Age, smoking and overweight contribute to the development of intestinal metaplasia of the cardia

Factors associated with precancerous stomach lesions and progresion: A 7-year multi-center prospective cohort study on the low incidence of gastric cancer in central Saudi Arabia

BACKGROUND

In Saudi Arabia (SA) no data are available on precancerous stomach lesions (PSLs) or the associated risk factors. We aimed to identify PSLs and investigate factors associated with PSLs and their progression.

METHODS

This 7-year prospective study screened for PSLs in asymptomatic Saudi patients aged 45-75 years in central SA ( n = 35,640). Those who had high-sensitivity guaiac fecal occult blood tests (HSgFOBT+) and negative colonoscopy results ( n = 1242) were subjected to upper GI endoscopy to identify PSLs and were followed up every 3 years or earlier, depending on the type of PSL. Factors associated with PSLs were investigated.

RESULTS

The 7-year participation rate was 86.9% (1080/1242). The 7-year prevalence of PSLs was 30.9% (334/1080). The incidence rate of PSLs was 134 new cases/100,000 population/year, total population at risk - 35,640 and 44.3 new cases/1,000 persons/year among the 1080 participants with HSgFOBT+ and negative colonoscopy results. Among the 334 participants with PSLs, 8 (2.4%) had neoplastic progression to GC during the surveillance period. Age, Helicobacter pylori infection, smoking status, a diet with preserved salty foods, low income, and a family history of GC were associated with PSLs.

CONCLUSIONS

The incidence of GC is low in central SA, but screening for PSLs among participants with HSgFOBT+ and negative colonoscopy findings may contribute to the early detection and subsequent treatment of GC. HP eradication, not smoking, normal body weight, and adhering to a healthy diet seem to be potential factors associated with the development of PSLs. Further studies are needed to search if such interventions would decrease the incidence of PSLs and progression to early GC.

Aberrant DNA methylation and expression of EYA4 in gastric cardia intestinal metaplasia

BACKGROUND

Intestinal metaplasia (IM) of the gastric cardia is an important premalignant lesion. However, there is limited information concerning its epidemiological and molecular features. Herein, we aimed to provide an overview of the epidemiological data for gastric cardiac IM and evaluate the role of EYA transcriptional coactivator and phosphatase 4 (EYA4) as an epigenetic biomarker for gastric cardiac IM.

METHODS

The study was conducted in the context of the gastric cardiac precancerous lesion program in southern China, which included 718 non-cancer participants, who undertook endoscopic biopsy and pathological examination in three endoscopy centers, between November 2018 and November 2021. Pyrosequencing and immunohistochemistry were performed to examine the DNA methylation status and protein expression level of EYA4.

RESULTS

Gastric cardiac IM presented in 14.1% (101/718) of participants and was more common among older (>50 years; 22.0% [95% CI: 17.8-26.8]) than younger participants (≤50 years; 6.7% [95% CI: 4.5-9.9]; P < 0.001). IM was more common in male participants (16.9% [95% CI: 13.2-21.3] vs. 11.3% [95% CI: 8.3-15.1]; P = 0.04). Pyrosequencing revealed that IM tissues exhibited significantly higher DNA methylation levels in EYA4 gene than normal tissues (P = 0.016). Further, the protein expression level of EYA4 was reduced in IM and absent in intraepithelial neoplasia tissues compared to normal tissues (P < 0.001).

CONCLUSIONS

Detection rates of gastric cardiac IM increase with age and are higher in men. Our findings highlight the important role of promoter hypermethylation and downregulation of EYA4 in gastric cardiac IM development.

Plasma VEGF and Leptin Values in Patients With Gastric Intestinal Metaplasia and Metabolic Syndrome

Intestinal metaplasia of the stomach (IM) is considered a pre-cancerous lesion and is a potential precursor to adenocarcinoma. Metabolic syndrome (MetS) has been associated with lesions to the gastrointestinal tract such as the risk of developing Barett esophagus. Vascular endothelial growth factor and leptin have been associated with either gastrointestinal tract carcinogenesis or MetS. In this context, this study was designed to analyze plasma levels of VEGF and leptin in patients with IM and MetS. Four groups of 137 participants (a control group and three patient groups, IM, MetS and IM- MetS) were created. Inclusion criteria for the presence of IM were endoscopic findings and histological confirmation, while for MetS the ATP III and IDF guidelines. Levels of plasma vascular endothelial growth factor (VEGF) and leptin (Leptin) were determined. VEGF levels were increased in IM (IM vs Control, p=0,011) and IM-MetS groups (IM-MetS vs Control, p <0.001 and IM-MetS vs MetS, p=0.001). Leptin levels were found to be increased in the MetS group (MetS vs. Control, p <0.001 and MetS vs IM, p <0.001) and in IM-MetS (IM-MetS vs Control, p = 0.002, IM-MetS vs IM, p=0.033). Patients with intestinal metaplasia and metabolic syndrome (I M - Me t S g r o u p) have elevated levels of VEGF, while leptin levels were associated predominantly with MetS and not with IM.

