LabMed

Menetriers Disease

At a Glance

Menetrier's disease is a rare form of hypertrophic gastropathy. It should be suspected in middle-aged patients (average age at diagnosis is 55 years of age and more frequent in men than women) presenting epigastric pain (the most frequent symptom) variably associated with nausea and vomiting, anorexia, abdominal pain, weight loss, and sometimes gastrointestinal (GI) bleeding, such as hematemesis or lower GI bleeding. Physical examination may reveal edema of peripheral tissues, epigastric tenderness, and signs of anemia. There is also an increased incidence of thrombotic events most likely caused by low intravascular volume.

It is thought to be an acquired and progressive disorder of uncertain etiology, caused by dysregulated epidermal growth factor receptor signaling, resulting in selective expansion of surface mucous cells in the corpus and fundus of the stomach with reduced numbers of parietal cells and chief cells.

Adult form usually starts with an insidious onset followed by a progressive clinical course, whereas childhood form, which has been related with Cytomegalovirus (CMV) infection, is characterized by abrupt onset and spontaneous resolution. Some CMV-related cases with these characteristics have been described in adults.

What Tests Should I Request to Confirm My Clinical Diagnosis? In addition, what follow-up tests might be useful?

The following tests should be ordered:

  • Complete blood cell count (CBC) is recommended to recognize anemia caused by gastrointestinal chronic bleeding.

  • Serum albumin is needed, since the most common laboratory abnormality is hypoalbuminemia due to gastrointestinal protein loss.

  • Stool measurement of alpha 1 antitrypsin may be useful to assess enteric protein loss.

  • Serum gastrin should be ordered, because, as the disease progresses, the secretion of acid and pepsin decreases producing hypo- or a-chlorhydria. Despite high gastric pH, serum gastrin levels result normal to slightly elevated and not very high as one could expect, since the disease also affects the antrum and, therefore, gastrin secreting cells are reduced.

  • CMV serology is recommended, because CMV associated form of Menetrier's disease is more frequent in children but may also be seen in adults.

  • Helicobacter pylori infection diagnosis might be useful, since some studies demonstrated that Menetrier's disease ameliorates after H. pylori eradication.

(Table 1)

Table 1

Tests Results Indicative of Gastrontestinal Protein Loss in Menetrier's Disease
Serum albumin Stool alpha-1-antitrypsin Serum gastrin
Reduced Increased Normal or slightly elevated

Are There Any Factors That Might Affect the Lab Results? In particular, does your patient take any medications - OTC drugs or Herbals - that might affect the lab results?

Use of proton pump inhibitors (PPIs) raises serum levels of gastrin and may cause false-positive results.

Therapy should be discontinued at least 15 days before both tests.

What Lab Results Are Absolutely Confirmatory?

A range of laboratory values should be requested, as a single laboratory test cannot confirm or deny diagnosis.

Current guidelines recommend the integration of EGDS (EsophagoGastroDuodenoScopy) with appropriate multiple full thickness mucosal biopsies, laboratory tests results, and histological findings.

Additional Issues of Clinical Importance

The etiology of Menetrier's disease is not clear, although a causative role has been proposed for allergy, toxicants, and various infections. Hereditary disposition probably plays a minor role, but some cases, especially among siblings, have been described.

The risk of malignancy in Menetrier's disease remains uncertain, and an incidence rate of gastric carcinoma from 0 to 8% has been reported.

An association with ulcerative colitis has been described.

The extent of gastric resection is not standardized, and it has to consider the potential risk of malignant transformation of the disease. Epidermal growth factor receptor inhibitors (Cetuximab) have also demonstrated favorable results.

The only resolute treatment is total gastrectomy, especially for patients with uncontrollable bleeding or protein loss.

Errors in Tests Selection

No laboratory test or test panel presents a diagnostic sensitivity and specificity high enough to allow the clinicians to exclude or confirm the disease. Previously discussed laboratory tests must be requested as a part of the diagnostic pathway, including EGDS.

Differential diagnosis includes other hyperproliferative disorders of gastric mucosa, such as Zollinger-Ellison syndrome, Cronkite-Canada Syndrome, Peutz-Jeghers syndrome, lymphoma, and especially mucosa-associated lymphoid tissue (MALT) lymphoma.

Chronic acid suppression with increased gastrin hyperplasia of ECL and chronic gastric and acute gastritis with G cells hyperplasia could mimic Menetrier's disease.

Juvenile polyposis syndrome (JPS) and other familiar polyposis should be distinguished from Menetrier's disease. Careful anamnesis and family history, as well as endoscopy and histological findings, can help the physician. Genetically, JPS has been linked to mutation in two genes, SMAD4 and BMPRIA.

Errors may derive for any laboratory test by wrong procedures and mistakes in all phases (pre-, intra- and post-analytical) of the testing process. The main mistake is to reach a conclusion that Menetrier's disease is absent in the case of normal laboratory tests results or that it is present based on laboratory tests results alone.

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