Chronic gastritis is organized into three types based on related causes: Type A is caused by . [QxMD MEDLINE Link]. A feeling of fullness in your upper abdomen after eating. by Jason Wasserman MD PhD FRCPC Patients with reactive gastropathy secondary to bile reflux typically have an enterogastric anastomosis and most commonly present with continuous burning midepigastric pain that is often exacerbated by food and recumbency. Gastric changes due to injury to the mucosa by abnormal luminal contents Alternate/Historical Names Chemical gastropathy Environmental gastritis / gastropathy Reactive gastritis Type C gastritis Some names based on specific causes Bile reflux gastritis NSAID gastritis Diagnostic Criteria Foveolar hyperplasia and expansion Avoid foods that are greasy, fried, spicy, or acidic. Re-seal . The mucus protects the cells from the strong acids normally found in the stomach. Normal gastric antrum (original magnification 100). 43(4):303-6. In contrast to H pylori gastritis, the surface epithelium lacked Ki67 expression and a downward elongation of the proliferative zone was noted. thoughts? Reactive increase in gastric mucus secretion is an adaptive defense mechanism against low-dose aspirin-induced gastropathy. The mucosa may be normal or may exhibit erythema, congestion, edema, or erosions 8. Nausea, bilious vomiting, and other dyspeptic symptoms may also be present19. What does squamous mucosa mean? Gastritis and carditis. [10]. [QxMD MEDLINE Link]. The most common cause of reactive gastropathy is the movement of bile or pancreatic secretions into the stomach from the small bowel. Read More The ingredients are tested by the manufacturer for. Antral gastritis can cause excessive discomfort in the gastrointestinal tract of those affected. [23] Although the findings are not specific, several authors claim that weight loss and a hypochromic microcytic anemia are also associated features. This medication can be purchased over the counter and works very well. [QxMD MEDLINE Link]. Surg Clin North Am. May be seen in the context of a previous resection/surgical reconstruction, e.g. In the stomach, it may be called gastric intestinal metaplasia. Arch Pathol Lab Med. Erosive gastritis is gastric mucosal erosion caused by damage to mucosal defenses. The biopsy is usually performed after the patient is sedated and a camera called an endoscope is inserted into the stomach. It may range from mild to severe, triggering vomiting in some cases. Histology of the postoperative stomach before and after diversion of bile. Antral Ulcer Symptoms Due to the location of an antral ulcer, the symptoms can be more severe and take longer to heal than another form of peptic ulcer known as a duodenal ulcer. Differential diagnosis of reactive gastropathy. [Full Text]. 1996 Oct. 20(10):1161-81, Pathology of Reactive Gastropathy. By following a healthy lifestyle and a well-balanced diet, most people can prevent gastritis from developing. Yes. Finally . In the esophagus, this condition is also known as Barrett's esophagus. Arch Pathol Lab Med. The mucosal changes seen in reactive gastropathy are usually most prominent in the antrum and prepyloric region. Nodular GAVE and gastric hyperplastic polyps have similar appearance on upper GI endoscopy (EGD) as well as histology, which could delay specific targeted therapy. The updated Sydney System. N Engl J Med. International Workshop on the Histopathology of Gastritis, Houston 1994. Gastritis can also be exacerbated by the use of certain pain medications and excessive alcohol consumption. This can lead to a burning sensation that happens with indigestion to occur in the upper abdomen. As inflammation develops in the stomachs antrum, the digestion process and also the process of the food getting emptied into the intestine will get affected. [QxMD MEDLINE Link]. tortuosity of glands in the "neck" region (S shaped glands), smooth muscle hyperplasia, scant inflammatory cells, +/-edema, +/-erosions, Sodium polystyrene sulfonate (Kayexalate). what does it mean? 39(5):700-4. Dixon MF, O'Connor HJ, Axon AT, King RF, Johnston D. Reflux gastritis: distinct histopathological entity?. Johannesson KA, Hammar E, Stael von Holstein C. Mucosal changes in the gastric remnant: long-term effects of bile reflux diversion and Helicobacter pylori infection. Mamoun Younes, MD Professor of Pathology, Director of Gastrointestinal and Liver Pathology Service, University of Texas Health Science Center at Houston, McGovern Medical School Burden WR, Hodges