Intestinal metaplasia at the gastroesophageal junction is associated with gastroesophageal reflux but not with Helicobacter pylori infection

OBJECTIVE

Studies of the etiology of intestinal metaplasia (IM) at a normal appearing gastroesophageal junction (GEJ) are conflicting as associations with both H. Pylori (HP) infection and gastroesophageal reflux has been reported. The aim of this study was to investigate whether IM at the GEJ is associated with gastroesophageal reflux or HP infection.

MATERIAL AND METHODS

Fifty asymptomatic volunteers and 149 patients with reflux symptoms underwent endoscopy with biopsies obtained from the gastric antrum and the squamocolumnar junction (SCJ). All subjects underwent wireless 48 h pH monitoring with the electrode placed immediately above the SCJ and a fecal antigen test for HP infection. Clinical characteristics and the pattern of reflux were compared in subjects with and without IM.

RESULTS

Three asymptomatic volunteers and 35 patients who had clearly irregular SCJs with short extensions of columnar mucosa were excluded from the study. In the remaining 47 asymptomatic volunteers and 114 patients, variables that reached a significance level of 0.1 or less on univariate analyses were used in a binomial regression analysis to assess their relative importance for the finding of IM. IM at the GEJ was significantly associated with abnormal distal esophageal acid exposure (5.5 (1.2-24.6), p = .026), the frequency of reflux episodes/hour (1.5 (1.1-2.2), p = .031), and an endoscopic appearance of the SCJ corresponding to ZAP grade I (4.6 (1.4-15.6), p = .013). There was no association with HP infection.

CONCLUSION

The finding of IM at an endoscopically normal-appearing GEJ is associated with gastroesophageal reflux but not with HP infection.

Body Mass Index and Risk of Intestinal Metaplasia: A Cohort Study

BACKGROUND

We examined the association between body mass index (BMI) and development of endoscopic intestinal metaplasia.

METHODS

This retrospective cohort study included 142,832 Korean adults free of endoscopic intestinal metaplasia and atrophic gastritis who underwent upper endoscopy at baseline and subsequent visits and were followed for up to 5 years. A parametric proportional hazards model was used to estimate the adjusted HR with 95% confidence interval (CI) for incident intestinal metaplasia.

RESULTS

In more than 444,719.1 person-years of follow-up, 2,281 participants developed endoscopic intestinal metaplasia (incidence rate, 5.1 per 1,000 person-years). Increased BMI categories were associated with increased risk of new-onset intestinal metaplasia in a dose-response manner. After adjustment for age, sex, center, year of screening exam, smoking status, alcohol intake, exercise, total calorie intake, history of diabetes and hypertension, and history of Helicobacter pylori infection, the multivariable adjusted HRs (95% CIs) for incident intestinal metaplasia comparing BMIs of <18.5, 23-24.9, 25.0-29.9, and >30 kg/m² with a BMI of 18.5-22.9 kg/m² were 0.84 (0.64-1.09), 1.03 (0.93-1.16), 1.07 (0.96-1.20), and 1.48 (1.20-1.83), respectively. These associations did not differ by clinically relevant subgroups. Risk of endoscopic atrophic gastritis also increased as the baseline BMI category increased.

CONCLUSIONS

In a large cohort of Korean men and women, obesity was independently associated with increased incidence of endoscopic atrophic gastritis and intestinal metaplasia.

IMPACT

Excessive adiposity appears to play a role in development of stomach precursor lesions of stomach cancer, requiring further studies to determine whether strategies to reduce obesity will also help reduce precancerous lesions and, in turn, gastric cancer.

[Associations between Body Mass Index and Chronic Atrophic Gastritis and Intestinal Metaplasia]

Background/Aims

Chronic atrophic gastritis (AG) and intestinal metaplasia (IM) of the stomach are premalignant lesions. The present study aimed to examine the associations between obesity and these lesions.

Methods

A total of 2,997 patients, who underwent gastroscopy, participated in this study, excluding those who had been diagnosed with gastric cancer. Participants were divided into four groups based on their body mass index (BMI). The risk of AG and IM with increasing BMI was analyzed in men and women, separately.

Results

The association between BMI and AG was not significant. After adjusting for age, smoking, alcohol, and AG, the odds ratios for IM in the overweight, obesity, and severe obesity groups were 2.25 (95% confidence interval [CI], 1.50-3.37), 2.32 (95% CI, 1.58-3.42), and 4.86 (95% CI, 2.04-11.5) in men, and 2.66 (95% CI, 1.29-5.47), 4.46 (95% CI, 2.28-8.75), and 9.57 (95% CI, 3.26-28.12) in women, compared with the normal BMI group.

Conclusions

Gastric IM was significantly associated with increased BMI.

Risk factors for intestinal metaplasia in a southeastern Chinese population: an analysis of 28,745 cases

PURPOSE

To identify risk factors for intestinal metaplasia in a southeastern Chinese population.

