document: helicobacter pylori ( hp ) 
   infection may cause several clinical manifestations , ranging from asymptomatic 
   to significant gastroduodenal disease including ulcer , bleeding , perforation , 
   and adenocarcinoma . no pathogenic mechanism is known to explain the above 
   diversity . 
   celiac disease ( cd ) is a 
   t - cell - mediated disorder of the small bowel triggered by gluten in susceptible 
   subjects . 
   the damage is not confined only to the small bowel but may affect the 
   gastric mucosal structure and function . in 
   both conditions , hp and cd , a systemic humoral immune response is detected , but 
   much interest has been focused on the local immune inflammatory reaction . 
   it is 
   defined by the presence of > 25 intraepithelial lymphocytes ( iels ) ( surface 
   and upper foveolar epithelium ) per 100 epithelial cells , without taking into 
   account the mononuclear inflammatory 
   cell infiltration of the lp . 
   this condition may be recognized endoscopically as 
   varioliform gastritis , nodularity , hypertrophic gastropathy , and aphtous erosions 
   [ 5 , 6 ] . 
   a similar histological entity has been reported in association with a 
   variety of gastric infections , inflammatory diseases , and in autoimmune 
   disorders affecting the gastric mucosa including cd , in adults [ 79 ] , as well 
   as in pediatric patients [ 1012 ] . 
   additionally , hp is a major etiology for lg , 
   extensively documented in adults [ 13 , 14 ] and children [ 15 , 16 ] . 
   furthermore , 
   investigations of the relationship between hp infection and cd have yielded 
   conflicting results [ 9 , 17 ] , probably because of the different prevalence of hp 
   in the populations studied . 
   others have focused on the hp - related lg in cd 
   [ 6 , 8 ] and recently on the link between anemia , hp , and cd . 
   the pathogenetic 
   relationship between cd , hp and lg is even more complicated since gastric hp 
   existence attenuates duodenal lesions in cd patients . 
   it is generally accepted that the major cytokine 
   response to hp and cd has a t - helper 1 ( th1)-type profile . 
   the exact 
   nature of the cellular response contributing to this inflammatory profile has 
   not been determined , and less so in children . 
   conflicting results exist in the 
   literature on the lymphocytic subpopulations , quantity and quality , 
   infiltrating the gastric mucosa in cd and hp . 
   as lg is a morphologic endpoint of numerous etiologies , the literature is ripe with controversy   and since extensive characterization of the lymphocytic populations infiltrating the gastric mucosa in cd and hp infected children is lacking , the present study was undertaken . 
   the aims were to look for additional quantitative and qualitative histological features , to define the immunophenotype of the gastric mucosa of the two most prevalent etiologies of pediatric lg ( cd and hp infection ) . 
   our secondary aim was to demonstrate a unique histopathology profile of lg by immunohistocemistry staining , trying to clarify the interrelationship between hp and cd in the pediatric population , thus shedding new light on the two entity 's enigma . 
   forty patients referred 
   for endoscopy due to upper gastrointestinal symptoms ( mostly recurrent 
   abdominal pain , or iron deficiency anemia ) were included in the study . 
   patients 
   were divided into 4 groups group1 is eight normal controls ( without cd nor hp 
   infection ) ; group 2 is ten patients with new active cd without hp infection ; 
   group 3 is twelve celiac negative patients infected by hp ; and group 4 is ten new 
   active cd patients infected by hp ( table 1 ) . 
   none of these patients had any 
   other gastrointestinal underlying disease including evidence for food allergy , 
   giardiasis , or inflammatory bowel disease . 
   the diagnosis of cd was based on the 
   accepted histological findings   supported by positive serology for cd 
   ( antiendomysial and antitissue transglutaminase antibodies ) . 
   all cd 
   patients were under normal gluten containing diet at the time of diagnosis . 
   hp 
   status was assessed according to conventional biopsy - based criteria plus 
   positive urease test . 
