Detection of gastric precancerous conditions in daily clinical practice: a nationwide survey

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Endoscopic and histological assessment in first-degree relatives of gastric cancer patients undergoing gastroscopy: a cross-sectional study

BACKGROUND

First-degree relatives of gastric cancer (GC) patients are known to have an increased risk of developing GC. However, guidelines in low-intermediate incidence regions often lack specific recommendations for managing both asymptomatic and symptomatic relatives at risk.

AIM

This study aimed to evaluate the differences in relevant histological findings (e.g. Helicobacter pylori infection, gastric precancerous and neoplastic conditions) between asymptomatic patients undergoing esophagogastroduodenoscopy due to first-degree relatives with GC and patients with symptoms or other clinical indications and presence of first-degree relatives with GC. The secondary aim was to identify the patient's risk factors of relevant histological findings.

METHODS

This single-center retrospective study included patients undergoing esophagogastroduodenoscopy with biopsies with the indication for first-degree relatives with GC from January 2008 to September 2022. They were analyzed in two groups based on whether they had additional symptoms or clinical indications for esophagogastroduodenoscopy.

RESULTS

Overall, 283 patients were included (54.5% asymptomatic vs. 45.5% symptomatic). Histological findings that led to changes in patient management were identified in 32% of cases. No significant differences in histological findings between the two groups were observed ( P = 0.077). A subanalysis revealed that patients with male relatives affected by GC had a higher incidence of relevant histological findings than those with female family members with GC ( P = 0.013) with an odds ratio of 3.10.

CONCLUSION

First-degree relatives of GC patients may be at risk for H. pylori infection and gastric precancerous conditions regardless of symptoms or other indications, and a proactive endoscopic screening could be considered even in countries with low GC incidence.

A novel endoscopic artificial intelligence system to assist in the diagnosis of autoimmune gastritis: a multicenter study

BACKGROUND

 Autoimmune gastritis (AIG), distinct from Helicobacter pylori-associated atrophic gastritis (HpAG), is underdiagnosed due to limited awareness. This multicenter study aimed to develop a novel endoscopic artificial intelligence (AI) system for assisting in AIG diagnosis.

METHODS

 Patients diagnosed with AIG, HpAG, or nonatrophic gastritis (NAG), were retrospectively enrolled from six centers. Endoscopic images with relevant demographic and medical data were collected for development of the AI-assisted system based on a multi-site feature fusion model. The diagnostic performance of the AI model was evaluated in internal and external datasets. Endoscopists' performance with and without AI support was tested and compared using Mann-Whitney U test. Heatmap analysis was performed to interpret AI model outputs.

RESULTS

 18 828 endoscopy images from 1070 patients (294 AIG, 386 HpAG, 390 NAG) were collected. On testing datasets, AI identified AIG with 96.9 % sensitivity, 92.2 % specificity, and area under the receiver operating characteristic curve (AUROC) of 0.990 (internal), and 90.3 % sensitivity, 93.1 % specificity, and AUROC of 0.973 (external). The performance of AI (sensitivity 91.3 %) was comparable to that of experts (87.3 %) and significantly outperformed nonexperts (70.0 %; P = 0.01). With AI support, the overall performance of endoscopists was improved (sensitivity 90.3 % [95 %CI 86.0 %-93.2 %] vs. 78.7 % [95 %CI 73.6 %-83.2 %]; P = 0.008). Heatmap analysis revealed consistent focus of AI on atrophic areas.

CONCLUSIONS

 This novel AI system demonstrated expert-level performance in identifying AIG and enhanced the diagnostic ability of endoscopists. Its application could be useful in guiding biopsy sampling and improving early detection of AIG.

Prevalence of Endoscopic and Histological Lesions at Upper Endoscopy: A Cross-Sectional, Multicentre Study in Clinical Practice

Background/Aim

Prevalence of gastroduodenal endoscopic and histological lesions may modify over time due to different factors. We assessed both macroscopic and histological lesions currently detected at upper endoscopy performed in routine practice.

Patients and Methods

Clinical, endoscopic, and histological data of consecutive adult patients referred for upper endoscopy in the 28 participating centres were analysed. Only patients who underwent the first endoscopic examination were considered. Prevalence of erosive/ulcerative lesions, cancers and extensive precancerous lesions in the stomach, and Helicobacter pylori infection was computed.

Results

A total of 1,431 patients underwent endoscopy for gastro-oesophageal reflux symptoms (31.5%), dyspepsia (29.4%), or alarm symptoms (18.5%). Erosive oesophagitis or Barrett's oesophagus was detected in 210 (14.7%) cases, peptic ulcer in 49 (3.4%), and a neoplastic lesion in 17 (1.2%). H. pylori was present in 201 (22.6%) cases, and extensive precancerous lesions on gastric mucosa in 46 (5.6%) patients. Gastric lesions were more prevalent in patients aged ≥50 years (26% vs. 18%; p = 0.001), and peptic ulcers were more frequently detected in patients with H. pylori (9.4% vs. 2.3%; p = 0.001) and in males (5.8% vs. 1.6%; p = 0.001), while neoplastic lesions in patients with alarm symptoms (3.8% vs. 0.6%; p = 0.001).

Conclusions

The overall endoscopic lesions were more prevalent in patients aged ≥50 years, peptic ulcer and erosions were more frequent in H. pylori-infected patients, and extensive gastric precancerous lesions were present in less than 6% of cases.

Upper endoscopy in elderly patients: a multicentre, cross-sectional study

BACKGROUND

Both macroscopic and histological lesions are frequently detected at upper endoscopy in elderly patients. We assessed the prevalence of main endoscopic and histological alterations in elderly (> 65 years old) patients.

METHODS

In this study, clinical, endoscopic and histological features of patients referred for upper endoscopy in clinical practice were retrieved. Both univariate and multivariate analyses were executed. Comparisons with previous data were performed.

RESULTS

A total of 1336 underwent upper endoscopy in the 28 participating centres. At endoscopy, at least one macroscopic lesion was present in overall 420 (31.4%) patients. Erosive gastritis (13.3%) and erosive oesophagitis (9.8%) were the most prevalent lesions, whilst Barrett's oesophagus, gastric ulcer, duodenal ulcer and erosive duodenitis were observed in 1.8%, 2%, 1.4% and 3.1% patients, respectively. Nine (0.6%) cases of oesophageal, 25 (1.8%) gastric and 2 (0.1%) duodenal neoplasia were detected. At histology, Helicobacter pylori infection was diagnosed in 99 (15.9%) patients, and extensive precancerous lesions on gastric mucosa were detected in 80 (14.5%) patients. Endoscopic lesions were more frequent in males, at first endoscopy and in those with alarm symptoms and lower during PPI therapy. At multivariate analysis, PPI therapy significantly reduced the probability of finding endoscopic lesions (OR: 0.68, 95% CI: 0.46-0.99; P = 0.04), whilst neoplastic lesions were associated with presence of alarm symptoms (OR: 1.5, 95% CI: 1.1-2.1; P = 0.005).

