Discussion: Adults with collagenous gastritis usually present with anemia, abdominal pain, and diarrhea. It is categorized by three different inflammatory environments, a lymphocytic gastritis-like pattern, an eosinophil-rich pattern, and an atrophic gastritis-like pattern. There are many proposed treatments for collagenous gastritis that have not been substantiated with clinical trial data. Observational data suggests that topical budesonide may be efficacious for collagenous gastritis. IV vedolizumab is a monoclonal antibody against a4b7 integrin and is commonly used in inflammatory bowel disease. One proposed mechanism of collagenous gastritis is band-like collagen deposition as a result of inflammation and mucosal injury however this does not consider the active inflammatory milieu found in certain cases. A more likely explanation involves an immune-mediated phenomenon related to epithelial injury and antibody production. Therefore, the efficacy of IV vedolizumab may be related to its ability to reduce the inflammatory response in the intestinal epithelium. Further investigation is necessary to assess the response to vedolizumab in other patients with collagenous gastritis.[3570] Figure 1. Histopathology of gastric body before and after treatment with IV vedolizumab. A, Initial histopathology prior to treatment showing subepithelial collagen deposition of .10 um with sloughing of surface epithelium, loss of specialized gastric glands, and an inflammatory infiltrate of eosinophils, plasma cells, and lymphocytes. B, Initial histopathology prior to treatment with Trichrome stain highlighting collagen deposition. C, Histopathology following treatment with IV vedolizumab showing healthy surface foveolar cells and specialized gastric glands with few plasma cells and no increase in subepithelial collagen. All photomicrographs obtained at 403 original magnification.

Figure 1. A: Endoscopic image of the ulcerated mass in the gastric remnant B: Biopsy of the mass showing invasive adenocarcinoma, poorly differentiated with signet ring cells.

Infectious workup was pursued when the patient reported recent unprotected sex with male partners, and revealed negative HIV screen, positive IgM/IgG antibodies to both CMV and EBV, positive treponemal antibody, and RPR titer of 1:128. After one dose of Penicillin, the patient had resolution of his symptoms and lab abnormalities. Discussion: Hepatitis is a rare manifestation of syphilis, occurring in 0.2%-3% of patients with syphilis. 1 It is defined as abnormal liver enzyme levels with serological evidence of syphilis, exclusion of other causes of liver injury, and resolution of abnormal liver enzymes after treatment of syphilis. 2 Although liver involvement in syphilis can be observed at any stage of the disease, secondary syphilis is most common. 3 The clinical presentation of syphilitic hepatitis is nonspecific and usually involves rash and fatigue. Other symptoms are jaundice, fever, and abdominal pain. Lab tests usually show a marked elevation of serum ALP. 4 AMA antibodies, typically highly specific for PBC, can be positive due to molecular mimicry. 5 A diagnosis of syphilitic hepatitis is supported here by rapid resolution in symptoms and lab abnormalities after treatment with penicillin. Syphilis should be considered a cause of liver injury in patients with high-risk features, including unprotected sex with multiple partners. Early diagnosis and prompt treatment are important for preventing progression to late syphilis.

Figure 1. (A) Colonoscope view of transverse colon; inflammation characterized by congestion, erythema, and friability in a continuous and circumferential pattern from descending colon to the transverse colon, graded as Mayo Score 3 (severe, with spontaneous bleeding, ulcerations) preventing colonoscope from advancing past the transverse colon. (B) Rectal biopsy found severe chronic active proctitis, crypt abscesses, and mucosal erosions/ulceration; negative for dysplasia or granulomas. (C) Repeat colonoscope view of transverse colon; colitis with altered vascularity, congestion and pseudopolyps in a continuous circumferential pattern from transverse colon to the cecum. (D) Final colonoscope view of transverse colon; mild to severe pancolitis from rectum to cecum, with superficial ulcerations and friability of mucosa, Mayo Score 3.

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