Kyoto classification risk scoring system and endoscopic grading of gastric intestinal metaplasia for gastric cancer: Multicenter observation study in Japan

Long-term endoscopic gastric mucosal changes up to 20 years after Helicobacter pylori eradication therapy

Helicobacter pylori eradication therapy reduces the risk of gastric cancer. However, it is unclear whether the severity of risk factors for gastric cancer such as atrophy and intestinal metaplasia are reduced after eradication in the long term. We aimed to study long-term changes in endoscopic risk factors for gastric cancer up to 20 years post-eradication. The endoscopic severity of gastritis according to the Kyoto Classification of Gastritis in 167 patients was retrospectively evaluated over an average follow-up 15.7 years. A significant improvement in mean total gastric cancer risk score (4.36 ± 1.66 to 2.69 ± 1.07, p < 0.001), atrophy (1.73 ± 0.44 to 1.61 ± 0.49, p = 0.004), and diffuse redness (1.22 ± 0.79 to 0.02 ± 0.13, p < 0.001) was observed compared to baseline in the Eradication group. However, there was no change in the never infection and current infection groups. The frequency of map-like redness increased over time until 15 years (3.6% to 18.7%, p = 0.03). The Cancer group had significantly higher risk scores at all time points. Endoscopic atrophy significantly improved in eradicated patients over long-term, suggested that eradication is one of the key elements in gastric cancer prevention. Individualized surveillance strategies based on endoscopic gastritis severity before eradication may be important for those at risk of gastric cancer.

Impact of metabolic dysfunction-associated fatty liver disease on the incidence of Helicobacter pylori-negative gastric cancer

AIM

The incidence of Helicobacter pylori-negative gastric cancer (HPNGC) is increasing worldwide. Recently, metabolic dysfunction-associated fatty liver disease (MAFLD) has been reported to be associated with various cancers, but its association with HPNGC has not been reported. We aimed to identify important independent factors associated with HPNGC, including MAFLD.

METHODS

This multicenter observational cohort study enrolled patients with gastric cancer (n = 1078) and health checkup examinees (n = 17 408). We analyzed patients with HPNGC (n = 26) and healthy participants with no H. pylori infection or any abnormal findings on upper gastrointestinal endoscopy (n = 1130). A logistic regression model was used to identify independent factors associated with HPNGC. The priority of the factors associated with HPNGC was evaluated using a decision-tree algorithm and random forest analysis.

RESULTS

Among all patients with gastric cancer, 2.4% (26/1078) were diagnosed with HPNGC (mean age, 64 years; male/female, 13/13). In the logistic regression analysis, age, smoking, and MAFLD (odds ratio, 6.5359; 95% confidence interval, 2.5451-16.7841; p < 0.0001) were identified as independent factors associated with HPNGC. Metabolic dysfunction-associated fatty liver disease was also identified as the most important classifier for the presence of HPNGC in decision-tree analyses. Helicobacter pylori-negative gastric cancer was observed in 5.2% of patients with MAFLD and 0.8% of patients without MAFLD. In the random forest analysis of the HPNGC, MAFLD was identified as the distinguishing factor with the highest variable importance (0.32).

CONCLUSIONS

Metabolic dysfunction-associated fatty liver disease was the most influential independent factor associated with HPNGC. These findings suggest that fatty liver and metabolic dysfunction could be involved in the pathogenesis of HPNGC.

Non-improvement of atrophic gastritis in cases of gastric cancer after successful Helicobacter pylori eradication therapy

BACKGROUND

Helicobacter pylori (H. pylori) infection is closely related to the development of gastric cancer (GC). However, GC can develop even after H. pylori eradication. Therefore, it would be extremely useful if GC could be predicted after eradication. The Kyoto classification score for gastritis (GA) is closely related to cancer risk. However, how the score for GC changes after eradication before onset is not well understood.

AIM

To investigate the characteristics of the progression of Kyoto classification scores for GC after H. pylori eradication.

METHODS

Eradication of H. pylori was confirmed in all patients using either the urea breath test or the stool antigen test. The Kyoto classification score of GC patients was evaluated by endoscopy at the time of event onset and three years earlier. In addition, the modified atrophy score was evaluated and compared between the GC group and the control GA group.

RESULTS

In total, 30 cases of early GC and 30 cases of chronic GA were evaluated. The pathology of the cancer cases was differentiated adenocarcinoma, except for one case of undifferentiated adenocarcinoma. The total score of the Kyoto classification was significantly higher in the GC group both at the time of cancer onset and three years earlier (4.97 vs 3.73, P = 0.0034; 4.2 vs 3.1, P = 0.0035, respectively). The modified atrophy score was significantly higher in the GC group both at the time of cancer onset and three years earlier and was significantly improved only in the GA group (5.3 vs 5.3, P = 0.5; 3.73 vs 3.1, P = 0.0475, respectively).