CONCLUSIONS

We found that the frequency of erosive and neoplastic lesions remained high in elderly patients, whilst the prevalence of both H. pylori infection and peptic ulcer was decreased.

The real-time analysis of gastric juice (Endofaster) for detection of Helicobacter Pylori: a reliable tool in substitution of histology

BACKGROUND

EndoFaster perform gastric juice analysis providing real-time Helicobacter pylori (HP) diagnosis during esophagogastroduodenoscopy (EGD), based on ammonium level. We aimed to assess its accuracy in detecting HP infection compared to the paired histology and to establish the optimum ammonium concentration cut-off point (COP).

METHODS

Consecutive adult outpatients referred for EGD were prospectively enrolled between December 2021 and March 2022. In-patients, those with surgically altered anatomy, suspected neoplasia, and bleeding were excluded. EndoFaster and histology were performed in all patients, with additional stool antigen test (SAT) reserved for discordant cases. EndoFaster diagnostic measures were calculated, and ammonium level COP established using AUROC curve analysis.

RESULTS

101 patients (64 female, mean age 56.7±16.1 years) were included. HP infection was diagnosed in 35 (34.6%) and 15 (14.8%) patients by EndoFaster and histology, respectively. Diagnostic accuracy in comparison with histology was 77.8% (95%CI 68.3% - 85.5%). After implementing SAT for gold standard assessment, EndoFaster accuracy increased to 81.6% (95%CI 72.5%-88.7%). AUROC curve (0.93±0.03, 95%CI 0.86-0.99) identified an ammonium COP of ≥67.5ppm. Using the new COP, EndoFaster accuracy further increased to 88.8% (95%CI 80.8%-94.2%).

CONCLUSIONS

Endofaster showed high accuracy for HP detection, with moderate agreement to histology. An ammonium COP of 67.5 ppm seems to be the threshold with the highest accuracy for HP detection.

Prevalence of Gastric Precursor Lesions in Countries With Differential Gastric Cancer Burden: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The prevalence of precursor lesions for gastric cancer (GC) and the differential burden between countries of varying GC risk is not well-understood. We conducted a systematic review and meta-analysis to estimate the global prevalence of precursor lesions.

METHODS

We estimated the prevalence of atrophic gastritis (AG), gastric intestinal metaplasia (IM), and dysplasia in regions with low, medium, and high GC incidence. Because IM is an advanced manifestation of AG, we assessed the prevalence of less advanced precursors, regardless of the presence of more advanced lesions. Prevalence was sub-stratified by Helicobacter pylori infection, symptomatology, and period (<2000, 2000-2010, and >2010).

RESULTS

Among the 582 articles that underwent full-text review, 166 studies met inclusion criteria. The global prevalence estimates of AG, IM, and dysplasia were 25.4%, 16.2%, and 2.0%, respectively, on the basis of 126 studies that reported the prevalence of less advanced precursors, regardless of the presence of more advanced lesions. The prevalence of all precursor lesions was higher in high and medium compared with low GC incidence countries (P < .01). Prevalence of AG and IM was significantly higher among H pylori-infected individuals (P < .01) but not statistically different between symptomatic and asymptomatic individuals (P > .17). All precursors demonstrated a secular decrease in prevalence over time.

CONCLUSIONS

Gastric precursor lesions have differences in prevalence in regions with differential GC incidence and are associated with H pylori infection. Because of the substantial prevalence of precursor lesions in both symptomatic and asymptomatic individuals, symptomatic evaluation may not be sufficient to identify individuals at risk. These estimates provide important insights for tailoring GC prevention strategies.

Can Gastric Juice Analysis with EndoFaster® Reduce the Environmental Impact of Upper Endoscopy?

Gastrointestinal (GI) endoscopy services are in third place as major contributors to CO2 emissions among healthcare facilities, especially due to their massive waste production. One of the measures suggested to reduce this environmental impact is a reduction in histological examinations performed on biopsy specimens taken during endoscopy. A reliable candidate to reduce the rate of biopsies and, consequently, the impact of CO2 emissions could be EndoFaster®, an innovative medical device that allows one to suspect or rule out both H. pylori infection and precancerous lesions on the gastric mucosa by analyzing a small amount of gastric juice aspirated during endoscopy in real time. In the present study, we investigated the ability of EndoFaster® to reduce the environmental impact of upper endoscopy, comparing the CO2 production of standard biopsy sampling as suggested in guidelines and biopsies guided by real-time EndoFaster® results during endoscopy. By estimating an overall 90% rate of biopsies according to standard guidelines and a reduction of 50% of gastric biopsies based on EndoFaster® results, we calculated a 44% overall reduction in CO2 emissions, demonstrating that by using this tool, it is possible to distinctly reduce the contribution of upper endoscopy to global warming.

Impact of improved upper endoscopy quality on detection of gastric precancerous lesions

OBJECTIVE

Intestinal metaplasia (IM) is the point of no return in gastric carcinogenesis, and patients with extensive (antrum plus corpus) IM are at high risk of developing gastric cancer. We evaluated the impact of improved gastroscopy quality on the detection of gastric IM in an Italian area at high risk for gastric cancer.

METHODS

Data of consecutive patients with gastric biopsies according to the updated Sydney System observed in 2013, 2016 and 2019 resulting in IM diagnosis were retrieved. In the first period, endoscopy was performed with standard white light instruments. In the second period, preendoscopic gastric preparation was administered, and the examinations lasting at least 7 min with standard endoscopes were performed. In the third period, the latter procedure was followed, with virtual chromoendoscopy equipped instruments. The prevalence of IM in any gastric site and that of extensive IM were compared among the three periods.

RESULTS

Data of 3485 patients were available. The detection of IM in at least one gastric site increased from 29.9 to 33.6% and 34.5% (95% CI, 32.1-36.8) in the first, second and third period, respectively. The difference was statistically significant between the first and last (P = 0.02; OR, 1.24; 95% CI, 1.04-1.48) period. When considering extensive IM, the detection increased from 4.28 to 6.1% and 5.44%, although the difference failed to reach statistical significance (P = 0.076).