RP, Hsu M, O'Leary JP. Genta RM. Pathologic duodenogastric reflux associated with persistence of symptoms after cholecystectomy. Hepatologist & Transplant Hepatologist, Sign up for our free Health Library Daily Newsletter, What Is Antral Gastritis? gi doctor told me to check up in a year. This increase in intraluminal bacteria leads to subsequent generation of relatively increased concentrations of deconjugated and secondary bile acids within the refluxate. An antral ulcer is a form of peptic ulcer as it is concentrated in the stomach lining. Devon has written extensively for Bel Marra Health. Reactive gastropathy is associated with inflammatory conditions throughout the gastrointestinal tract. What is the antrum in the body? Having chronic inflammation with extensive intestinal metaplasia is the precursor for developing gastric cancer. negative h.pylori/malignancy/metaplasia/dysplasia. [13], Although it is known that NSAIDs that selectively inhibit COX-2 cause significantly fewer GI complications than nonselective COX inhibitors do, it is still unclear whether administration of selective inhibitors results in less severe reactive gastropathy (chemical gastropathy). Educational text answers on HealthTap are not intended for individual diagnosis, treatment or prescription. (Dec 2014). When they occur, symptoms can include stomach distress, such as acid reflux, ulcers, gastritis, or gastroesophageal reflux disease (GERD). Special stains for H pylori are negative. Maguilnik I, Neumann WL, Sonnenberg A, Genta RM. [14] However, most of these COX-2 inhibitors have been withdrawn from the market or have had their indications drastically limited in view of their potential serious cardiovascular side effects. Thus, inhibition of COX by NSAIDs reduces prostaglandin synthesis, thereby diminishing mucosal blood flow and decreasing mucus and bicarbonate secretion. The endoscopic findings of reactive gastropathy are mostly nonspecific. Go to Peptic Ulcer Disease for complete information on this topic. Representative histology of healthy antral mucosa (A), antral . Of all the antral gastritis symptoms, one of the most common symptoms is indigestion. Acute gastritis: Acute gastritis can include serious complications, such . [Full Text]. Reactive gastropathy refers to a group of endoscopic and histologic findings caused by chemical injury to the gastric mucosa1. Another name for this condition is chemical gastropathy. It seems that indomethacin and stress (restraint) ulcer formation were followed by a predominant fundic (oxyntic cell area) mucosal DNA increase, while in the antral mucosa this phenomenon was connected to a significant RNA increase. Stool may become dark or tarry, but this is a seldom occurrence as it is an indication of bleeding in the gastrointestinal tract. However, if left untreated, antral gastritis may lead to progressive damage of the stomach lining and potentially create conditions for bacteria to proliferate, resulting in further complication. Gas. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTk2Mjg5My1vdmVydmlldw==. Br Med J (Clin Res Ed). [11, 12] Prostaglandins are derived from arachidonic acid via the cyclooxygenase (COX) pathway. ; Plieschnegger, W.; Schmack, B.; Bordel, H.; Hfler, B.; Eherer, A.; Schulz, T.; Vieth, M. et al. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. N Engl J Med. (2005). Aliment Pharmacol Ther. Diagram of the alkaline mucous layer in the stomach with mucosal defense mechanisms. [5] The term "chemical gastropathy" was recommended by the Updated Sydney System, These features were originally described in biopsy specimens obtained from patients who had undergone gastric surgery and were felt to be specific for bile reflux. 137(4):527-31. It mixes the food with stomach acids. Northeast Ohio 216.444.7000 Appointments & Locations If your doctor is unsure about what is the exact cause of antral gastritis in your particular case, the symptoms are commonly treated with antacids. One may also feel a burning sensation in the upper abdomen. - Scant or minimal inflammatory cells (white arrow), i.e. Copyrights - 2020. Yes. (black arrow), as a tortuosity in the "neck" region of the gastric glands. Malagelada JR, Phillips SF, Shorter RG, et al. Persistent epithelial damage may result in the release of platelet-derived growth factor (PDGF), which stimulates smooth muscle proliferation, followed by fibroblastic proliferation. This is called reflux. The cause is uncertain, and the lesion may represent a response to mucosal trauma from contraction waves in the antrum. 