CONCLUSION

The course of the modified atrophy score is useful for predicting the onset of GC after eradication. Patients with severe atrophy after H. pylori eradication require careful monitoring.

Endoscopic and histological risk stratification for gastric cancer using gastric intestinal metaplasia

BACKGROUND AND AIM

Intestinal metaplasia (IM) of the gastric mucosa is strongly associated with the risk of gastric cancer (GC). This study was performed to investigate the usefulness of endoscopic and histological risk stratification for GC using IM.

METHODS

This was a post-hoc analysis of a multicenter prospective study involving 10 Japanese facilities (UMINCTR000027023). The ridge/tubulovillous pattern, light blue crest (LBC), white opaque substance (WOS), endoscopic grading of gastric IM (EGGIM) score using non-magnifying image-enhanced endoscopy, and operative link on gastric IM assessment (OLGIM) were evaluated for their associations with GC risk in all patients.

RESULTS

In total, 380 patients (115 with GC and 265 without GC) were analyzed. The presence of an LBC (limited to antrum: odds ratio [OR] 2.4 [95% confidence interval 1.1-5.0], extended to corpus: OR 3.6 [2.1-6.3]), the presence of WOS (limited to antrum: OR 3.0 [1.7-5.3], extended to corpus: OR 4.2 [2.1-8.2]), and histological IM (limited to antrum: OR 3.2 [1.4-7.4], extended to corpus: OR 8.5 [4.5-16.0]) were significantly associated with GC risk. Additionally, the EGGIM score (5-8 points: OR 8.8 [4.4-16.0]) and OLGIM (stage III/IV: OR 12.5 [6.1-25.8]) were useful for stratification of GC risk. The area under the receiver operating characteristic curve value for GC risk was 0.740 for OLGIM and 0.706 for EGGIM.

CONCLUSIONS

The LBC, WOS, EGGIM, and OLGIM were strongly associated with GC risk in Japanese patients. This finding can be useful for GC risk assessment in daily clinical practice.

The value of LCI-based modified Kyoto classification risk scoring system in predicting the risk of early gastric cancer

OBJECTIVE

To study and compare the value of the Kyoto classification risk scoring system and the modified Kyoto classification risk scoring system based on linked color imaging (LCI) in predicting the risk of early gastric cancer.

METHODS

One hundred and fifty patients with pathologically confirmed non-cardia early gastric cancer by endoscopic LCI and 150 non-gastric cancer patients matched for age and gender were included. Basic patient data and whole gastric endoscopic images under LCI were collected, and the images were scored according to the LCI-based Kyoto classification risk scoring system and the LCI-based modified Kyoto classification risk scoring system.

RESULTS

Compared with the LCI-based Kyoto classification risk scoring system, the LCI-based modified Kyoto classification risk scoring system had a higher AUC for predicting the risk of early gastric cancer (0.723 vs. 0.784, p = 0.023), with a score of ≥3 being the best cutoff value for predicting the risk of early gastric cancer (sensitivity 61.33%, specificity 86.00%), and scores of 3 to 5 were significantly associated with early gastric carcinogenesis significantly (OR = 9.032, 95% CI: 4.995-16.330, p < 0.001).

CONCLUSIONS

Compared with the LCI-based Kyoto classification risk scoring system, the LCI-based Kyoto modified classification risk scoring system has a better value for predicting the risk of early gastric cancer, and the score of 3 to 5 is a high-risk factor for the risk of early gastric cancer development, which is more strongly correlated with the risk of early gastric cancer.

Histopathological staging of atrophic lesions of gastric mucosa

Objective

To study the histopathological staging of atrophic lesions of the gastric mucosa.

Methods

Histology and immunohistochemistry were used to closely examine 2144 specimens of atrophic gastric mucosa that were taken from endoscopic biopsies.

Results

When the gastric mucosa epithelium is affected by infection, chemical stimulation, immune factors, genetic factors, and other factors, it may cause an atrophy of gastric mucosa epithelium and a decrease in the number of glands, intestinal metaplasia, hyperplasia of smooth muscle fibers, and atrophy of stem cells in the proliferative zone. In this study, we characterized the above lesions as atrophic lesions of the gastric mucosa. Based on the morphological and histological characteristics of the lesion, as well as the law of cell proliferation and transformation during its occurrence and development, we propose five stages. We also noted the onset age, gender correlation, and histopathological characteristics of each stage of gastric mucosal atrophies.