CONCLUSION

Our data showed that implementation of a quality protocol increased the probability to detect IM in the stomach, allowing us to select patients deserving stricter follow-up.

Real-time gastric juice analysis with EndoFaster for H. pylori diagnosis: a large, multicentre study

BACKGROUND

Helicobacter pylori infection is the main cause of the most frequent gastroduodenal diseases. Because its prevalence is decreasing in developed countries, gastric biopsies are negative in several patients. By measuring ammonium in the gastric juice, EndoFaster allows to exclude H. pylori infection during endoscopy. This study aimed to assess the accuracy of device versions working with either 6 ml or 3 ml of gastric juice.

STUDY DESIGN

This prospective study involved 12 endoscopic units. During endoscopy, EndoFaster testing was performed and standard five gastric biopsies were taken. The accuracy was calculated by considering histological assessment as the gold standard for H. pylori diagnosis.

RESULTS

Gastric juice analysis was attempted in 1279 patients, but it failed in 131 (15.5%) and in 10 (2.3%), with the 6 ml and the 3 ml device, respectively (P &lt; 0.001). Overall, EndoFaster detected H. pylori infection with an 86.3% sensitivity, 83.3% specificity, 52.7% positive predictive value, 96.6% negative predictive value and 83.8% accuracy. The performance was not affected either by ongoing proton pump inhibitor therapy or a previous H. pylori eradication. No significant difference in accuracy emerged between the two versions of the device.

CONCLUSION

The novel version of the EndoFaster device operating with 3 ml gastric juice may be performed in virtually all patients, and it allows excluding H. pylori infection with a very high accuracy. Gastric biopsies can be avoided in a definite portion of cases without endoscopic lesions or other clinical indications.

Is There an Optimal Age Threshold for Searching for Intestinal Metaplasia on Gastric Mucosa in Western Populations?

INTRODUCTION

Since screening programs for gastric cancer are not applicable in Western countries, identification and follow-up of gastric precancerous lesions, such as extensive intestinal metaplasia (IM), are worthwhile to increase the diagnosis of cancer at an early stage. We investigated whether an optimal age threshold to detect extensive IM in a European country exists.

METHODS

This was a post hoc analysis of prospectively collected data in a nationwide study involving consecutive patients aged between 50 and 65 years who underwent an upper endoscopy with the standard 5 gastric biopsies. The presence of extensive (antral and gastric body) IM on gastric mucosa was considered.

RESULTS

Data found that the prevalence of extensive IM was distinctly higher in patients aged 60-65 years, with a 2.28-fold increased probability compared to younger patients. None of the other considered factors (sex, BMI, smoking habit, first-degree family history, and symptoms) emerged as an independent predictor of extensive IM in the stomach.

CONCLUSION

When deciding for an occasional gastric cancer screening in Western populations, the choice of an age range of 60-65 years might be appropriate, allowing detection of a distinctly high prevalence of extensive IM deserving scheduled follow-up.

Optimizing the searching for H. pylori in clinical practice with EndoFasterⓇ

BACKGROUND/AIM

H. pylori plays a major role in gastroduodenal diseases. Since its incidence is decreasing in developed countries, gastric biopsies were negative in several patients managed in clinical practice. We tested whether EndoFaster^Ⓡ - a device allowing real-time H. pylori detection by gastric juice analysis - may optimize the need of biopsies.

METHODS

In this prospective, multicentre study, the accuracy of EndoFaster^Ⓡ for H. pylori detection was computed by using histology of gastric biopsies as a gold standard.

RESULTS

Data of 525 consecutive patients were available, including 90 (17.1%) patients with infection. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy of EndoFaster^Ⓡ were 87%, 84%, 53%, 97% and 85%, respectively. The overall accuracy of test was not affected neither by ongoing proton pump inhibitor therapy nor by previous eradication therapy. By using EndoFaster^Ⓡ in our series, biopsy sampling could have been eventually avoided in a total of 279 patients, accounting for a reduction of 42.3%, accepting the risk of only 8 false negative cases.

CONCLUSIONS

The very high NPV of EndoFaster^Ⓡ might allow to safely halve the need of taking gastric biopsies in unselected patients managed in clinical practice, avoiding an unavailing consume of health resources.

Diagnostic Accuracy of EndoFaster® and Narrow-Band Imaging Endoscopy in Patients with Impaired Gastric Acid Secretion: A Real-Time Prospective Study

BACKGROUND

EndoFaster® analyzes gastric juice in real time during gastroscopy allowing the detection of hypo-achlorhydric conditions, like corpus atrophic gastritis. Narrow-band imaging (NBI) endoscopy allows to accurately detect and perform target biopsies in areas of intestinal metaplasia, a histological change often associated to corpus atrophic gastritis.

AIMS

To compare the diagnostic accuracy of EndoFaster® with histological evaluation for corpus atrophic gastritis through high-resolution (HR) NBI targeted biopsies.

METHODS

Prospective study on consecutive adult patients undergoing gastroscopy between April and November 2018. Patients in therapy with proton pump inhibitors, previous gastric surgery, and/or known gastric neoplasia were excluded. At the beginning of gastroscopy, gastric juice was aspirated and analyzed by EndoFaster® in 15 seconds. Endoscopists were blinded to the report of EndoFaster®. Evaluation of gastric mucosa in HR-white light was firstly performed, then with HR-NBI allowing to perform targeted biopsies on areas suspected for intestinal metaplasia; otherwise, biopsies were performed according to the updated Sydney System protocol and sent for histopathological evaluation.

RESULTS

Overall, 124 patients were included [64% F; 56 (18-85) years]. Corpus atrophic gastritis was present in 41.9% of patients. EndoFaster® showed an accuracy for corpus atrophic gastritis diagnosis, compared to histopathological evaluation as gold standard, of 87.1% and a sensitivity, specificity, PPV, and NPV of 78.8%, 93.1%, 89.1%, and 85.9%, respectively. pH showed a positive correlation with the severity score of atrophy (r = 0.67, 95% CI: 0.73-0.81, and p < 0.0001). EndoFaster® allowed to diagnose corpus atrophic gastritis in 3.7% of patients negative to NBI (corpus atrophic gastritis without intestinal metaplasia).

CONCLUSION

EndoFaster® seems a promising tool to diagnose corpus atrophic gastritis. The evaluation of hypo-achlorhydria during gastroscopy can address bioptic sampling in corpus atrophic gastritis patients without intestinal metaplasia.