   all patients underwent esophago - gastro - duodenoscopy using 
   gif - xp 20 endoscope ; pentax , tokyo , japan . 
   at least 
   6 biopsies were obtained : 3 from the second part of the duodenum for diagnosing 
   or exclusion of cd , and 3 from the antrum ; one for quick urease test and two 
   for histologic examination . 
   sections obtained from 
   gastric biopsies were immediately fixed in buffered formalin and embedded on 
   edge in paraffin . 
   the diagnosis of lg was established if 25 lymphocytes per 100 
   gastric epithelial cells infiltrated the surface epithelium . 
   furthermore , we 
   estimated the extent to which the inflammatory infiltrate involved the lp and 
   the mucosal glands . in addition , the number of 
   mucosal and submucosal lymphoid aggregates were counted . to clarify the 
   nature of these inflammatory cells 
   three  m sections were prepared from formalin - fixed , paraffin - embedded 
   tissue blocks , air dried , and subjected to deparaffinization with xylene and 
   absolute alcohol . 
   the immunoperoxidase stains were performed using a panel of 
   antibodies that included cd20 , cd3 , cd4 , cd8 , cd57 , cna42 , and ki67 ( table 2 ) , 
   with appropriate dilutions as recommended by the manufactures , using the 
   ventana es autoimmunostainer and the iviewdab detection kit from ventana . 
   the gastric iels were counted on the 
   hematoxylin - eosin stains per 100 consecutive gastric surface mucosal cells with 
   a x400 magnification ( objectivex10 ) . 
   the density of subepithelial lymphocytes was 
   determined semiquantitatively using a 4 tier grading system , according to the 
   percentage of the area in the lp infiltrated by the inflammatory cells . 
   grade 0 is if less than 5% of the area was infiltrated by inflammatory cells , grade 1 is 
   between 530% , grade 2 is between 3060% , and grade 3 is if > 60% of the area was 
   infiltrated . in order to evaluate the inflammatory glandular involvement , 
   glands containing inflammatory cells 
   were counted out of a fixed total number 
   of superficial glands ; calculated as the percent of involved glands . 
   continuous variables were compared across groups using 
   analysis of variance ( anova ) with bonferroni 's correction for multiple 
   comparisons . 
   discrete ( semi quantitative ) variables were compared using 
   kruskal - wallis nonparametric one - way analysis of variance , with multiple 
   comparisons . a p - value less or equal than 0.05 was considered significant . 
   demographic data of the four examined groups 
   of patients are summarized in table 1 . 
   the mean age of all groups and gender 's ratio 
   were not statistically significant different . in cd as well as in hp 
   gastritis patients , increased numbers of iel 
   compatible with the diagnosis of lg ( 45.518.5 per 100 gastric epithelial 
   cells ) compared to patients without lg ( 10.84.5 per 100 gastric epithelial 
   cells ) , were observed . 
   the highest proportion of lg ( 50% ) was found in cd patients without hp 
   infection , followed by patients with cd infected by hp ( 20% ) , hp positive 
   patients without cd ( 8.3% ) and 
   none in the control group . 
   the distribution and 
   total number of lymphoid aggregates in the antrum among the four different 
   groups are shown in table 3 . 
   patients infected with hp had the highest number 
   of lymphoid aggregates irrespective of the cd status . 
   three cd patients with hp 
   and nine hp infected patients without cd had more than 2 lymphoid aggregates . the mean number of 
   intraepithelial lymphocytes ( iels ) positive for cd3 was increased significantly 
   in cd patients with or without hp infection compared to controls [ p0.01,p0.05 
   respectively ] , ( table 4 ) . 
   similarly the mean number of cd8 + iels was increased 
   significantly in cd patients with or without hp infection compared to controls 
   ( p<0.05 ) ( figure 1 ) . 