Conclusion

Understanding the pathological staging of gastric mucosal atrophy is essential for treating patients correctly and keeping track of changes in malignant cells. It is also very important in preventing the initiation of gastric cancer or from getting worse.

RE.GA.IN.: the Real-world Gastritis Initiative-updating the updates

At the end of the last century, a far-sighted 'working party' held in Sydney, Australia addressed the clinicopathological issues related to gastric inflammatory diseases. A few years later, an international conference held in Houston, Texas, USA critically updated the seminal Sydney classification. In line with these initiatives, Kyoto Global Consensus Report, flanked by the Maastricht-Florence conferences, added new clinical evidence to the gastritis clinicopathological puzzle.The most relevant topics related to the gastric inflammatory diseases have been addressed by the Real-world Gastritis Initiative (RE.GA.IN.), from disease definitions to the clinical diagnosis and prognosis. This paper reports the conclusions of the RE.GA.IN. consensus process, which culminated in Venice in November 2022 after more than 8 months of intense global scientific deliberations. A forum of gastritis scholars from five continents participated in the multidisciplinary RE.GA.IN. consensus. After lively debates on the most controversial aspects of the gastritis spectrum, the RE.GA.IN. Faculty amalgamated complementary knowledge to distil patient-centred, evidence-based statements to assist health professionals in their real-world clinical practice. The sections of this report focus on: the epidemiology of gastritis; Helicobacter pylori as dominant aetiology of environmental gastritis and as the most important determinant of the gastric oncogenetic field; the evolving knowledge on gastric autoimmunity; the clinicopathological relevance of gastric microbiota; the new diagnostic horizons of endoscopy; and the clinical priority of histologically reporting gastritis in terms of staging. The ultimate goal of RE.GA.IN. was and remains the promotion of further improvement in the clinical management of patients with gastritis.

An artificial intelligence system for chronic atrophic gastritis diagnosis and risk stratification under white light endoscopy

BACKGROUND AND AIMS

The diagnosis and stratification of gastric atrophy (GA) predict patients' gastric cancer progression risk and determine endoscopy surveillance interval. We aimed to construct an artificial intelligence (AI) system for GA endoscopic identification and risk stratification based on the Kimura-Takemoto classification.

METHODS

We constructed the system using two trained models and verified its performance. First, we retrospectively collected 869 images and 119 videos to compare its performance with that of endoscopists in identifying GA. Then, we included original image cases of 102 patients to validate the system for stratifying GA and comparing it with endoscopists with different experiences.

RESULTS

The sensitivity of model 1 was higher than that of endoscopists (92.72% vs. 76.85 %) at image level and also higher than that of experts (94.87% vs. 85.90 %) at video level. The system outperformed experts in stratifying GA (overall accuracy: 81.37 %, 73.04 %, p = 0.045). The accuracy of this system in classifying non-GA, mild GA, moderate GA, and severe GA was 80.00 %, 77.42 %, 83.33 %, and 85.71 %, comparable to that of experts and better than that of seniors and novices.

CONCLUSIONS

We established an expert-level system for GA endoscopic identification and risk stratification. It has great potential for endoscopic assessment and surveillance determinations.

Precision endoscopy in the era of climate change and sustainability

Global warming caused by increased greenhouse gas (GHG) emissions has a direct impact on human health. Gastrointestinal (GI) endoscopy contributes significantly to GHG emissions due to energy consumption, reprocessing of endoscopes and accessories, production of equipment, safe disposal of biohazardous waste, and travel by patients. Moreover, GHGs are also generated in histopathology through tissue processing and the production of biopsy specimen bottles. The reduction in unnecessary surveillance endoscopies and biopsies is a practical approach to decrease GHG emissions without affecting disease outcomes. This narrative review explores the role of precision medicine in GI endoscopy, such as image-enhanced endoscopy and artificial intelligence, with a focus on decreasing unnecessary endoscopic procedures and biopsies in the surveillance and diagnosis of premalignant lesions in the esophagus, stomach, and colon. This review offers strategies to minimize unnecessary endoscopic procedures and biopsies, decrease GHG emissions, and maintain high-quality patient care, thereby contributing to sustainable healthcare practices.

Artificial intelligence for evaluating the risk of gastric cancer: reliable detection and scoring of intestinal metaplasia with deep learning algorithms

BACKGROUND AND AIMS

Gastric cancer (GC) is associated with chronic gastritis. To evaluate the risk, the Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM) system was constructed and showed a higher GC risk in stage III or IV patients, determined by the degree of intestinal metaplasia (IM). Although the OLGIM system is useful, evaluating the degree of IM requires substantial experience to produce precise scoring. Whole-slide imaging is becoming routine, but most artificial intelligence (AI) systems in pathology are focused on neoplastic lesions.