Clinical validation of Endofaster® for a rapid diagnosis of Helicobacter pylori infection

BACKGROUND

this study aimed to evaluate the diagnostic accuracy of the Endofaster® for the detection of Helicobacter pylori.

METHODS

during upper gastrointestinal endoscopy, gastric juice was aspirated to perform an analysis using the Endofaster®. This test was considered as positive when the ammonium concentration was > 67 ppm, negative when < 57 ppm and weakly positive between 57 and 67. Biopsy specimens were also taken as the gold standard.

RESULTS

among the 86 patients enrolled in the study, the Endofaster® result was positive in 23.7%, negative in 54.7% and weakly positive in 11.6%, whereas infection was detected via histology in 38.4% of patients. The accuracy was 81.4%, with a Kappa value of 0.57.

CONCLUSIONS

the Endofaster® could be useful to perform a rapid diagnosis of Helicobacter pylori infection (area under the curve = 0.81).

Helicobacter pylori and Upper Endoscopy in Systemic Sclerosis: A Cross-sectional Study in the Real World

BACKGROUND/AIMS

A role for Helicobacter pylori in triggering systemic sclerosis (SSc) has been proposed, but data are conflicting. In previous studies, infection has been generally searched for by using serology. We designed this study to assess H. pylori prevalence in SSc patients with histology of gastric mucosa, considered the criterion standard for infection diagnosis.

METHODS

This cross-sectional study enrolled 30 SSc patients who complained of upper gastrointestinal symptoms. All underwent upper endoscopy with gastric biopsies. Endoscopic alterations were recorded, and gastric mucosa biopsies were used for both histological examination and searching for H. pylori. The role for proton-pump inhibitor (PPI) therapy was considered. Fisher exact test was used for statistical analysis.

RESULTS

Data of 28 SSc patients were available, 14 with ongoing PPI therapy. Helicobacter pylori infection at histology was detected in 14.3% patients, and it equally occurred in patients with or without PPI therapy. Erosive esophagitis/Barrett esophagus was detected in 26.6% of cases. Among patients with PPI therapy, 30% received half dose only. The prevalence of intestinal metaplasia was low (14.3%). Endoscopic esophageal alterations were significantly more frequent in those patients showing anti-Scl70 antibody positivity.

CONCLUSIONS

This study showed that prevalence of H. pylori is very low in SSc patients, so that it seems not having a role in triggering SSc. Management of gastroesophageal diseases in SSc patients needs to be improved, and looking to the autoimmune profile may be of help. Thus, collaboration between rheumatologist and gastroenterologist is highly recommended.

Real-Time Diagnosis of Helicobacter pylori During Endoscopy by Gastric Juice Analysis

EndoFaster is a high precision device for gastric juice analysis in real time during gastroscopy that enables detection of Helicobacter pylori infection and hypochlorhydric/achlorhydric conditions through the measurement of ammonium concentration and gastric pH. The high accuracy and feasibility of this technology enables a more accurate diagnosis and a reduced number of histologies, focusing the attention of the endoscopist on patients with high risk for cancer progression and limiting or avoiding biopsies on the low-risk ones while also saving costs and time.

Lesiones premalignas y malignas del estómago en pacientes sin tamización para cáncer gástrico

Introducción. Para establecer una frecuencia de seguimiento como método de tamización en cáncer gástrico, se propone la endoscopia en pacientes mayores de 35 años con síntomas de dispepsia, y en pacientes mayores de 40 años con alto riesgo. La demora en la realización de la primera endoscopia en la vida de un paciente incrementa el riesgo de no detectar lesiones premalignas ni cáncer potencialmente prevenible. Los objetivos de nuestro estudio fueron describir el número de pacientes mayores de 40 años con endoscopia de primera vez y evaluar la presencia de lesiones premalignas y malignas del estómago en pacientes sin tamización. Métodos. Revisión retrospectiva de base de datos. Se describieron hallazgos de informes de histopatología en pacientes mayores de 40 años (lesiones premalignas y malignas). Adicionalmente se describieron las variables sociodemográficas de los pacientes con endoscopia de primera vez y la presencia de infección por Helicobacter pylori en la población mencionada. Resultados. Setenta y ocho pacientes (23,6 %) tuvieron una endoscopia de primera vez siendo mayores de 40 años. En el 44 % de los pacientes se encontró la presencia de Helicobacter pylori, 25,4 % de los pacientes presentaron atrofia gástrica, 23,1 % metaplasia, ningún paciente presentó displasia y un paciente (1,3 %) presentó un adenocarcinoma gástrico. Discusión. Los resultados de nuestro estudio muestran un número elevado de pacientes sin endoscopia de tamización. Nuestro estudio resalta la importancia del uso de la endoscopia de tamización en la prevención, así como en el diagnóstico temprano de cáncer gástrico y sugiere mayor adherencia a las guías de práctica clínica.

Helicobacter pylori "Test-and-Treat" strategy with urea breath test: A cost-effective strategy for the management of dyspepsia and the prevention of ulcer and gastric cancer in Spain-Results of the Hp-Breath initiative

BACKGROUND

Data from clinical trials comparing Helicobacter pylori (H. pylori) management strategies in patients with dyspepsia are limited. Cost-effectiveness simulation models might help to identify the optimal strategy.

OBJECTIVE

To assess the cost-effectiveness of the H. pylori "Test and Treat" (T&T) strategy including the use of urea breath test (UBT) vs symptomatic treatment (ST) and vs upper gastrointestinal endoscopy (UGE) as a first procedure in patients with dyspepsia.

METHODS

Three main strategies: "T&T" strategy including the use of UBT, "UGE" and "ST" have been compared using cost-effectiveness models developed in accordance with the Spanish medical practice. For the model simulations, a time horizon of 4 weeks was considered for the endpoint "Dyspepsia symptoms relief" and 10 years when using "Peptic ulcer avoided" and "Gastric cancer avoided" endpoints.

RESULTS

For the endpoint "Dyspepsia symptoms relief", T&T strategy appears to be the most cost-effective (883€/success) compared to UGE strategy and to ST strategy (respectively 1628€ and 990€/success). For the endpoint "Probability of peptic ulcer", the T&T strategy appears to be the most cost-effective (421€/peptic ulcer avoided/y) compared to UGE strategy and ST strategy (respectively 728€ and 632€/peptic ulcer avoided/y). For the endpoint "Gastric cancer avoided", the T&T strategy appears to be the most cost-effective (524€/gastric cancer avoided/y) compared to UGE strategy and "ST" strategy (respectively 716€ and 696€/gastric cancer avoided/y).

