Endoscopic patterns of gastric mucosa and its clinicopathological significance

A Comprehensive Review of Upper Gastrointestinal Symptom Management in Autoimmune Gastritis: Current Insights and Future Directions

Autoimmune gastritis is characterized by inflammation of the gastric mucosa due to autoimmune dysregulation. Upper gastrointestinal symptoms associated with autoimmune gastritis can significantly impact an individual's quality of life and require effective management strategies. This review article provides a comprehensive overview of the current understanding of upper gastrointestinal symptom management in autoimmune gastritis, aiming to consolidate existing knowledge, identify gaps, and offer insights for future research and clinical practice. The review begins by discussing the background and significance of autoimmune gastritis, highlighting its prevalence and the impact of upper gastrointestinal symptoms on affected individuals. The pathophysiology and clinical presentation of autoimmune gastritis-related upper gastrointestinal symptoms are explored, emphasizing the need for accurate diagnosis and targeted management approaches. Diagnostic approaches, including diagnostic criteria, endoscopy, histology, and biomarkers, are critically examined, along with the challenges and limitations associated with diagnosing autoimmune gastritis. The review then delves into the pharmacological approaches for symptom relief, such as proton pump inhibitors (PPIs) and H2 receptor antagonists. It explores the role of dietary modifications and lifestyle changes in symptom control. The article further discusses recent advancements in pharmacological interventions, novel therapeutic approaches, and the potential benefits of complementary and alternative medicine in symptom management. The concept of patient-centered approaches and personalized management strategies is emphasized, highlighting the importance of considering individual patient characteristics, treatment goals, and preferences. Recommendations for future research and clinical management are provided, including exploring emerging therapeutic targets, precision medicine approaches, and collaboration among researchers, clinicians, and patient advocacy groups. The review concludes by emphasizing the significance of implementing the findings and recommendations in clinical practice to enhance patient care and improve the quality of life for individuals with autoimmune gastritis.

From part to whole, operative link on to endoscopic grading of gastric intestinal metaplasia, pathology to endoscopy: gastric intestinal metaplasia graded by endoscopy

Objective: To conduct a systematic review and meta-analysis on the prediction of severity of gastric intestinal metaplasia (GIM) in localized and entire gastric mucosa using endoscopy. Methods: The authors searched Web of Science, PubMed, Embase and Cochrane Central Register of Controlled Trials and performed systematic searches on endoscopic grading of GIM of the entire stomach using Meta-DiSc and Stata. Results: Sensitivity and specificity for the stratified prediction of overall GIM were 0.91 (95% CI: 0.85-0.95) and 0.91 (95% CI: 0.88-0.93), respectively. Sensitivity in predicting the different grades of GIM was higher in operative link on GIM assessment grades 0, III and IV but lower in grades I and II. Conclusion: Digital chromoendoscopy is well suited to predicting the severity of localized and overall GIM.

Role of endoscopy in suspicion of atrophic gastritis with and without intestinal metaplasia in comparison to histopathology

Background and study aims

Atrophic gastritis (AG) and intestinal metaplasia (IM) are established premalignant gastric lesions. Many studies documented a poor correlation between esophagogastroduodenoscopy (EGD) and histopathological (HP) findings of precancerous gastric lesions. The aim was to bridge the gap between endoscopy and HP in detection of chronic gastritis, AG and IM.

Patients and methods

a prospective single-center study involved 150 patients with endoscopic criteria of gastric lesions with upper gastrointestinal symptoms referred for upper GI endoscopy met the endoscopic criteria and classified according to HP of biopsies from targeted gastric lesions into chronic gastritis (GI), AG(GII) or IM(GIII). We correlated the endoscopic criteria of the 3 groups with the HP results.

Results

(73 males & 75 females) with ages ranged17-75 years and mean± SD was 41.96 ± 15.95. GI, GII & GIII were [42 patients (28%),82 patients (54.7%) and 26 patients (17.3%)], respectively. Diffuse gastric mottling was more common in GI (74.3%, P<0.001), visible submucosal vessels, gastric atrophy predominated in GII (75.6, 82.3 & 73.1% (P 0.005,0.4 & <0.01)), respectively. Whitish raised lesions were more specific in GIII (85.7%) (P<0.001). The sensitivity and specificity of endoscopic suspicion of chronic gastritis were (86&88% in GI), (87&85% in GII) and (54% & 100% in GIII) (p-0.001). The logistic regression model for risk factors was χ2= 25.74 and 49.32, p < 0.001.

Conclusion

Conventional endoscopy has high sensitivity and specificity for suspicion of chronic gastritis and AG, but low sensitivity and very high specificity for IM. Targeted biopsies may be valuable with image enhanced techniques.

The endoscopic predictors of Helicobacter pylori status: a meta-analysis of diagnostic performance

Objective:

The endoscopic findings associated with Helicobacter pylori–naïve status, current infection or past infection are an area of ongoing interest. Previous studies have investigated parameters with a potential diagnostic value. The aim of this study was to perform meta-analysis of the available literature to validate the diagnostic accuracy of mucosal features proposed in the Kyoto classification.