2013 Aug. 58(8):2266-74. in government-approved facilities. enable_page_level_ads: true Iacobuzio-Donahue, Christine A.; Montgomery, Elizabeth A. The foveolar cells show regenerative changes with mucin depletion, nuclear hyperchromasia, and increased mitoses. [Full Text]. Postoperative reflux gastritis: pathophysiology and long-term outcome after Roux-en-Y diversion. K29.60 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Most people have a problem with their stomach at one time or another. If you are experiencing mild forms of gastritis discomfort, you can try some home remedies: Diet can play in important role in the manifestation of symptoms associated with any type of gastric pain, and following a gastric-specific diet is advisable to help better manage symptoms. International Workshop on the Histopathology of Gastritis, Houston 1994. This damage prevents the foveolar cells from producing mucus. 2013:393015. Is There a Genetic Link Between Gastrointestinal Tract Disorders and Alzheimer's Disease? Smoking has also been shown to cause reactive gastropathy. An antral ulcer is also known as an antral gastric ulcer. Reactive increase in gastric mucus secretion is an adaptive defense mechanism against low-dose aspirin-induced gastropathy. Reflux gastritis in the intact stomach. Schoenfeld P, Kimmey MB, Scheiman J, Bjorkman D, Laine L. Review article: nonsteroidal anti-inflammatory drug-associated gastrointestinal complications--guidelines for prevention and treatment. Are there neutrophils in the mucosa? We'll go over some of the most common types of gastropathy, frequent symptoms . Treatment is supportive, with removal of the inciting cause and initiation of acid-suppressant therapy. Mod Pathol. Abha Goyal, MD is a member of the following medical societies: American Society for Clinical Pathology, American Society of Cytopathology, College of American Pathologists, United States and Canadian Academy of PathologyDisclosure: Nothing to disclose. Weir, MR.; Espaillat, R. (Jun 2015). 2015 May. The results probably reflect regeneration process from an. November 9, 2022. Squamous cells are flat cells that look similar to fish scales when viewed under the microscope. You are being redirected to Bile gastritis occurring after cholecystectomy. Consuming smaller meals five to six times a day can help control gastric acid production. Gastric oxyntic and antral mucosa with active chronic h.p associated gastritis. 2003 Apr. Symptoms of Intestinal Metaplasia. The study concluded that foveolar hyperplasia, smooth muscle fibers and vasodilatation and congestion as key histologic parameters for the diagnosis of reactive gastropathy. http://emedicine.medscape.com/article/175909-overview#a6. The articles on MyPathologyReport are intended for general informational purposes only and they do not address individual circumstances. Infections, physical stress, and even the use of certain medications may be the culprit. The cumulative reflux gastritis score therefore ranged from 0 to 15. stress. They generate the mucus inside the stomach that's accountable for shielding the tummy from the gastric acids. Eur J Gastroenterol Hepatol. This finding, along with its distinctive endoscopic appearance ("watermelon stomach"), aids in the differentiation of GAVE from other similar-appearing entities. Infection is more common in rural areas and in the developing parts of the world. Sepulveda AR, Patil M. Practical approach to the pathologic diagnosis of gastritis. Although the findings are not specific, several authors claim that weight loss and a hypochromic microcytic anemia are also associated features 3. Maguilnik I, Neumann WL, Sonnenberg A, Genta RM. It stores swallowed food. [QxMD MEDLINE Link]. There is smooth muscle hyperplasia in the lamina propria with edema and congestion of superficial capillaries. Bile reflux occurs when bile (a digestive liquid produced by the liver) refluxes or backs up into your stomach and, in certain cases and, into the esophagus (the tube that connects your mouth and stomach). GASTRIC ANTRAL AND OXYNTIC MUCOSA WITH CHRONIC INACTIVE GASTRITIS: . J Clin Pathol. Billroth II. Copyright 2023 Bel Marra Health. Reactive (chemical) gastropathy is a gastric mucosal pattern of injury induced by endogenous (bile / pancreatic reflux) or exogenous (chronic use of NSAIDs, acetylsalicylic acid, ethanol or chemotherapeutics) agents . 