CONCLUSIONS

T&T strategy including the use of UBT is the most cost-effective medical approach for management of dyspepsia and for the prevention of ulcer and gastric cancer.

Upper Endoscopy in Patients with Extra-Oesophageal Reflux Symptoms: A Multicentre Study

BACKGROUND

There are no evidence-based recommendations for performing upper gastrointestinal endoscopy (UGIE) in patients with extra-oesophageal symptoms of gastro-oesophageal reflux disease (GORD). However, UGIEs are often performed in clinical practice in these patients. We aimed to assess the prevalence of gastro-oesophageal lesions in patients with atypical GORD symptoms.

METHODS

Patients complaining of at least one extra-oesophageal GORD symptom and undergoing UGIE in seven centres were prospectively enrolled. Clinically relevant lesions (Barrett's oesophagus, erosive oesophagitis, gastric precancerous conditions, peptic ulcer, cancer, and H. pylori infection) were statistically compared between groups regarding GORD symptoms (atypical vs. both typical and atypical), type of atypical symptoms, age, and presence of hiatal hernia.

RESULTS

Two hundred eleven patients were enrolled (male/female: 74/137; mean age: 55.5 ± 14.7 years). Barrett's oesophagus was detected in 4 (1.9%), erosive oesophagitis in 12 (5.7%), gastric precancerous conditions in 22 (10.4%), and H. pylori infection in 38 (18%) patients. Prevalence of clinically relevant lesions was lower in patients with only atypical GORD symptoms (28.6 vs. 42.5%; p = 0.046; χ2 test), in patients ≤50 years (20 vs. 44.8%; p = 0.004; χ2 test), and in those in ongoing proton pump inhibitor (PPI) therapy (21.1 vs. 40.2%; p = 0.01; χ2 test). No clinically relevant lesions were detected in patients ≤50 years, without alarm symptoms, and receiving PPI therapy. Hiatal hernia was diagnosed in only 6 patients with cardiologic and in 41 patients with ear-nose-throat symptoms (11.3 vs. 35.1%; p = 0.03; χ2 test).

CONCLUSIONS

Clinically relevant lesions are uncommon among young (≤50 years) patients with extra-oesophageal GORD symptoms. Hiatal hernia is not more prevalent in patients with cardiologic symptoms and suspicion of GORD. The usefulness of UGIE in these patients is questionable.

Autoimmune gastritis

Autoimmune gastritis (AIG) is an increasingly prevalent, organ-specific, immune-mediated disorder characterized by the destruction of gastric parietal cells, leading to the loss of intrinsic factor and reduced acid output. These alterations result in malabsorption of iron, vitamin B₁₂ (pernicious anaemia) and potentially other micronutrients. For several years, most studies have focused on pernicious anaemia only, generating confusion between the two entities. In AIG, the gastric proton pump, H⁺/K⁺ ATPase, is the major autoantigen recognized by autoreactive T cells. The T cell-dependent activation of B cells stimulates the production of anti-parietal cell antibodies, the serological hallmark of AIG. The role of Helicobacter pylori infection in activating or favouring the autoimmune process is still uncertain. Early histopathological alterations allowing a more precise and prompt recognition have recently been described. AIG is burdened by a substantial diagnostic delay as it can present with varied clinical signs including, among others, gastrointestinal symptoms and neuropsychiatric manifestations. In advanced stages, AIG might progress to neuroendocrine tumours and gastric adenocarcinoma. Management includes early detection through a proactive case-finding strategy, micronutrient supplementation and endoscopic surveillance. This Primer comprehensively describes the most important insights regarding the epidemiology, pathophysiology, diagnosis and management of AIG, focusing on the most controversial, outstanding issues and future directions.

Frequency and Types of Pathological Upper Gastrointestinal Endoscopy Findings in Clinically Healthy Individuals

BACKGROUND AND OBJECTIVE

Beyond its application for diagnostics in patients, esophagogastroduodenoscopy (EGD) is used to assess gastrointestinal drug effects in clinical trials, where the interpretation of any pathological findings depends on the respective background variability. The objective of this analysis was to characterize the occurrence of pathological findings in the upper gastrointestinal tract in symptom-free healthy individuals.

METHODS

A baseline EGD was performed in clinically healthy individuals in three clinical trials aimed to assess gastrointestinal tolerability of drugs. Pathological findings were described by type (redness, erosion, ulcer or other), number, size and location, and by clinical relevance as assessed by the endoscopist. Characteristics of volunteers were tested as potential covariates.

RESULTS

A total of 294 EGDs were assessed. Characteristics of individuals were as follows: 257 (87.4%) males, age (mean ± SD) 32.0 ± 8.1 years, body weight 76.0 ± 10.6 kg, body mass index (BMI) 24.0 ± 2.5 kg/m2, 200 consumed alcohol, 250 (of 290 where this information was available) consumed caffeine and 39 (of 152) were smokers, 30 (of 151) tested positive for H. pylori. Any pathological finding was present in 79.6%. Clinically relevant findings occurred in 44.2%, mainly erosions (39.1%). Nine stomach ulcers were observed. Only age and BMI had a statistically significant relationship to overall pathological findings [age 3.4 years higher (p = 0.027), and BMI 1.6 kg/m2 higher (p < 0.001); for clinically relevant vs no findings].

CONCLUSION

Upper gastrointestinal tract mucosal lesions, including those assessed as clinically relevant, are frequent in clinically healthy individuals, impeding the assessment of causality for both disease and drug effects on gastrointestinal health.

Chronic atrophic gastritis: Natural history, diagnosis and therapeutic management. A position paper by the Italian Society of Hospital Gastroenterologists and Digestive Endoscopists [AIGO], the Italian Society of Digestive Endoscopy [SIED], the Italian Society of Gastroenterology [SIGE], and the Italian Society of Internal Medicine [SIMI]

Chronic atrophic gastritis (CAG) is an underdiagnosed condition characterised by translational features going beyond the strict field of gastroenterology as it may manifest itself by a variable spectrum of gastric and extra-gastric symptoms and signs. It is relatively common among older adults in different parts of the world, but large variations exist. Helicobacter pylori-related CAG [multifocal] and autoimmune CAG (corpus-restricted) are apparently two different diseases, but they display overlapping features. Patients with cobalamin and/or iron deficiency anaemia or autoimmune disorders, including autoimmune thyroiditis and type 1 diabetes mellitus, should be offered screening for CAG. Pepsinogens, gastrin-17, and anti-H. pylori antibodies serum assays seem to be reliable non-invasive screening tools for the presence of CAG, helpful to identify individuals to refer to gastroscopy with five standard gastric biopsies in order to obtain histological confirmation of diagnosis. Patients with CAG are at increased risk of developing gastric cancer, and they should be estimated with histological staging systems (OLGA or OLGIM). H. pylori eradication may be beneficial by modifying the natural history of atrophy, but not that of intestinal metaplasia. Patients with advanced stages of CAG (Stage III/IV OLGA or OLGIM) should undergo endoscopic surveillance every three years, those with autoimmune CAG every three-five years. In patients with CAG, a screening for autoimmune thyroid disease and micronutrient deficiencies, including iron and vitamin B12, should be performed. The optimal treatment for dyspeptic symptoms in patients with CAG remains to be defined. Proton pump inhibitors are not indicated in hypochlorhydric CAG patients.

