Utility of ancillary stains for Helicobacter pylori in near-normal gastric biopsies

Reducing reflex first-line prescriptions in a surgical pathology laboratory: toward sustainable practice with positive economic and clinical effects

In surgical pathology departments, reflex first-line techniques (RFLTs) are aimed at reducing workloads and addressing recent shortages of medical personnel. However, the impacts thereof on economic and diagnostic factors have been poorly addressed. Also, in the era of global warming, environmental considerations are crucial. This study assessed the economic and diagnostic efficacies of routine pathological RFLT and the quality of care and sustainability. Ten RFLTs of the Bordeaux University Hospital pathology department (six special stains, one cytology technique, and three immunohistochemical tests) were studied. First, a retrospective economic analysis evaluated the average cost of these RFLTs per slide and per year. Second, diagnostic relevance was prospectively surveyed. Third, the effects of changes made were analyzed over 2 years. The ten RFLTs were associated with average annual costs of €46,708. Diagnostic relevance analysis indicated that most stains were unnecessary; only 17% were requested as second-line techniques. Elimination of 7/10 tests afforded annual cost savings of €22,522 and reduced the workload by 5568 tests/year, without compromising the workflow or diagnostic quality. Seven of ten RFLTs could be eliminated without compromising diagnostic quality or the workflow. This afforded not only financial benefits but also positive social and environmental impacts. We offer valuable insights into appropriate practices in surgical pathology laboratories. Collaboration between the medical and technical teams was crucial; other healthcare sectors would also benefit from our approach.

Retrospective analysis of discordant results between histology and other clinical diagnostic tests on helicobacter pylori infection

BACKGROUND

A reliable test is essential for diagnosing Helicobacter pylori (H. pylori) infection, and crucial for managing H. pylori-related diseases. Serving as an excellent method for detecting H. pylori infection, histologic examination is a test that clinicians heavily rely on, especially when complemented with immunohistochemistry (IHC). Additionally, other diagnostic tests for H. pylori, such as the rapid urease test (CLO test) and stool antigen test (SA), are also highly sensitive and specific. Typically, the results of histology and other tests align with each other. However, on rare occasions, discrepancy between histopathology and other H. pylori diagnostic tests occurs.

AIM

To investigate the discordance between histology and other H. pylori tests, the underlying causes, and the impact on clinical management.

METHODS

Pathology reports of gastric biopsies were retrieved spanning August 2013 and July 2018. Reports were included in the study only if there were other H. pylori tests within seven days of the biopsy. These additional tests include CLO test, SA, and H. pylori culture. Concordance between histopathology and other tests was determined based on the consistency of results. In instances where histology results were negative while other tests were positive, the slides were retrieved for re-assessment, and the clinical chart was reviewed.

RESULTS

Of 1396 pathology reports were identified, each accompanied by one additional H. pylori test. The concordance rates in detecting H. pylori infection between biopsy and other tests did not exhibit significant differences based on the number of biopsy fragments. 117 discrepant cases were identified. Only 20 cases (9 with CLO test and 11 with SA) had negative biopsy but positive results in other tests. Four cases initially stained with Warthin-Starry turned out to be positive for H. pylori with subsequent IHC staining. Among the remaining 16 true discrepant cases, 10 patients were on proton pump inhibitors before the biopsy and/or other tests. Most patients underwent treatment, except for two who were untreated, and two patients who were lost to follow-up.

CONCLUSION

There are rare discrepant cases with negative biopsy but positive in SA or CLO test. Various factors may contribute to this inconsistency. Most patients in such cases had undergone treatment.

Impact of Helicobacter pylori colonization density and depth on gastritis severity

BACKGROUND AND OBJECTIVES

Helicobacter pylori (H. pylori) infection is the most common etiology of chronic gastric. H. pylori gastritis would gradually evolve into gastric atrophy, intestinal metaplasia, dysplasia and malignant lesions. Herein, this study aimed to investigate the potential impact of H. pylori colonization density and depth on the severity of histological parameters of gastritis.