2005 Jun 23. Gastritis in patients on non-steroidal anti-inflammatory drugs. Pernicious anemia: Autoimmune gastritis might impair vitamin B12 absorption. Although a correlation between histological evidence of chemical gastropathy and clinical manifestations, particularly risk of bleeding, is yet to be documented, reporting the suspicion of drug-induced gastric damage may help clinicians to identify patients that might benefit from change, reduction, or discontinuation of certain medications 5. Gastropathy indicates there is something wrong there, typically inf. Antonia R Sepulveda, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Gastroenterological Association, American Society for Investigative Pathology, College of American Pathologists, United States and Canadian Academy of PathologyDisclosure: Nothing to disclose. Furthermore, NSAIDs, being weak organic acids, can freely diffuse into the gastric epithelium. PDF | Sleeve gastrectomy (SG) often induces gastroesophageal reflux, with few and discordant long-term data on the risk of Barrett's esophagus (BE) in. Upper gi, antral mucosa w/ regenerative epithelial changes and vascular congestion. }); Aspirin / nonsteroidal anti-inflammatory drugs (NSAIDs). Br Med J (Clin Res Ed). [QxMD MEDLINE Link]. 340(24):1888-99. Gastric antral mucosa showing vascularcongestion and increase no of neautrophils and plsma-lymphocyticcell infiltrate vth lympoid aggregates means? none? Reactive gastropathy is characterized by prominent foveolar hyperplasia with elongation and tortuosity of the gastric pits that gives these structures a corkscrew appearance. Buxbaum KL. "Reactive gastropathy is associated with inflammatory conditions throughout the gastrointestinal tract.". Haber MM, Lopez I. Gastric histologic findings in patients with nonsteroidal anti-inflammatory drug-associated gastric ulcer. [8] The bile reflux may be visible. The mucosa becomes inflamed when something damages or weakens this protective layer, resulting in gastritis. Heart Inside Out Everything About Your Heart, All You Need to Know About High Cholesterol, Hodgkins Lymphoma Disease: Causes, Symptoms and Treatment, Glioblastoma: Types, Symptoms, Causes, Treatment and Diagnosis, Choriocarcinoma Cancer: Symptoms, Causes, Treatment and Diagnosis. Occasionally, focal intestinal metaplasia may be present. To estimate the light action spectrum for the in vivo phototherapy of H. pylori in the visible range, we performed a simulation of the light transmitted by a simple optical model of the gastric wall structure. No statement herein is to be construed as a diagnosis, treatment, preventative, or cure for any disease, disorder or abnormal physical state. 20021610541-overviewDiseases & Conditions, encoded search term (Pathology of Reactive Gastropathy) and Pathology of Reactive Gastropathy, Helicobacter Pylori-Associated Active Gastritis, Fast Five Quiz: Helicobacter pyloriAssociated Gastritis, A Guide to Managing Gastric Intestinal Metaplasia, Prevalence and Prognostic Significance of Vitamin C Deficiency in Patients With Acute Upper Gastrointestinal Bleeding, AGA Offers Key Guidance on Managing Subepithelial GI Lesions, Early Satiety, Nausea, and Vomiting After Meals: Case Presentation. Watt PC, Sloan JM, Spencer A, Kennedy TL. 46(4):269-74. 2. Chemical or reactive gastritis is caused by injury to the gastric mucosa resulting from reflux of bile and pancreatic secretions into the stomach, but it can also be caused by exogenous. [4] The secondary (deoxycholic and lithocholic) and deconjugated bile acids are more injurious to the gastric mucosa than the primary (colic and chenodeoxycholic) and conjugated bile acids. 1999 Oct. 13(10):1273-85. Gastritis is when the lining of the stomach becomes inflamed or swollen. Mod Pathol. Am J Gastroenterol. gastric antral mucosa with moderate intestinal metaplasia Please tell me what is the meaning of this . This form is rarely noticed and only affects the upper layers of the mucous membrane of the stomach. Genta RM, Sonnenberg A. Characteristics of the gastric mucosa in patients with intestinal metaplasia. 1992 Feb. 45(2):135-9. HealthTap uses cookies to enhance your site experience and for analytics and advertising purposes. The deficiency of red blood cells within the human body is an indication of Foveolar Hyperplasia. Slides were stained for caudal type homeobox 2 (CDX-2), villin, trefoil . Most stomach polyps are not cancerous, but there are some types that have a higher risk to turn into cancer. After a meal, avoid lying down for up to 2 to 3 hours. Sepulveda AR, Patil M. Practical approach to the pathologic diagnosis of gastritis. 