A single vial is enough in the absence of endoscopic suspected intestinal metaplasia - less is more!

Background: For the correct staging of chronic atrophic gastritis (AG) and gastric intestinal metaplasia (GIM) at least 4 biopsies are recommended: 2 from the antrum/incisura and 2 from the body sent in two different vials. As virtual chromoendoscopy with narrow-band-imaging (NBI) is valid both in the diagnosis and staging of GIM, it is reasonable to question the need to separate biopsy samples in all procedures. Aims: To evaluate if biopsy samples can be placed in the same vial without implications in the diagnosis and follow-up of the patient, if during gastroscopy no typical endoscopic pattern of GIM with NBI is observed. Methods: Multicentre prospective study of a consecutive sample of patients (n = 183) submitted to gastroscopy using NBI with no superficial neoplastic lesions and no suggestive areas of GIM. Biopsies of both antrum/incisure and body were performed in all patients and samples were placed in the same vial for histologic assessment [according to OLGA (operative link for gastritis assessment) and OLGIM (operative link for gastric intestinal metaplasia)], blinded to endoscopic features. Results: In all patients, OLGA and OLGIM calculation was possible as the pathologists could distinguish biopsy samples from antrum/incisure from those of gastric body. The negative predictive value was 100% for advanced stages of GIM or AG as 179 (98%) patients presented OLGIM 0 and only 4 (2%) presented OLGIM I. Regarding AG, 150 (82%) presented OLGA 0, 23 (13%) OLGA I and 10 (6%) OLGA II. Conclusion: In the absence of a typical endoscopic pattern of GIM using NBI, it is effective to place biopsies' specimens in the same vial (for Helicobacter pylori diagnosis) or even to abstain from biopsies as no single patient with significant changes seems to be missed. This change in clinical practice can have a significant impact on endoscopy costs.

DNA variants in Helicobacter pylori infected patients with chronic gastritis, dysplasia and gastric cancer

PURPOSE

The main scope of this study was to evaluate the importance of selected DNA variants for developing inflammation of gastric mucosa and carcinogenesis in gastrointestinal diseases in patients infected with Helicobacter pylori.

PATIENTS AND METHODS

Patients subjected to analysis constituted a group of 131 consecutive cases, with control groups consisting of 100 healthy volunteers and 13 dyspeptic patients. Molecular analysis included the following genes: TP53 (c.743 G > A, c.746 G > A, c.749C > T), MSH2 (c.942 + 3A > T), MLH1 (c.2041 G > A), NOD2/CARD15 (c.3016_3017insC, c.802C > T), IL1A (c.-949C > T) and IL1B (c.315C > T). DNA variants were detected using PCR-RFLP, pyrosequencing and sequencing.

RESULTS

Mutations of the analyzed genes were observed more frequently in patients with a higher degree of mucosal lesions (50.9%) than in patients with milder mucosal changes (27.6%). Single mutations and polymorphisms did not affect the course of the disease. Our analysis confirms the influence of the NOD2/CARD15 c.802C > T polymorphism on the development of mucosal changes. A correlation of the frequency of the CT genotype of the NOD2/CARD15 c.802C > T polymorphism with the NOD2/CARD15 c.3016_3017insC mutation was observed. The TT genotype frequency in the c.315C > T IL1B gene polymorphism was statistically significantly higher in patients with mucosa changes.

CONCLUSIONS

Accumulation of molecular abnormalities may increase the susceptibility to inflammatory response of the gastric mucosa in H. pylori-infected patients and play an important role in the development of chronic active gastritis, atrophy, intestinal metaplasia, dysplasia and the intestinal type of gastric cancer. The severity of gastric mucosal damage correlates with the presence of mutations in the gastric mucosa and the age of patients.

Diagnostic yield of upper endoscopy according to appropriateness: A systematic review

BACKGROUND/AIM

Despite some official guidelines are available, a substantial rate of inappropriateness for upper gastrointestinal (UGI) endoscopies has been reported. This study aimed to estimate the inappropriate rate of UGI in different countries, also including the diagnostic yield.

METHODS

A systematic review of studies on UGI endoscopy appropriateness was performed by adopting official guidelines as reference standard. Diagnostic yield of relevant endoscopic findings and cancers was compared between appropriate and inappropriate procedures. The Odd Ratio (OR) values and the Number-Needed-to-Scope (NNS) were calculated.

RESULTS

Data of 23 studies with a total of 53,392 patients were included. UGI indications were overall inappropriate in 21.7% (95% CI = 21.4-22.1) of the patients. The inappropriateness rate significantly (P < 0.0001) decreased from 35.1% in the earlier studies to 22.1%-23% in the more recent ones. A relevant finding was found in 43.3% of appropriate and in 35.1% of inappropriate endoscopies (P < 0.0001; OR: 1.42, 95% CI = 1.36-1.49; NNS = 12). Prevalence of cancers was also higher in appropriate than in inappropriate UGIs (2.98% vs. 0.09%, P < 0.0001; OR = 3.33; NNS = 48). The prevalence of detected cancers significantly (P < 0.004) increased from 1.38% in the earlier studies to 2.11% in the more recent ones, whilst prevalence of other relevant findings remained similar.

CONCLUSIONS

Rate of inappropriate UGI endoscopies is still high. Diagnostic yield of appropriate endoscopies is higher than that of inappropriate procedures, including upper GI cancers. Therefore, implementation of guidelines in clinical practice is urged.

Occurrence and predictors of metaplastic atrophic gastritis in a nation-wide consecutive endoscopic population presenting with upper gastrointestinal symptoms

OBJECTIVES

The frequency of metaplastic atrophic gastritis in noninvestigated dyspepsia and its associated symptoms pattern are not known. This study aimed to assess the occurrence and clinical predictors of metaplastic atrophic gastritis in a consecutive endoscopic population presenting with upper gastrointestinal symptoms.