METHODS

A prospective monocentric study was conducted from December 2019 to July 2022, enrolling patients with confirmed chronic H. pylori infection via histopathological evaluation. H. pylori colonization status was detected by immunohistochemical staining, pathological changes of gastric specimens were detected by hematoxylin eosin staining. Epidemiological, endoscopic and histopathological data were collected.

RESULTS

A total of 1120 patients with a mean age of 45.8 years were included. Regardless of the previous history of H. pylori eradication treatment, significant correlations were observed between the density and depth of H. pylori colonization and the intensity of gastritis activity (all P < 0.05). Patients with the lowest level of H. pylori colonization density and depth exhibited the highest level of mild activity. In whole participants and anti-H. pylori treatment-naive participants, H. pylori colonization density and depth were markedly correlated with the severity of chronic gastritis and gastric atrophy (all P < 0.05). H. pylori colonization density (P = 0.001) and depth (P = 0.047) were significantly associated with ulcer formation in patients naive to any anti-H. pylori treatment. No significant associations were observed between the density and depth of H. pylori colonization and other histopathological findings including lymphadenia, lymphoid follicle formation and dysplasia.

CONCLUSIONS

As the density and depth of H. pylori colonization increased, so did the activity and severity of gastritis, along with an elevated risk of ulcer formation.

Helicobacter pylori Infection, Its Laboratory Diagnosis, and Antimicrobial Resistance: a Perspective of Clinical Relevance

Despite the recent decrease in overall prevalence of Helicobacter pylori infection, morbidity and mortality rates associated with gastric cancer remain high. The antimicrobial resistance developments and treatment failure are fueling the global burden of H. pylori-associated gastric complications. Accurate diagnosis remains the opening move for treatment and eradication of infections caused by microorganisms. Although several reports have been published on diagnostic approaches for H. pylori infection, most lack the data regarding diagnosis from a clinical perspective. Therefore, we provide an intensive, comprehensive, and updated description of the currently available diagnostic methods that can help clinicians, infection diagnosis professionals, and H. pylori researchers working on infection epidemiology to broaden their understanding and to select appropriate diagnostic methods. We also emphasize appropriate diagnostic approaches based on clinical settings (either clinical diagnosis or mass screening), patient factors (either age or other predisposing factors), and clinical factors (either upper gastrointestinal bleeding or partial gastrectomy) and appropriate methods to be considered for evaluating eradication efficacy. Furthermore, to cope with the increasing trend of antimicrobial resistance, a better understanding of its emergence and current diagnostic approaches for resistance detection remain inevitable.

Objective Visual Analog Scale for Biopsy Diagnosis of Helicobacter pylori Infection in Clinical Practice

Historic and current pathology society guidelines recommend using visual gestalt to identify substantial inflammatory cell infiltrate in Helicobacter pylori gastritis, but these scales were subjectively designed. This study aims to objectively investigate the density of inflammation that justifies additional workup for H. pylori infection. We retrospectively identified 2 patient cohorts who had undergone endoscopy with gastric biopsies; 1 with H. pylori infection (n=66), confirmed with a positive stool antigen test and/or Campylobacter-like organism test, and 1 without infection (n=81). Antral and body biopsies were selected from each case, if available, and stained with MUM-1 to highlight mucosal plasma cells. Digital analysis was performed to calculate the number of plasma cells/mm2, termed the "inflammatory score" (IS). Patients with H. pylori infection had an average of 1289 plasma cells/mm2 in the antrum and 835 plasma cells/mm2 in the body, compared with 346 plasma cells/mm2 in the antrum and 178 plasma cells/mm2 in the body in patients without infection. IS cut-off values for a positive infection were 714 plasma cells/mm2 in the antrum and 316 plasma cells/mm2 in the body, with high sensitivities and specificities in both the antrum (92%, 92%) and body (85%, 84%), respectively. A visual analog scale was created to provide a histologic correlate of the observed IS ranges and cut-offs. This practical and objective scale is associated with a high sensitivity and specificity for diagnosing H. pylori infection and justifies moving away from upfront universal H. pylori testing in routine clinical practice.