1983 Nov 12. (Aug 2012). By using our website, you consent to our use of cookies. Stomach Disorders Your stomach is an organ between your esophagus and small intestine. Arch Pathol Lab Med. [25]. Semin Diagn Pathol. Types, Treatment, and COVID-19, No time to work out? This lining shields the stomach from the corrosive stomach acid that aids digestion by breaking down food. Indigestion is usually temporary and does not necessitate medical attention. The esophagus reacts to the injury and tries to repair itself. [15], The epithelial injury results in excessive exfoliation of the surface epithelial cells, which gives rise to a reactive foveolar hyperplasia. 2013. El-Zimaity HM, Genta RM, Graham DY. Although decreasing in overall incidence with the routine use of histamine-2 (H 2 ) blockers, the overall death rate from peptic ulcer disease has remained stable. 19-15). [16] but the more proximal oxyntic mucosa may also be affected. what that mean? Semin Diagn Pathol. Medscape Education. Pathology needs to be tested further to determine whether the lymphoid tissue is polyclonal or monoclonal. Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. When associated with bile reflux secondary to partial gastrectomy, the lesions develop near the surgical stoma, It is estimated that about 85 percent of patients can sometimes be infected by ulcer-causing bacteria called Helicobacter pylori. The bacteria cause inflammation by breaking down the stomachs protective coating. [QxMD MEDLINE Link]. Thus, inhibition of COX by NSAIDs reduces prostaglandin synthesis, thereby diminishing mucosal blood flow and decreasing mucus and bicarbonate secretion. For these, please consult a doctor (virtually or in person). He embraces an active lifestyle combining diet, exercise and healthy choices. El-Zimaity HM, Genta RM, Graham DY. The bile reflux may be visible 20. Stomach, antrum, biopsy: Reactive (chemical) gastropathy No Helicobacter organisms identified on routine H&E stained sections . The 2023 edition of ICD-10-CM K29.60 became effective on October 1, 2022. This usually happens after the stomach lining has been damaged. Common types of gastritis and gastropathy include . The mucosal changes seen in reactive gastropathy are usually most prominent in the antrum and prepyloric region. Home Colon And Digestive What causes antral gastritis and how to treat it? I. Maguilnik W. L. Neumann A Sonnenberg R. M. Genta. [10] The various bile acid species differ in their capacity to cause injury to the gastric mucosa. 39(5):524-30. Mar 16, 2018 #6 Drinking milk causes an increase in stomach acid production, which might aggravate gastritis symptoms. Excess gas may also build up within the stomach, leading to burping. Reactive gastropathy, chemical gastropathy also called gastritis of C type or "chemical gastritis" is an abnormality in the stomach caused by chemicals, . The management of this condition may include discontinuance of NSAID use along with administration of proton pump inhibitors (PPIs) and prostaglandin analogues. Create an account to follow your favorite communities and start taking part in conversations. Benign Diseases Causing Mucosal Ulcerations. Lauwers GY, Furman J, Michael LE, Balis UJ, Kubilis PS. The antrum refers to the lower portion of the stomach. BIOPSY: GASTRIC ANTRAL MUCOSA WITH MILD REACTIVE CHANGES; NEGATIVE FOR HELICOBACTER PYLORI TYPE ORGANISMS. Traditional teaching holds that the normal stomach has three types of mucosae. [2, 3, 4] It has since become apparent, however, that the constellation of histologic features seen in reactive gastropathy is a nonspecific response to chemical injury of the gastric mucosa. It can lead to ulcers and may also increase the risk of developing stomach cancer. The updated Sydney System. . Reactive gastropathy has also been referred to as chemical gastropathy, reflux gastritis, and type C gastritis6. Evolving patterns in the diagnosis of reactive gastropathy: data from a prospective Central European multicenter study with proposal of a new histologic scoring system. Genta RM. At present, reactive gastropathy is usually encountered in the clinical setting of chronic nonsteroidal anti-inflammatory drug (NSAID) use. The statements herein have not been evaluated by the Foods and Drugs Administration or Health Canada. Another name for this condition is chemical gastropathy. Antral gastritis can cause excessive discomfort in the gastrointestinal tract of those affected. 