PATIENTS AND METHODS

A post-hoc cross-sectional study was carried out on endoscopic-histological data from 668 patients (64% women, age: 58 years) with upper gastrointestinal symptoms obtained during a multicenter study. Patients with dyspeptic (46%), reflux-like symptoms (22%), and both (32%) as indications for gastroscopy were included. Gastroscopy with biopsies (Sydney System) was performed. Clinical data and symptoms were collected using a structured questionnaire.

RESULTS

Metaplastic atrophic gastritis was detected in 201 (30.1%) patients: 22.3% antrum-restricted, 4.5% corpus-restricted, and 3.3% extensive. Postprandial fullness was more frequent in patients with metaplastic atrophic gastritis compared with those without metaplastic atrophic gastritis (29.8 vs. 18.8%, P=0.002); epigastric pain/burning, early satiety, and reflux symptoms occurred similarly in both groups. At multivariate logistic regression, metaplastic atrophic gastritis (any site) was associated with age older than 55 years [odds ratio (OR): 1.86, 95% confidence interval (CI): 1.26-2.73], Helicobacter pylori (OR: 1.66, 95% CI: 1.1-2.39), postprandial fullness (OR: 1.62, 95% CI: 1.03-2.54), and smoking (OR: 1.53, 95% CI: 1.02-2.31). Corpus-restricted atrophic gastritis was associated with postprandial fullness (OR: 4.16, 95% CI: 1.79-9.63) and NSAIDs (OR: 2.98, 95% CI: 1.01-8.88), extensive and antrum-restricted atrophic gastritis was associated with age older than 55 (OR 3.6, 95% CI: 1.20-12.67 and OR: 1.63, 95% CI: 1.06-2.49).

CONCLUSION

Metaplastic atrophic gastritis, a preneoplastic condition, may be found in about one of three patients undergoing endoscopy for upper gastrointestinal symptoms, and clinical predictors are age older than 55 years, smoking, H. pylori infection, and postprandial fullness, especially for corpus-restricted metaplastic atrophic gastritis. An accurate pre-endoscopic characterization of patients with upper gastrointestinal symptoms with easily achievable clinical information may help to better address an endoscopic investigation.

Low yield for non-targeted biopsies of the stomach and esophagus during elective esophagogastroduodenoscopy

BACKGROUND AND STUDY AIMS

 Biopsies of non-specific mucosal findings are often performed during esophagogastroduodenoscopy (EGD). We sought to determine the prevalence and clinical utility of non-targeted biopsies of the stomach and esophagus.

PATIENTS AND METHODS

 We conducted a retrospective review of 949 outpatient EGDs performed at a US tertiary referral center. Non-targeted biopsies of the stomach were defined as either "normal" or "mild" to "moderate" "erythema" or "inflammation" without other endoscopic features. Non-targeted biopsies of the esophagus and gastroesophageal junction (GEJ) were defined as endoscopically "normal" mucosa. The primary outcome was the proportion of non-targeted biopsies resulting in "definite management change." Secondary outcomes included histopathologic diagnoses of Helicobacter pylori, intestinal metaplasia and esophageal eosinophilia.

RESULTS

 Of 949 EGDs, 332 (35.0 %, 95 % CI 31.9 - 38.1 %) had a non-targeted biopsy taken at any site. Erythema in the gastric body and antrum was biopsied at a rate of 83 - 86 %, while biopsies of "normal"-appearing mucosa occurred at rates from 3 % (GEJ) to 15 % (body and antrum). The percentage of non-targeted biopsies that led to definite management change ranged from 5 % in the GEJ and esophagus to 9 % in the antrum, but did not significantly differ by mucosal appearance. Multivariable regression analyses suggested associations of language and age > 50 with management change from non-targeted gastric biopsy.

CONCLUSIONS

 Non-targeted biopsies of the stomach and esophagus led to definite management change in a small proportion of patients. Further studies are needed to identify patient and/or endoscopic characteristics and techniques to improve the yield of this practice.

Time trend occurrence of duodenal intraepithelial lymphocytosis and celiac disease in an open access endoscopic population

BACKGROUND

Duodenal intraepithelial lymphocytosis (DIL) is a histological finding characterized by the increase of intraepithelial CD3T-lymphocytes over the normal value without villous atrophy, mostly associated to coeliac disease (CD), Helicobacter pylori (Hp) gastritis and autoimmune diseases.

OBJECTIVE

To assess the occurrence of DIL, CD and Hp gastritis in an endoscopic population over a 13 year period.

METHODS

From 2003 to 2015 we included adult patients who consecutively underwent oesophago-gastro-duodenoscopy (OGD) with duodenal biopsies assessing the overall and annual occurrence of DIL and CD and the prevalence of Hp gastritis.

RESULTS

160 (2.3%) patients with DIL and 275 (3.9%) with CD were detected among 7001 patients. CD occurrence was higher from 2003 to 2011, while since 2012 DIL occurrence gradually increased significantly compared to CD (p = 0.03). DIL patients were more frequently female (p = 0.0006) and underwent OGD more frequently for dyspepsia (p = 0.002) and for indications not related to gastrointestinal symptoms than CD patients (p = 0.0003). Hp gastritis occurred similarly in CD and DIL patients but the latter had higher frequency of atrophic body gastritis (p = 0.005).

CONCLUSIONS

DIL is a condition increasing in the general endoscopic population mainly diagnosed by chance. Concomitant gastric histological evaluation is able in one third of DIL patients to identify associated possible causes of DIL, such as Hp and atrophic gastritis.

Cost of detecting gastric neoplasia by surveillance endoscopy in atrophic gastritis in Italy: A low risk country

BACKGROUND

Atrophic gastritis (AG) is at increased risk of gastric neoplasia, thus surveillance gastroscopy has been proposed.

AIMS

To assess cost of detecting gastric neoplasias by surveillance endoscopy according to identified risk factors in Italy.

METHODS

Post-hoc analysis of a cohort study including 200 AG-patients from Italy followed up for a mean of 7.5 (4-23.4) years was done. Considered risk factors were: age >50years, extensive atrophy, pernicious anaemia, OLGA-OLGIM scores 3-4 at diagnosis. The number of 4-year-surveillance endoscopies needed to be performed to detect one gastric neoplasia (NNS) was calculated.