METHODS

Hematoxylin and eosin-stained slides were scanned. Images were divided into each gastric biopsy tissue sample and labeled with an IM score. IM was scored as follows: 0 (no IM), 1 (mild IM), 2 (moderate IM), and 3 (severe IM). Overall, 5753 images were prepared. A deep convolutional neural network (DCNN) model, ResNet50, was used for classification.

RESULTS

ResNet50 classified images with and without IM with a sensitivity of 97.7% and specificity of 94.6%. IM scores 2 and 3, involved as criteria of stage III or IV in the OLGIM system, were classified by ResNet50 in 18%. The respective sensitivity and specificity values of classifying IM between scores 0 and 1 and 2 and 3 were 98.5% and 94.9%, respectively. The IM scores classified by pathologists and the AI system were different in only 438 images (7.6%), and we found that ResNet50 tended to miss small foci of IM but successfully identified minimal IM areas that pathologists missed during the review.

CONCLUSIONS

Our findings suggested that this AI system would contribute to evaluating the risk of GC accuracy, reliability, and repeatability with worldwide standardization.

Staging of operative link on gastritis assessment and operative link on gastric intestinal metaplasia systems for risk assessment of early gastric cancer: a case-control study

AIMS

Operative link on gastritis assessment (OLGA) and operative link on gastric intestinal metaplasia assessment (OLGIM) systems are histological staging systems of gastritis for gastric cancer (GC) risk estimation. Intermediate OLGA/OLGIM stages are of concern in a region with high incidence of GC. This study aimed to validate OLGA and OLGIM staging systems for early GC (EGC) in Chinese population.

METHODS

This single-centre, case-control study included 196 patients with EGC and 196 age-matched and sex-matched health screening control subjects. OLGA and OLGIM systems, and other clinical parameters were evaluated using logistic regression analysis.

RESULTS

OLGA and OLGIM stages II/III/IV were more prevalent in patients with EGC than in the control subjects. Multivariable analysis revealed family history of GC, previous Helicobacter pylori (H. pylori) infection, OLGA stages II and III-IV, OLGIM stages II and III-IV as independent risk factors for EGC (ORs, 4.04, 1.87, 2.52, 6.79, 4.11 and 10.78, respectively). Area under the receiver operating characteristic curve on EGC risk estimation was improved for OLGIM compared with OLGA (0.78 vs 0.71, p<0.001). Autoantibody seropositivity of gastric mucosa was not associated with EGC risk stratified by H. pylori status.

CONCLUSIONS

Surveillance of intermediate-risk patients (OLGA/OLGIM II) should be emphasised in our region. The OLGIM may be preferred over the OLGA for EGC risk estimation.

Comparison of different risk stratifications for gastric cancer and establishing a simplified risk-scoring model based on the Kyoto classification

BACKGROUND AND AIM

The study aims to assess the value of different risk stratifications in diagnosing early gastric cancer (GC) and explore risk factors based on Kyoto gastritis classification.

METHODS

This study was a single-centered cross-sectional study; all epidemiological data and endoscopic findings were obtained prospectively. To evaluate the proportion of GC in each risk stratification and to compare the diagnostic performance of different methods using the receiver operating characteristic curve, univariable and multivariable analyses were used to explore the correlation between endoscopic findings and GC.

RESULTS

A total of 240 subjects were enrolled, and the diagnostic efficacy of the Kyoto Classification Score was similar to Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM) stage, and the accuracy was higher than that of the Japanese scoring system and OLGA stage. Moderate atrophy (odds ratio [OR] = 3.52, 95% confidence interval [CI]: 1.52-8.16), severe atrophy (OR = 4.96, 95% CI: 1.75-14.04), map-like redness (OR = 9.89, 95% CI: 1.16-84.15), and xanthelasma (OR = 3.57, 95% CI: 1.15-11.15) were independent risk factors for GC. The simplified Kyoto classification (area under the receiver operating characteristic [AUROC] = 0.76, P = 0.58) based on multivariable analysis demonstrated favorable diagnostic value compared with traditional Kyoto classification score (AUROC = 0.74).

CONCLUSIONS

This study confirms the value of the Kyoto classification score and the OLGIM stage in the risk stratification of GC. Simplified Kyoto classification is also promising in risk assessment of GC but still requires validation in the population.

Metachronous primary gastric cancer after endoscopic resection in patients with esophageal squamous cell carcinoma

BACKGROUND

This study aimed to evaluate the risk factors for developing metachronous primary Gastric Cancer (GC) after Endoscopic Resection (ER) for esophageal Squamous Cell Carcinoma (SCC).