Evaluation of Better Staining Method among Hematoxylin and Eosin, Giemsa and Periodic Acid Schiff-Alcian Blue for the Detection of Helicobacter pylori in Gastric Biopsies

Background

This study was undertaken to evaluate the preferred method (Giemsa or periodic acid Schiff-Alcian blue [PAS-AB] stains) of detecting Helicobacter pylori (H. pylori) in gastric mucosal biopsies in terms of sensitivity, specificity and applicability. To the best of my knowledge, this is the first report comparing Giemsa and PAS-AB staining for the detection of H. pylori in such biopsies.

Methods

The formalin-fixed paraffin-embedded blocks of 49 gastric biopsies from different patients were collected from the archive of anatomical pathology at King Abdulaziz Medical City, National Guard, Riyadh, Saudi Arabia. From each block, three slides were prepared and analysed using the hematoxylin and eosin (H&E), Giemsa and PAS-AB stains to detect the presence/absence of H. pylori, and the results were compared in terms of sensitivity, specificity and applicability.

Results

The majority of the biopsies in this study showed antrum-type gastric mucosa. Only 15 biopsies showed active gastritis, whereas the rest showed chronic gastritis. Three biopsies showed intestinal metaplasia. All were detected by PAS-AB stain, but only two-thirds were detected by H&E stain. Fifteen gastric biopsies showed H. pylori infection in general and in 13 of them, active gastritis cases were discovered. Fourteen out of these 15 H. pylori infection cases were detected by Giemsa stain, whereas only 13 cases were detected by H&E stain. PAS-AB stain showed the worst results since it demonstrated only 40% sensitivity and 67.65% specificity in H. pylori detection.

Conclusion

Giemsa stain has better sensitivity and specificity in gastric H. pylori infection detection than PAS-AB. Therefore, using PAS-AB stain to detect H. pylori infection is not recommended.

An Update on the Role of Immunohistochemistry in the Evaluation of Gastrointestinal Tract Disorders

As in other organ systems, immunohistochemistry (IHC) serves as an ancillary diagnostic tool for a wide variety of neoplastic and non-neoplastic disorders, including infections, work-up of inflammatory conditions, and subtyping neoplasms of the gastrointestinal (GI) tract. In addition, IHC is also used to detect a variety of prognostic and predictive molecular biomarkers for carcinomas of the GI tract. The purpose of this review is to highlight the use of IHC in common diagnostic scenarios throughout the tubular GI tract. The clinical indication and guidelines for performing IHC for detecting Helicobacter pylori is discussed along with role of gastrin and neuroendocrine markers in the diagnosis of autoimmune metaplastic atrophic gastritis. The major portion of this review discusses the use of IHC in the diagnostic workup of malignant neoplasms of the GI tract, such as adenocarcinoma versus squamous cell carcinoma, workup of poorly differentiated malignant neoplasms, and evaluation of uncommon gastric neoplasms (alpha-feto protein-producing carcinomas) and switch/sucrose-nonfermenting complex-deficient carcinomas. Lastly, localization of neuroendocrine tumors of unknown origin to aid clinical management, as well as HPV-driven anal neoplasia and IHC in the workup of basaloid anal neoplasms are also reviewed.

Utilization Rate of Helicobacter pylori Immunohistochemistry Is Not Associated With the Diagnostic Rate of Helicobacter pylori Infection

BACKGROUND

Utilization rates of immunohistochemistry (IHC) for the diagnosis of Helicobacter pylori infection may vary by laboratory and/or pathologists. IHC for H. pylori is not performed routinely in our practice. Instead, it is used in selected cases at the pathologists' discretion (and according to their specific criteria). The purpose of this study was to determine if IHC utilization rates correlated with rates of detecting H. pylori infection.

MATERIALS AND METHODS

We searched our records and investigated all gastric biopsies for 1 calendar year. H. pylori diagnostic rate and IHC utilization rate was calculated for each pathologist.

RESULTS

Overall, the rate of diagnosis was 12.1% and the IHC utilization rate was 45.2%. Individual pathologists had H. pylori diagnostic rates ranging from 3.6% to 34.1% (median: 11.1%) and IHC utilization ranging from 17.1% to 95.2% (median: 42.2%). The rate of detection of H. pylori infection among pathologists showed no significant correlation with rates of IHC utilization (Pearson coefficient=0.121).