RESULTS

In 19 patients neoplasias (4 gastric cancers, 8 type 1 gastric carcinoids, 7 dysplasias) were detected at the 361 surveillance gastroscopies, corresponding to NNS of 19 and a cost per gastric neoplastic lesion of €2945. By restricting surveillance to pernicious anaemia patients, reduction of NNS and cost per neoplasia to 13.8 and €2139 may be obtained still detecting 74% of neoplasias. By limiting the surveillance to pernicious anaemia patients and OLGA 3-4, 5 (26.3%) neoplasias would have been detected with a corresponding NNS of 5.4 and a cost per lesion of €837.

CONCLUSION

Risk factors may allow an efficient allocation of financial and medical resources for endoscopic surveillance in AG in a low risk country.

Gastric precancerous conditions and Helicobacter pylori infection in dyspeptic patients with or without endoscopic lesions

OBJECTIVE

In dyspeptic patients, esophagogastroduodenoscopy is often negative for visible lesions. Biopsies of the normal-appearing mucosa for Helicobacter pylori detection are not routinely obtained. Diagnostic gain of routine biopsies is still debated. This study aimed to assess the occurrence of H. pylori infection and related gastric premalignant conditions in dyspeptic patients without visible lesions at esophagogastroduodenoscopy and whether the presence/absence of endoscopically visible lesions may address the endoscopist to obtain gastric biopsies.

MATERIALS AND METHODS

Post hoc study on endoscopic-histological data from 589 patients with dyspepsia (median age 57 years) obtained during a prospective nationwide study. Patients with dyspepsia as indication for esophagogastroduodenoscopy, never treated for H. pylori, were included. All the patients underwent esophagogastroduodenoscopy with biopsies according to Sydney system. Clinical data were collected using a structured questionnaire.

RESULTS

In 66.4% patients, the gastricduodenal mucosa appeared normal at esophagogastroduodenoscopy. In patients with or without visible lesions at esophagogastroduodenoscopy, H. pylori infection (51.5% vs. 50.1%, p = 0.82) and atrophic-metaplastic gastritis (33.3% vs. 27.6%, p = 0.18) were similar. Endoscopically visible lesions were poor predictors for H. pylori infection or gastric precancerous conditions showing positive and negative predictive values of 51.5% and 49.8% for H. pylori and 33.3% and 72.3% for atrophic-metaplastic gastritis. At logistic regression, the presence of H. pylori infection showed a negative association with ongoing antisecretory treatment (OR: 0.67), the presence of visible gastroduodenal lesions was not associated.

CONCLUSIONS

Dyspeptic patients with or without visible endoscopic lesions had the same occurrence of H. pylori infection and related premalignant conditions, which might be missed without biopsies, in particular, in patients on anti-secretory treatment.

Real-time diagnosis of H. pylori infection during endoscopy: Accuracy of an innovative tool (EndoFaster)

BACKGROUND

EndoFaster is novel device able to perform real-time ammonium measurement in gastric juice allowing H. pylori diagnosis during endoscopy. This large study aimed to validate the accuracy of EndoFaster for real-time H. pylori detection.

METHODS

Consecutive patients who underwent upper endoscopy in two centres were prospectively enrolled. During endoscopy, 4 ml of gastric juice were aspirated to perform automatic analysis by EndoFaster within 90 seconds, and H. pylori was considered present (>62 ppm/ml) or absent (≤62 ppm/ml). Accuracy was measured by using histology as gold standard, and (13)C-urea breath test (UBT) in discordant cases. Accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were calculated.

RESULTS

Overall, 189 patients were enrolled, but in seven (3.4%) the aspirated gastric juice amount was insufficient to perform the test. The accuracy, sensitivity, specificity, PPV, and NPV were 87.4%, 90.3%, 85.5%, 80.2%, 93.1%, respectively, and 92.6%, 97.1%, 89.7%, 85.9%, 98.0%, respectively, when H. pylori status was reclassified according to the UBT result in discordant cases.

CONCLUSIONS

This study found a high accuracy/feasibility of EndoFaster for real-time H. pylori diagnosis. Use of EndoFaster may allow selecting those patients in whom routine gastric biopsies could be avoided.

Correlation of nodular gastritis with Helicobacter pylori infection

Nodular gastritis (NG) is a form of chronic Helicobacter pylori (H. pylori) associated gastritis affecting the gastric antrum, which is characterized endoscopically by the presence of small nodular lesions resembling gooseflesh. It is generally accepted that NG is characterized histologically by hyperplasia of lymphoid follicles. At present, there is a wide range of H. pylori infections in the world, and NG is an endoscopic sign of H. pylori infection. After H. pylori eradication therapy, the clinical manifestations, pathology and endoscopic performance of NG patients can be improved significantly. Therefore, H. pylori eradication should be performed as early as possible in NG patients. The research data about NG is still very limited. The relationship between NG as potentially precancerous lesions and gastroduodenal diseases is still a debate and needs to be further explored. Here we review the research progress in understanding the correlation between NG and H. pylori.

Prevalence of lesions detected at upper endoscopy: an Italian survey

BACKGROUND

Prevalence of gastroduodenal lesions is changing in the last decades. Prevalence of Helicobacter pylori infection, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitor (PPI) therapy may be involved in such a phenomenon. We assessed gastroduodenal lesions prevalence in a nationwide study.

MATERIALS AND METHODS

Consecutive patients who underwent upper endoscopy for the first time in 24 Italian centres between January 2012 and 31 March 2012 were enrolled. Prevalence of gastric ulcer (GU), duodenal ulcer (DU), gastric erosions (GE), duodenal erosions (DE), gastric polyp (GP), Barrett's oesophagus (BE), and neoplasia was assessed.

RESULTS

Overall, 1054 (M/F: 388/666; Mean age: 57.5 ± 5 years) patients were enrolled. H. pylori infection was detected in 356 (33.9%) patients, 358 (34%) were taking NSAIDs, and 532 (50.5%) PPIs. PPI therapy was associated with a significantly lower H. pylori detection rate (27.8% vs 39.8%; OR: 0.6, 95% CI 0.45-0.77; P<0.001). GU, DU, GE, DE, GP and BE were detected in 17 (1.6%), 13 (1.2%), 150 (14.2%), 50 (4.7%), 51 (4.8%) and 17 (1.6%), respectively. Moreover, 3 (0.3%) distal gastric cancers were observed. H. pylori infection remained the most prevalent factor for all gastroduodenal lesions, but gastric polyp. One third of patients with GU and GE were taking only NSAIDs therapy.

CONCLUSIONS

The prevalence of peptic ulcer was very low (<3%), with a similar rate between DU and GU. As many as half patients were on ongoing PPI therapy. Such a therapy could affect both the detection rate of H. pylori infection and the real prevalence of gastroduodenal lesions.