METHODS

We studied 283 patients with esophageal SCC who underwent ER. The study outcomes were as follows: (1) incidence of metachronous primary GC after ER; and (2) predictors for the development of metachronous primary GC after ER by the Cox proportional hazards model.

RESULTS

The median follow-up was 43.1 months (1.81-79.1), and the 3-year cumulative incidence of metachronous primary GC was 6.5% (95%CI: 4.1-10.4). The incidence of metachronous primary GC during the follow-up period was 2.31 per 100 person-years. The frequencies of severe gastric atrophy and macrocytosis at the timing of ER were significantly higher in patients with than without metachronous primary GC (91.7% vs. 73.2%, p = 0.0422, 20.8% vs. 5.2%, p = 0.0046, respectively). Severe gastric atrophy was associated with the development of metachronous primary GC (sex-and-age adjusted hazard ratio (HR) [95%CI] = 4.12 [0.95-27.78], p = 0.0093). Macrocytosis was associated with the development of metachronous primary GC (sex-and-age adjusted HR = 4.76 [1.75-13.0], p = 0.0012) and found to be an independent predictor for metachronous primary GC by multivariate Cox proportional hazards analysis (HR [95%CI] = 4.35 [1.60-11.84], p = 0.004).

CONCLUSIONS

Severe gastric atrophy and macrocytosis should be noted in the development of metachronous primary GC after ER for esophageal SCC. In particular, macrocytosis at the timing of ER was considered an important predictor.

CLINICAL TRIALS REGISTRY NUMBER

UMIN000001676.

Risk assessment of metachronous gastric cancer after endoscopic submucosal dissection based on endoscopic intestinal metaplasia

Background and Aim

The incidence of metachronous gastric cancer (MGC) after endoscopic treatment for early gastric cancer (EGC) is high, but a method of risk assessment for MGC based on endoscopic findings has not been established. In this study, we focused on endoscopic intestinal metaplasia (IM) and investigated the risk for MGC after endoscopic submucosal dissection (ESD) for EGC.

Methods

This retrospective observational study involved patients who underwent curative ESD for EGC from April 2015 to January 2021. We assessed endoscopic IM using the pretreatment endoscopic examination images. The severity of endoscopic IM was classified into four levels: 0 (none), 1 (mild), 2 (moderate), and 3 (severe). Four different gastric areas were evaluated. We divided the patients into a low-score group and a high-score group, and compared the cumulative incidence of MGC.

Results

In total, 156 patients who met the inclusion criteria were followed up for at least 12 months after ESD, and MGC developed in 14 patients during a mean period oof 41.5 months. The endoscopic IM scores in the lesser curvature of the antrum, lesser curvature of the corpus, and greater curvature of the corpus were higher in patients with MGC than in those without MGC. In the corpus, the 5-year cumulative incidence of MGC was significantly higher in the high-score group than in the low-score group (29.8% vs 10.0%, P = 0.004).

Conclusion

The severity of endoscopic corpus IM was associated with MGC. Thus, patients with severe corpus IM at the time of ESD require careful examination and intensive follow-up.

Helicobacter pylori-associated Chronic Atrophic Gastritis and Progression of Gastric Carcinogenesis

Chronic inflammation due to a Helicobacter pylori (H. pylori) infection is a representative cause of gastric cancer that can promote gastric carcinogenesis by abnormally activating immune cells and increasing the inflammatory cytokines levels. H. pylori infections directly cause DNA double-strand breaks in gastric epithelial cells and genetic damage by increasing the enzymatic activity of cytidine deaminase. Eventually, gastric cancer is induced through dysplasia. Hypermethylation of tumor suppressor genes is an important cause of gastric cancer because of a H. pylori infection. In addition, the changes in gastric microbiota and the mucosal inflammatory changes associated with a co-infection with the Epstein-Barr virus are associated with gastric cancer development. DNA damage induced by H. pylori and the subsequent responses of gastric stem cells have implications for gastric carcinogenesis. Although the pathogenesis of H. pylori has been established, many uncertainties remain, requiring more study.

Gastric cancer incidence based on endoscopic Kyoto classification of gastritis

BACKGROUND

Gastric cancer (GC) incidence based on the endoscopic Kyoto classification of gastritis has not been systematically investigated using time-to-event analysis.

AIM

To examine GC incidence in an endoscopic surveillance cohort.