CONCLUSIONS

Increasing use of IHC is not independently associated with the diagnostic rate of infection. Ultimately, if we assume that the case mix was similar for each pathologist, it suggests that more liberal criteria to order IHC does not result in more infections diagnosed.

Comparison of tests for detecting Helicobacter pylori in gastric biopsy

AIM

To figure out a method to detect Helicobacter pylori (H. pylori) infection that is of high sensitivity and specificity as well as clinically easy-handling by comparing four common H. pylori detection methods.

METHODS

Four hundred and ninety gastric mucosa biopsies were tested separately by the rapid urease test (RUT), fluorescence quantitative polymerase chain reaction (qPCR), methylene blue staining, and immunohis-tochemistry (IHC). Positive rates obtained by the different methods were analyzed by the χ² test.

RESULTS

The positive rates of H. pylori obtained by RUT, qPCR, methylene blue staining, and IHC were 18.98%, 63.88%, 32.04%, and 38.16%, respectively, which were statistically different (P < 0.005).

CONCLUSION

IHC provides a visual scene for observers, and there is a sharp contrast for IHC images between H. pylori infected and surrounding areas. This feature can facilitate researchers to obtain morphological information with potential clinical value. Furthermore, IHC protocols are friendly to instruments and operators. Hence, we recommend that IHC be used to detect H. pylori in gastric biopsies for diagnosing H. pylori infection and determining H. pylori treatment.

Pathologic Features of Infectious Gastritis

This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.

Fifth Chinese National Consensus Report on the management of Helicobacter pylori infection

BACKGROUND

Since the 'Fourth Chinese National Consensus Report on the management of H. pylori infection' was published in 2012, three important consensuses (Kyoto global consensus report on H. pylori gastritis, The Toronto Consensus for the Treatment of H. pylori Infection in Adults and Management of H. pylori infection-the Maastricht V/Florence Consensus Report) have been published regarding the management of H. pylori infection.

MATERIALS AND METHODS

A Delphi method was adopted to develop the consensus of relevant 'statements'. First, the established 'statements' were sent to experts via email. Second, after undergoing two rounds of consultation, the initial statements were discussed face to face and revised in the conference item by item on 16 December 2016. Finally, 21 core members of conferees participated in the final vote of statements. Voting for each statement was performed using an electronic system with levels of agreements shown on the screen in real time.

RESULTS

Consensus contents contained a total of 48 "statements" and related 6 parts, including indications for H. pylori eradication, diagnosis, treatment, H. pylori and gastric cancer, H. pylori infection in special populations, H. pylori and gastrointestinal microbiota.

CONCLUSIONS

Recommendations are provided on the basis of the best available evidence.

Sensitivity of Helicobacter pylori detection by Giemsa staining is poor in comparison with immunohistochemistry and fluorescent in situ hybridization and strongly depends on inflammatory activity

BACKGROUND

Conventional stainings (including H&E and special stains like Giemsa) are the most widely applied histopathologic detection methods of Helicobacter pylori (HP).

MATERIALS AND METHODS

We aimed to compare the diagnostic performance of Giemsa staining with immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH) on a monocentric cohort of 2896 gastric biopsies and relate results to histologic alterations in order to find such histopathologic subgroups in which these methods underperform. All cases were categorized regarding presence or absence of chronic gastritis, inflammatory activity, and mucosal structural alterations.

RESULTS

Giemsa revealed 687 cases (23.7%), IHC 795 cases (27.5%), and FISH 788 cases (27.2%) as being HP positive. Giemsa showed significantly lower overall sensitivity (83.3%) compared to IHC (98.8%) and FISH (98.0%). Moreover, the sensitivity of Giemsa dramatically dropped to 33.6% in the nonactive cases. We found that sensitivity of Giemsa strongly depends on HP density and, accordingly, on the presence of activity. Structural alterations (intestinal metaplasia, atrophy, etc.) had only no or weak effect on sensitivity of the three stainings. Both IHC and FISH proved to be equally reliable HP detecting techniques whose diagnostic performance is minimally influenced by mucosal inflammatory and structural alterations contrary to conventional stainings.