   hp infection did not contribute to the number of cd8 + 
   iels . in the hp infected group without cd , the number of cd8 + iels was not 
   significantly different from the normal controls [ table 4 ] . 
   a slight increase 
   in cd8 + lymphocytes was noted in the lp and intra mucosal glands in the cd 
   group patients compared with all the other groups , although these results did 
   not reach statistical significance . 
   cd4 + lymphocytes were 
   slightly increased in the lp and in the mucosal glands of the hp+ patients 
   compared with controls and cd cases . 
   no statistical 
   significant differences were found for the number and distribution of b 
   lymphocytes ( cd20 + ) , natural killer ( nk ) lymphocytes ( cd57 ) and follicular 
   dendritic cells ( cna42 ) within all different examined compartments ( iels , lp 
   and glands ) . 
   in order to investigate the differential contribution 
   of hp infection to lg in an inflammatory condition like cd , the gastric tissue 
   inflammatory subpopulation profile was investigated , by immunohistochemistry , 
   and compared between the 4 groups of patients . 
   past studies focused mainly on 
   the surface epithelial infiltrate as well as on the superficial pit gastric 
   epithelium invasion by lymphocytes , and to a lesser extent on the infiltrate in 
   the lp and in the gastric glands . 
   the main finding of the 
   present study was the highest prevalence lg in pediatric cdhp followed by cdhp . 
   forty five percent of cd 
   patients are estimated to have lg like in our study [ 8 , 12 ] 
   . however , lg appears 
   to be similarly frequent in hp positive children with and without cd . 
   previous studies demonstrated that lg was found to be more common in hp 
   positive children without cd than in hp negative children without cd . 
   there are still controversial results on 
   the contribution of cd and hp infection to lg . 
   moreover , the association 
   between these pathologies to lg is not well established [ 1315 ] . 
   lymphocytic 
   gastritis was reported in 3645% of children with cd [ 6 , 10 , 13 ] , and disappears 
   after a gluten free diet . 
   hp infection is less frequently found in patients 
   with lg [ 13% ] than with the usual chronic antral gastritis [ 6590% ] . 
   cd is 
   considered to be a population at greatest risk for lg compared to hp affected 
   patients . 
   our study confirmed the 
   published results of an increased number of iels in both cd and hp infected 
   patients . 
   surprisingly , cd patients with associated hp infection showed a lower rate of 
   lg . 
   this evidence might be explained by the well known limited roll of 
   bacterial infection in cytotoxicity . 
   hp convergent the immune response towards 
   th2 response and suppress the th1 immune response . 
   previous investigators 
   have published several sets of data concerning the composition of the 
   lymphocytic infiltrates in the different diseases [ 1620 ] . 
   drut et al found 
   that lg in pediatric cd patients contains a peculiar cd3 , cd7 and cd8 
   intraepithelial lymphocyte population , that is not associated with the presence 
   of cd4 , cd20 , cd56 and cd57 iels . in hp gastritis there is an increased 
   number of mononuclear cells in the gastric lp , including b and t lymphocytes , plasma cells , macrophages and mast 
   cells . 
   it has been shown that hp stimulates b lymphocytes and causes an increase 
   in their numbers predominantly in the lp . 
   although immunity against hp 
   infection appears not to be dependent on b cells , the role of t cells still 
   remains to be clarified . 
   it appears however that the b cell proliferation 
   might be driven by activated lymphocytes ( cd4 + cells ) that might recall and 
   activate mononuclear phagocytes . 
   demonstrated 
   that the cellular response includes an innate nonspecific response represented 
   mainly by polymorphonuclear cells and macrophages , as well as a t cell response 
   with abundant positive staining with anti - cd8 antibodies , was observed 
   indicative of a predominance of suppressor / cytotoxic t lymphocytes both in the 
   lp and in the epithelium . 
   similarly we also showed 
   the presence of cd3 + iels in both diseases ( cd ; hp infection ) . despite a 
   potential additive effect between these two pathological processes , it is 
   impossible to differentiate between them , based only on the number of the cd3 + 
   iels in the antral mucosa . 