METHODS

This study was retrospectively conducted at the Toyoshima Endoscopy Clinic. Patients who underwent two or more esophagogastroduodenoscopies were enrolled. GC incidence was based on Kyoto classification scores, such as atrophy, intestinal metaplasia (IM), enlarged folds (EFs), nodularity, diffuse redness (DR), and total Kyoto scores. Hazard ratios (HRs) adjusted for age and sex were calculated using a Cox hazard model.

RESULTS

A total of 6718 patients were enrolled (median age 54.0 years; men 44.2%). During the follow-up period (max 5.02 years; median 2.56 years), GC developed in 34 patients. The average frequency of GCs per year was 0.19%. Kyoto atrophy scores 1 [HR with score 0 as reference: 3.66, 95% confidence interval (CI): 1.06 to 12.61], 2 (11.60, 3.82-35.27), IM score 2 (9.92, 4.37-22.54), EF score 1 (4.03, 1.63-9.96), DR scores 1 (6.22, 2.65-14.56), and 2 (10.01, 3.73-26.86) were associated with GC incidence, whereas nodularity scores were not. The total Kyoto scores of 4 (HR with total Kyoto scores 0-1 as reference: 6.23, 95%CI: 1.93 to 20.13, P = 0.002) and 5-8 (16.45, 6.29-43.03, P < 0.001) were more likely to develop GC, whereas the total Kyoto scores 2-3 were not. The HR of the total Kyoto score for developing GC per 1 rank was 1.75 (95%CI: 1.46 to 2.09, P < 0.001).

CONCLUSION

A high total Kyoto score (≥ 4) was associated with GC incidence. The endoscopy-based diagnosis of gastritis can stratify GC risk.

The conundrum of Helicobacter pylori-associated apoptosis in gastric cancer

Helicobacter pylori is a human microbial pathogen that colonizes the gastric epithelium and causes type B gastritis with varying degrees of active inflammatory infiltrates. The underlying chronic inflammation induced by H. pylori and other environmental factors may promote the development of neoplasms and adenocarcinoma of the stomach. Dysregulation of various cellular processes in the gastric epithelium and in different cells of the microenvironment is a hallmark of H. pylori infection. We address the conundrum of H. pylori-associated apoptosis and review distinct mechanisms induced in host cells that either promote or suppress apoptosis in gastric epithelial cells, often simultaneously. We highlight key processes in the microenvironment that contribute to apoptosis and gastric carcinogenesis.

Endoscopic diagnosis of Helicobacter pylori gastritis using white light imaging and texture and color enhancement imaging

Background and study aims  Texture and color enhancement imaging (TXI) is a new image-enhanced endoscopy that augments subtle tissue differences and color changes in gastric mucosa. This study aimed to compare the usefulness of TXI and white light imaging (WLI) for diagnosing Helicobacter pylori gastritis. Patients and methods  We retrospectively prepared one image set with 22 endoscopic images acquired by WLI and TXI from 60 consecutive patients individually. Five endoscopists independently reviewed the randomly displayed image sets and assessed the H. pylori infection status on endoscopy according to the Kyoto Classification of Gastritis. The primary endpoints were the accuracies of WLI and TXI in diagnosing H. pylori -active gastritis. The correlation of the endoscopic features with the three H. pylori infection statuses (current infection, past infection, and noninfection) was also evaluated. Results  Diagnostic accuracy for active gastritis was significantly higher in TXI than in WLI (85.3 % vs. 78.7 %; P  = 0.034). All the specific endoscopic features associated with H. pylori infection statuses had a higher odds ratio with TXI than with WLI. Additionally, interobserver agreement among the five reviewers was higher in TXI than in WLI, except for one pair. Conclusions  TXI may improve the endoscopic diagnosis accuracy for H. pylori infection.

Vietnam Association of Gastroenterology (VNAGE) consensus on the management of Helicobacter pylori infection

Helicobacter pylori (H. pylori) infection is prevalent and has a rapidly increasing antibiotic resistance rate in Vietnam. Reinfection is quite common, and gastric carcinoma remains one of the most common malignancies, which is not uncommon to develop after successful eradication. The purpose of this consensus is to provide updated recommendations on the management of H. pylori infection in the country. The consensus panel consisted of 32 experts from 14 major universities and institutions in Vietnam who were invited to review the evidence and develop the statements using the Delphi method. The process followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The consensus level was defined as ≥80% for agreement on the proposed statements. Due to the limited availability of high-quality local evidence, this consensus was also based on high-quality evidence from international studies, especially those conducted in other populations in the Asia-Pacific region. The panel finally reached a consensus on 27 statements after two voting rounds, which consisted of four sections (1) indications for testing and selection of diagnostic tests (2), treatment regimens, (3) post-treatment confirmation of H. pylori status, and (4) reinfection prevention methods and follow-up after eradication. Important issues that require further evidence include studies on third-line regimens, strategies to prevent H. pylori reinfection, and post-eradication follow-up for precancerous gastric lesions. We hope this consensus will help guide the current clinical practice in Vietnam and promote multicenter studies in the country and international collaborations.

