Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic epigastric pain, dyspepsia, and intermittent nausea. Symptoms are refractory to standard PPI therapy. History significant for [weight loss/diarrhea/anemia]. No history of NSAID overuse or H. pylori infection. Symptoms are consistent with lymphocytic/collagenous gastritis presentation.
Clinical Examination Findings
Abdominal examination reveals mild epigastric tenderness upon deep palpation. No guarding, rigidity, or rebound tenderness. Bowel sounds are normal. No palpable masses or organomegaly. Mucosal assessment via endoscopy shows [nodularity/erythema/atrophy] of the gastric mucosa; biopsies confirm increased intraepithelial lymphocytes (>25/100 epithelial cells) and/or subepithelial collagen deposition.
Treatment Protocol
Initiate trial of budesonide (9 mg daily) for induction of remission. Consider dietary modification, including gluten-free diet if celiac disease is suspected. PPIs may be continued if symptoms persist, though efficacy is variable. Monitor for clinical response and repeat endoscopy with biopsies in 3-6 months to assess histological healing.