2012 Oct. 36(8):736-43. It consists of simple columnar epithelium, lamina propria, and the . Surgery. [10]. RISK IS INCREASED BUT NOT HUGE. Am J Surg Pathol 1996; 20: 116181. what are my odds of getting colon or gastric cancer. Diagnosis is by endoscopy. However, if you are facing persistent gastritis symptoms for a lengthy period of time, then its recommended to consult your Apollo doctor at the earliest and get your gastritis symptoms checked to determine if any other condition or underlying disorder is causing it. What causes reactive gastropathy? When associated with bile reflux secondary to partial gastrectomy, the lesions develop near the surgical stoma 18, but the more proximal oxyntic mucosa may also be affected. what is the treatment for this? Mine said something similar. A: Sections from the gastric antrum show portions of antral and oxyntic-type gastric mucosa with edema, vascular congestion and patchy chronic inflammation of the lamina propria. Triad rarely present; mild inflammation common. Get doctor-approved health tips, news, and more. Am J Surg Pathol. J Clin Pathol. Chronic use of the medication may cause the cells maintaining the mucosal layer of the stomach to stop working, leading to gastric acid damage on the stomach lining. here is what was written: antral-type and body type gastric mucosa with focal intestinal metaplasia. Any relief a gastritis patient experiences after drinking milk is likely to be temporary, and the inflammation tends to increase after a while. [QxMD MEDLINE Link]. [8]. These alterations in mucin expression were shown in cases of both nonsteroidal anti-inflammatory drug (NSAID)-associated and bile refluxassociated reactive gastropathy (chemical gastropathy). In the gastric mucosa, metaplasia, dysplasia, cancer, and foveolar hyperplasia (FH), a feature of reactive gastritis or gastropathy, were sought in the antrum and fundus. [14, 17], This condition was originally described in patients who had undergone partial gastrectomymost frequently, Billroth II gastric reconstruction. Although it is known that NSAIDs that selectively inhibit COX-2 cause significantly fewer gastrointestinal complications than nonselective COX inhibitors do, it is still unclear whether administration of selective inhibitors results in less severe reactive gastropathy (chemical gastropathy)15. [1] The histologic picture is characterized by foveolar hyperplasia with edema, smooth muscle hyperplasia, and congestion of superficial capillaries in the lamina propria in the absence of significant inflammation (see an example in the image below). The duodenogastric reflux results in disruption of the protective mucus barrier and direct injury to the gastric mucosa, causing backflow of hydrogen ions and epithelial damage. Further symptoms of antral gastritis are noted, such as: decreased appetite; frequent heartburn; eructation (with reduced acidity - rotten, with increased - acid); an unpleasant aftertaste in the mouth (with reflux gastritis - bitter); A whitish or grayish-yellow coating on the surface of the tongue; nausea; vomiting; bloating and flatulence; Discomfort may be experienced in the epigastric region after eating. Figure 1 shows the changes in percent preoperative weight and food intake up to 24 weeks postoperatively. Severe reactive gastropathy with mucosal erosion of gastric antral mucosa (original magnification 200). Other causes that may result in gastric mucosal erosions include Crohn's disease and viral gastritis, such as cytomegalovirus or herpesvirus. Does anyone know what it means? Bile reflux usually occurs in patients who have undergone a Billroth II partial gastrectomy; it is also recognized to occur in intact stomachs in individuals with alcohol abuse, cigarette smoking, chronic respiratory disease, or duodenal ulcer, and even in healthy subjects. 287(6403):1410-2. Ann Intern Med. Only after we are satisfied with the products. These features were originally described in biopsy specimens obtained from patients who had undergone gastric surgery and were felt to be specific for bile reflux3. 117(4):421-8. What is the Difference Between Piles, Fissures and Fistula? 1986 May. Reactive gastropathy is a relatively common finding in gastric biopsies; in most instances it is associated with either reflux of duodenal contents or therapy with nonsteroidal. FACTORS INCREASING Internal Medicine - Hematology & Oncology. lack of large numbers of neutrophils and plasma cells. Nausea.
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