CONCLUSIONS

We highly recommend immunohistochemistry for clinically susceptible, nonactive chronic gastritis cases, if the conventional stain-based HP detection is negative. Moreover, we recommend to use IHC more widely as basic HP stain. Helicobacter pylori FISH technique is primarily recommended to determine bacterial clarithromycin resistance. Furthermore, it is another accurate diagnostic tool for HP.

A Strategy for Helicobacter Immunohistochemistry Utilization in Pediatric Practice: Insights From Morphologic and Cost-Benefit Analyses

OBJECTIVES

Recent studies in adults have examined the utility of immunohistochemistry (IHC) in detecting Helicobacter in gastric biopsy specimens and reached differing conclusions. Dedicated cost-benefit analysis of Helicobacter IHC in pediatric gastric biopsy specimens has not been performed.

METHODS

From 1,955 pediatric gastric biopsies in a 1-year period, we identified 63 Helicobacter -positive and 120 Helicobacter -negative biopsy specimens. All cases were scored according to the Updated Sydney System for the severity of inflammation.

RESULTS

We observed that pediatric Helicobacter infection was significantly associated with germinal center formation, active inflammation, oxyntic mucosa with moderate to severe chronic inflammation, and antral mucosa with any chronic inflammation, exclusive of mild and superficial chronic inflammation. At least one associated pattern was seen in each Helicobacter -positive biopsy specimen. In comparison with adults, pediatric Helicobacter -positive biopsy specimens are more likely to lack acute inflammation and more likely to show moderate to marked chronic inflammation.

CONCLUSIONS

We recommend performing Helicobacter IHC on pediatric gastric biopsy specimens with any of the above inflammatory patterns. This approach can sensitively identify pediatric patients with Helicobacter gastritis, limit IHC staining to approximately 30% of all gastric biopsy specimens, and reduce costs by up to $55,306.90 per 1,000 biopsy specimens.

Diagnostic of Helicobacter pylori infection

There is progress in endoscopy techniques. While it is not yet possible to detect Helicobacter pylori directly in the stomach, it becomes easier to detect the mucosal changes induced by the bacteria. Some small changes can also increase the sensitivity of the invasive tests, for example culture or histology, but the wide use of proton-pump inhibitors has a negative impact on these tests. Only molecular methods are able to detect a limited load of bacteria, especially by using real-time PCR but also with new methods, for example dual-priming oligonucleotide-based PCR, loop-medicated isothermal amplification, droplet-digital PCR or a multiple genetic analysis system. Among the noninvasive tests, urea breath test remains a test of major interest, while there are attempts to develop an ammonia breath test and other nanosensor devices. A new antigen stool test, a chemoluminescence immunoassay using the LIAISON apparatus has also been tested for the first time with success. Despite its limitations, serology remains the most popular test to detect H. pylori antibodies. It also allows pepsinogen dosage which is of interest for detecting atrophy.

Epidemiology and Diagnosis of Helicobacter pylori infection

During the period reviewed, prevalence studies were essentially performed in less economically advanced countries and a high prevalence was found. The traditional risk factors for Helicobacter pylori positivity were mostly found. Transmission studied by molecular typing showed a familial transmission. The eventual role of water transmission was explored in several studies with controversial results. Concerning diagnosis, most of the invasive and noninvasive methods used for the diagnosis of H. pylori infection are long standing with efficient performance. The most interesting recent improvements in H. pylori diagnosis include advances in endoscopy, developments in molecular methods, and the introduction of omics-based techniques. Interpretation of old or newer method should take into account the pretest probability and the prevalence of H. pylori in the population under investigation.

Diagnosis of Helicobacter pylori Infection in the Proton Pump Inhibitor Era

Proton pump inhibitors (PPI) are a major cause of false-negative Helicobacter pylori test results. Detecting PPI use and stopping it 2 weeks before testing is the preferred approach to improve the reliability of H pylori diagnostic tests. Immunoblot and molecular methods may be useful for the detection of H pylori infection in difficult cases. When conventional tests are negative and eradication is strongly indicated, empirical H pylori treatment should be considered. In this article, an updated critical review of the usefulness of the various invasive and noninvasive tests in the context of extensive PPI use is provided.