METHODS

Subjects who underwent upper GI endoscopy and endoscopic biopsy in the First Affiliated Hospital of Nanjing Medical University from 2008 to 2013 were included into this study. Various demographic, geographic, clinical and pathological data were analyzed separately to identify risk factors for intestinal metaplasia.

RESULTS

The incidence of intestinal metaplasia differed significantly in 17 municipal areas ranging from 16.79 to 38.56% and was positively correlated with the age range of 40-70 years, male gender, gastric ulcer, bile reflux, Helicobacter pylori infection, atrophic gastritis, dysplasia, gastric cancer, degree of chronic and acute inflammation, and gross domestic product per capita (P < 0.01). Multivariate linear regression analysis indicated that only gross domestic product per capita revealed a significant difference in the incidence of intestinal metaplasia among all factors mentioned.

CONCLUSION

This study confirms age, male gender, gastric ulcer, bile reflux, H. pylori infection, severe degree of chronic and acute inflammation to be the risk factors for intestinal metaplasia. We speculate that the gross domestic product per capita of different areas may be a potential independent risk factor impacting the incidence of intestinal metaplasia.

Risk factors for gastric intestinal metaplasia

Gastric intestinal metaplasia is the most common precancerous lesion of gastric cancer. Due to the unsatisfying treatment efficacy for gastric cancer especially advanced gastric cancer, the key steps of prevention and treatment of gastric cancer are lowering the incidence and improving the early diagnosis. Therefore, it is very important to clarify the risk factors associated with gastric cancer and its precancerous lesion for first-line prevention of gastric cancer. Accumulated evidence indicates that the development of gastric intestinal metaplasia is closely related to Helicobacter pylori infection, age, sex, family history of gastric cancer, smoking, high salt diet, bile acid reflux and so on. This review mainly focuses these factors associated with gastric intestinal metaplasia.

Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?

BACKGROUND

Roux-Y Gastric Bypass is a frequently used technique in bariatric surgery. Postoperative anatomy is altered by exclusion of the stomach, which makes this organ inaccessible for future esophagogastroduodenoscopy (EGD). The value of preoperative assessment of the stomach is unclear. Some institutions choose to investigate the future remnant stomach by EGD, others do not. Aim of the present study is to quantify the yield of preoperative EGD in our institution.

METHODS

Patients, planned for primary laparoscopic Roux-Y Gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy from December 2007 until August 2012, were screened by EGD in advance. Results of EGD and patient characteristics were retrospectively analyzed and categorized according to a classification system based on intervention needed.

RESULTS

523 patients (122 male, 401 female, mean age 44.3 years, average BMI 46.6) underwent preoperative EGD. In 257 patients (48.9%) no abnormality was found (group A), 117 patients (17.2%) had abnormalities without treatment consequences (B1), 84 patients (of the 326 tested [comment #1, reviewer #1, 26.8%] were H. Pylori positive (B2), in 75 (14.3%) treatment with proton pump inhibitors was required (B3), 6 (1.1%) required follow up EGD before surgery (C). For1 patient (0.2%) the operation was canceled because preoperative EGD presented with Barrett's esophagus with carcinoma (D). When all abnormalities were taken into account, baselines did show a significant difference for age, gender and reflux symptoms.

CONCLUSION

Standard preoperative assessment by EGD in patients who are planned for bariatric surgery is not indicated. The number needed to screen to find clinically significant abnormalities is high.

Patterns of recurrent and persistent intestinal metaplasia after successful radiofrequency ablation of Barrett's esophagus

OBJECTIVE

Radiofrequency ablation can eradicate Barrett's esophagus successfully in the majority of cases. We sought to determine (1) how often intestinal metaplasia is detected during follow-up endoscopy after successful ablation and (2) patterns of persistent/recurrent intestinal metaplasia.

METHODS

Patients ablated successfully during a phase II clinical trial of radiofrequency ablation for Barrett's esophagus were followed using endoscopic surveillance according to a defined protocol. Systematic biopsies were performed in all patients throughout the neosquamous epithelium as well as at the gastroesophageal junction, and patterns of recurrent or persistent intestinal metaplasia were documented.

RESULTS

Fifty-three patients were ablated successfully during this single-institution clinical trial. A total of 151 follow-up endoscopies were performed (range, 1-5 endoscopies per patient) and 2492 biopsies were obtained, of which 604 (24%) were from the gastroesophageal junction. The median follow-up period was 18 months (range, 3-50 months). Recurrent/persistent intestinal metaplasia was detected in 14 patients (26%) in 3 distinct patterns: endoscopically invisible intestinal metaplasia underneath the neosquamous epithelium (buried glands) in 3 patients, visible recurrence in the tubular esophagus in 3 patients, and intestinal metaplasia of the gastroesophageal junction (with a squamous-lined tubular esophagus) in 10 patients. Dysplasia or cancer was not detected in any patient during the follow-up period.

CONCLUSIONS

Recurrent/persistent intestinal metaplasia after successful radiofrequency ablation of Barrett's esophagus is relatively common. This finding has implications for the continued surveillance of patients who are ablated successfully.