Magnifying endoscopy with narrow-band imaging for diagnosis of subtype of gastric intestinal metaplasia

BACKGROUND AND AIM

Patients with incomplete gastric intestinal metaplasia (GIM) have a higher risk of gastric cancer (GC) than those with complete GIM. We aimed to clarify whether micromucosal patterns of GIM in magnifying endoscopy with narrow-band imaging (M-NBI) were useful for diagnosis of incomplete GIM.

METHODS

We enrolled patients with a history of endoscopic resection of GC or detailed inspection for suspicious or definite GC. The antrum greater curvature and corpus lesser curvature were regions of interest. Areas with endoscopic findings of light blue crest and/or white opaque substance (WOS) were defined as endoscopic GIM, and subsequent M-NBI was applied. Micromucosal patterns were classified into Foveola and Groove types, and targeted biopsies were performed on GIM with each pattern. GIM was classified into complete and incomplete types using mucin (MUC)2, MUC5AC, MUC6, and CD10 immunohistochemical staining. The primary endpoint was the association between micromucosal pattern and histological subtype. The secondary endpoint was endoscopic findings associated with incomplete GIM.

RESULTS

We analyzed 98 patients with 156 GIMs. Univariate analysis (odds ratio [OR] 3.4, P = 0.004), but not multivariate analysis (OR 0.87, P = 0.822), demonstrated a significant association between micromucosal pattern and subtype. The antrum (OR 3.7, P = 0.006) and WOS (OR 43, P = 0.002) were independent predictors for incomplete GIM. The WOS had 69% sensitivity and 93% specificity.

CONCLUSIONS

The M-NBI micromucosal pattern is not useful for diagnosis of GIM subtype. WOS is a promising endoscopic indicator for diagnosis of incomplete GIM. (UMIN-CTR000041119).

Kyoto classification of gastritis: Advances and future perspectives in endoscopic diagnosis of gastritis

This editorial provides an update of the recent evidence on the endoscopy-based Kyoto classification of gastritis, clarifying the shortcomings of the Kyoto classification, and providing prospects for future research, with particular focus on the histological subtypes of gastric cancer (GC) and Helicobacter pylori (H. pylori) infection status. The total Kyoto score is designed to express GC risk on a score ranging from 0 to 8, based on the following five endoscopic findings: Atrophy, intestinal metaplasia (IM), enlarged folds (EF), nodularity, and diffuse redness (DR). The total Kyoto score reflects H. pylori status as follows: 0, ≥ 2, and ≥ 4 indicate a normal stomach, H. pylori-infected gastritis, and gastritis at risk for GC, respectively. Regular arrangement of collecting venules (RAC) predicts non-infection; EF, nodularity, and DR predict current infection; map-like redness (MLR) predicts past infection; and atrophy and IM predict current or past infection. Atrophy, IM, and EF all increase the incidence of H. pylori-infected GC. MLR is a specific risk factor for H. pylori-eradicated GC, while RAC results in less GC. Diffuse-type GC can be induced by active inflammation, which presents as EF, nodularity, and atrophy on endoscopy, as well as neutrophil and mononuclear cell infiltration on histology. In contrast, intestinal-type GC develops via atrophy and IM, and is consistent between endoscopy and histology. However, this GC risk-scoring design needs to be improved.

The role of the endoscopic grading of gastric intestinal metaplasia in assessing gastric cancer risk: A systematic review and meta-analysis

BACKGROUND AND AIM

Patients with gastric intestinal metaplasia (IM) are at increased risk of gastric cancer (GC). The endoscopic grading of gastric intestinal metaplasia (EGGIM) with high-definition endoscopes has shown the potential to facilitate GC risk stratification. However, a comprehensive review and meta-analysis of published articles are lacking. We conducted a meta-analysis to access the value of EGGIM in the assessment of histological IM.

MATERIALS

Studies were selected from PubMed, Medline, Embase, and Cochrane (last selection, Jun 2022). We extracted relevant data to calculate the accuracy of EGGIM compared with the operative link of gastric intestinal metaplasia (OLGIM) and to calculate pooled odds ratio (OR) with a 95% confidence interval (CI) assessing GC risk with different grading.