   cd3 staining is a pan t lymphocyte marker and does 
   not differentiate between cd4 helper and cd8 suppressor / cytotoxic cells , 
   therefore we aimed to characterize the t cell subsets immunophenotype ( cd4 + , 
   cd8 + , cd57 ) . in our study the cd8 + 
   iels were significantly higher in cd patients ( 20/100 epithelial cells ) , 
   compared to controls ( 1/100 epithelial cells ) or hp infected patients without 
   cd ( 2/100 epithelial cells ) . 
   we assume that in undiagnosed patients with 
   histological features compatible with lg , higher counts of cd8 + iels may imply 
   that the diagnosis is cd rather than hp gastritis . 
   our findings support the 
   published data that cd8+/cd4 iels are involved significantly in the 
   pathogenesis of cd . 
   in our study , the low expression of cd57 in 
   the lymphoid cells , both in the epithelium , in the lp as well as in the mucosal 
   glands indicate that nk cells may play a negligible role in these two pathologies . 
   we also tried to differentiate between 
   these two causative agents of lg by looking at the proliferation marker , ki67 . 
   although both conditions were associated with a prominent adaptive immune 
   activity , no increase in the proliferation index of the surface epithelium was 
   demonstrated in these pathologies . 
   dendritic cells ( cna42 + ) which serve as 
   professional antigen presenting cells did not show an increased expression in 
   both pathologies . 
   this may indicate that the process of antigen presentation 
   occurred in the lymph nodes . 
   this notion is supported by the absence of cd4 ( t 
   helper ) cells in the immune cell infiltrates found in the affected tissues . 
   in addition to all the 
   above , we confirmed the published results that the highest number of lymphoid 
   follicles was observed in a similar proportion of children with or without cd , 
   who were hp positive independent of the presence of lg . 
   the inflammatory 
   infiltrate in the lp and in the mucosal glands does not contribute to the 
   differentiation between these diseases . in summary , our study 
   aimed to explore the contribution of cd and hp infection to lg and to 
   characterize the different immunoprofiles of the gastric inflammatory cells 
   involved in these diseases . 
   we were looking for an applicable histological tool 
   that might differentiate between cases of cd and hp infection with overlapping 
   clinical and histological features . 
   we suggest that in very 
   young patients infected by hp and suspicion for having atypical cd ( negative 
   serology with increased iels with normal villous architecture - marsh i 
   classification ) with a debatable diagnosis of cd versus hp infection , the 
   number of cd8 + iels in the antrum might hint toward the diagnosis of cd rather 
   than hp infection , and the number of lymphoid follicles directs toward the 
   diagnosis of hp infection . 
   thus , it is important to include immunohistochemical 
   analysis of cd8 lymphocytes in the antrum in undefined cases of cd .
summary: lymphocytic gastritis ( lg ) is associated with helicobacter pylori ( hp ) and celiac disease ( cd ) . 
   we aimed to clarify 
       the relationship between hp infection and cd by defining a unique histopathology profile of lg in these two diseases . 
   forty patients who underwent upper endoscopy were divided into four groups : eight controls , ten active cd patients 
       without hp , twelve cd negative with hp , and ten active cd with hp infection . 
   antral samples were assessed by 
       immunohistochemical staining for cd20 , cd3 , cd4 , cd8 , cd57 , cna42 , and ki67 for lymphoid aggregates , 
       intraepithelial lymphocytes ( iels ) number , density of lamina propria ( lp ) lymphocytes , and inflammatory glandular 
       involvement . only iels positive for cd3 and cd8 were increased significantly in cd patients with or without hp infection . 
   hp did not contribute to the number of cd8 iels . 
   in complicated cases with hp and suspicious for cd , the number of 
       cd8 + iels hints toward a cd rather than hp infection .