidental gastric finding

Correct answer: d.

Discussion

Lymphangiectatic cysts are found in the small bowel and the pale lesion is too superficial to be anything else than a gastric xanthelasma.

Gastric xanthelasmata appear as yellowish-white plaques in the stomach, most commonly in the antrum. However, they are not exclusively found in the stomach and have also been reported in the oesophagus, small bowel and colon. A Japanese group reviewing a series of 25 colorectal xanthelasmata concluded that the histological appearance was subtly different to xanthelasmata found elsewhere and proposed that the process was secondary to a mucosal injury.¹

Histologically, xanthelasmata consist of histiocytes (macrophages) in the lamina propria that are stuffed full of fat. Originally, they were thought to be caused by a local disturbance of fat metabolism because serum lipid levels are normal. However, in a Japanese series of more than 3,000 gastroscopies, xanthelasmata were found in 8% of examinations.² These researchers confirmed the well-known link with increasing age and also described a link with Helicobacter pylori infection, gastric atrophy, and with gastric cancer. However, the lesions themselves are not thought to be premalignant.

An interesting study used a polyclonal antibody to demonstrate the presence of Helicobacter pylori in the cytoplasm of the histiocytes of the xanthelasmata.³ Subsequent immuno-electron microscopy confirmed that Helicobacters were present both on the epithelial surface and also in the phagosome of the macrophages. These findings implicate lamina proprial invasion of surface-infected H. pylori in the aetiology of gastric xanthelasmata, though I have not seen these findings replicated elsewhere.