RESULTS

Four diagnostic studies and three case-control clinical trials were included in the analysis, which included 665 patients and 738 patients, respectively. Compared with OLGIM III/IV, EGGIM(5-10) had a pooled sensitivity and specificity of 0.92(95%CI 0.86-0.96) and 0.90(95%CI 0.88-0.93), and the area under the curve(AUC) was 0.9702. In assessing early GC, the pooled OR of patients with EGGIM(5-10) was 7.46(95%CI 3.41-16.31) compared with that of EGGIM(0-4).

CONCLUSIONS

EGGIM is highly consistent with OLGIM, and patients with EGGIM(5-10) are at a higher risk for early GC. Some heterogeneity in the current research suggests that we need to carry out more strict control of confounding factors.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=248691], (Prospero registration number: 248691).

Detection and Characterization of Early Gastric Cancer

In this review, we would like to focus on risk stratification and quality indicators of diagnostic upper gastrointestinal endoscopy in the detection and characterization of early gastric cancer. Preparation of the upper gastrointestinal tract with mucolytic agents or simethicone is often overlooked in the west, and this inexpensive step prior to endoscopy can greatly improve the quality of imaging of the upper digestive tract. Risk stratification based on epidemiological features including family history, Helicobacter pylori infection status, and tobacco smoking is often overlooked but may be useful to identify a subgroup of patients at higher risk of developing gastric cancer. Quality indicators of diagnostic upper gastrointestinal endoscopy are now well defined and include: minimal inspection time of 3 min, adequate photographic documentation of upper gastrointestinal landmarks, utilization of advanced endoscopic imaging technology including narrow band imaging and blue laser imaging to detect intestinal metaplasia and characterize early gastric cancer; and standardized biopsy protocols allow for histological evaluation of gastric mucosa and detection of atrophic gastritis and intestinal metaplasia. Finally, endoscopic and histologic classifications such as the Kimura–Takemoto Classification of atrophic gastritis and the OLGA–OLGIM classifications may help stratify patients at a higher risk of developing early gastric cancer.

Depictability of the upper gastrointestinal tract on forward‐viewing radial endoscopic ultrasonography versus standard upper esophagogastroduodenoscopy

Objectives

Esophagogastroduodenoscopy (EGD) is a widely used modality for investigating the upper gastrointestinal (GI) tract, similar to endoscopic ultrasonography (EUS) for the pancreaticobiliary system. A recent and novel forward‐viewing radial EUS has potential as an EGD. However, this potential has not yet been evaluated and reported in the literature. We compared the depictability of the upper GI tract on EUS using a standard EGD.

Methods

This was a prospective study in a single session in an identical patient and it was conducted at a single center.

Results

Sixty‐nine participants were enrolled in this study. A forward‐viewing radial EUS revealed equivalent visualizing performance compared with the standard EGD, except for the retroflex view of the three angular areas. Depiction scores of the anterior wall, lesser curvature, and posterior wall of the angulus in the retroflex view in the forward‐viewing radial EUS were 1.94 (95% confidence interval [CI], 1.36–2.52), 2.03 (95% CI, 1.48–2.58), and 1.93 (95% CI, 1.35–2.50), respectively. These scores were significantly lower compared with those of standard EGD scores of 2.97 (95% CI, 2.86–3.08), 2.97 (95% CI, 2.86–3.78), and 2.96 (95% CI, 2.83–3.09], respectively; p < 0.001). The rate of full‐mark score in these three angular areas was significantly lower in the forward‐viewing radial EUS than in the standard EGD (21/69, 30.4%; 23/69, 33.3%; 21/69, 30.4% vs. 67/69; 97.1%, 67/69; 97.1%, 66/69; 95.7%, p < 0.001 for all).

Conclusions

Although forward‐viewing radial EUS has the potential to simultaneously investigate the upper GI and pancreaticobiliary systems, it is too early to introduce it for this purpose.

Helicobacter pylori-induced NF-κB: trailblazer for gastric pathophysiology

NF-κB signaling pathways, induced by a variety of triggers, play a key role in regulating the expression of genes involved in the immune response and cellular responses to stress. The human pathogen Helicobacter pylori induces classical and alternative NF-κB signaling pathways via its effector ADP-L-glycero-β-D-manno-heptose (ADP-heptose). We review H. pylori- and NF-κB-dependent alterations in cellular processes and associated maladaptation leading to deleterious gastric pathophysiology that have implications for the diagnosis and treatment of gastric diseases. Therapeutic options for gastric cancer (GC) include clinically relevant small molecule inhibitors of NF-κB and epigenetic therapy approaches. In this context, gastric organoid biobanks originated from patient material, represent a valuable platform for translational applications to predict patient responses to chemotherapy, with a view to personalized medicine.