Data sources:

The databases of MEDLINE and Embase, clinicalTrials.gov and the Cochrane Library were systematically searched for relevant studies from October 1999 to October 2019.

Methods:

A bivariate random effects model was used to produce pooled diagnostic accuracy calculations for each of the studied endoscopic findings. Diagnostic odds ratios and sensitivity and specificity characteristics were calculated to identify significant predictors of H pylori status.

Results:

Meta-analysis included 4380 patients in 15 studies. The most significant predictor of an H pylori-naïve status was a regular arrangement of collecting venules (diagnostic odds ratio 55.0, sensitivity 78.3%, specificity 93.8%). Predictors of active H pylori infection were mucosal oedema (18.1, 63.7%, 91.1%) and diffuse redness (14.4, 66.5%, 89.0%). Map-like redness had high specificity for previous H pylori eradication (99.0%), but poor specificity (13.0%).

Conclusion:

The regular arrangement of collecting venules, mucosal oedema, diffuse redness and map-like redness are important endoscopic findings for determining H pylori status. This meta-analysis provides a tentative basis for developing future endoscopic classification systems.

Association between a regular arrangement of collecting venules and absence of Helicobacter pylori infection in a European population

BACKGROUND AND AIMS

Helicobacter pylori is the major cause of gastritis and gastritis-associated diseases. Detection of a regular arrangement of collecting venules (RAC) in the lesser gastric curvature correlates with negative H pylori status with a sensitivity and negative predictive value (NPV) higher than 90% in Asian countries. The aim of the study was to evaluate the value of RAC as a diagnostic method of H pylori infection in a European population.

METHODS

A prospective study with high-definition endoscopes without magnification was performed by 3 endoscopists. The presence of starfish-like minute points regularly distributed throughout the lesser curvature of the gastric body was considered RAC positive (RAC+). Gastric biopsies were performed during the procedure for H pylori diagnosis.

RESULTS

One hundred forty patients were included from February 2017 to May 2018. The prevalence of H pylori infection was 31% and 47 of 140 patients (34%) were RAC+; 13 of 23 patients in whom H pylori was eradicated were RAC+. The mean age of RAC+ patients was lower (44.4 vs 52.4 years, P = .004) and they had less- significant endoscopic findings (9; 19.1% vs 38; 80.9%; P = .017). Gender, use of nonsteroidal anti-inflammatory drugs, antithrombotic or anticoagulants treatments, and a history of H pylori eradication did not show differences in the RAC pattern. The absence of RAC was associated with H pylori infection in 47.3% (44/93) of cases. In contrast, all RAC+ patients were free of H pylori infection, with sensitivity and NPV of 100% for the exclusion of H pylori infection.

CONCLUSION

The presence of RAC+ in the lesser curvature evaluated with high-definition endoscopy can accurately identify patients without H pylori.

Detection of serum Mg7-Ag, CEA and pepsinogens combined with magnifying narrow-band imaging endoscopy for screening early gastric carcinoma in high risk patients

AIM

To assess the clinical value of serum Mg7-Ag, carcinoembryonic antigen (CEA), pepsinogen (PG) I, PGⅡ and PGI/PGⅡ ratio (PGR) combined with magnifying narrow-band imaging endoscopy (ME-NBI) for screening early gastric cancer (GC) in high-risk patients.

METHODS

A total of 802 patients at a high risk for GC were selected for the study. ELISA was used to detect serum Mg7-Ag, PGI, PGII, and CEA levels, and the PGR was calculated. According to the results, the patients were categorized as Mg7-Ag (+) and Mg7-Ag (-), PGI (+) and PGI (-), PGR (+) and PGR (-), and CEA (+) and CEA (-). Gastroscopy was performed for all enrolled patients, and gastric lesions were examined by ME-NBI and pathological examination was performed. According to the pathological results, the patients were divided into an inflammatory group, a precancerous disease group, an atypical hyperplasia group, an early GC group and an advanced GC group. Serum Mg7-Ag, PGI and PGR values and the number of patients with positive results were compared among different groups, and the sensitivity, specificity and accuracy of these indexes, alone or in combination, for early diagnosis of GC were calculated.

RESULTS

Serum level of PGI in the non-inflammatory group was significantly lower than that in the simple inflammatory group (P < 0.05). Serum levels of Mg7-Ag and CEA in the GC group were significantly higher than those in the non-GC group (P < 0.05). However, serum level of Mg7-Ag in the early GC group was not significantly different from that in the advanced GC group, while serum CEA level of the advanced GC group was significantly higher than that in the early GC group (P < 0.05). The sensitivity of Mg7-Ag combined with ME-NBI for diagnosing early GC was significantly higher than that of PGR and PGI (P < 0.05), but there was no significant difference in specificity between each group (P > 0.05). The accuracy of CEA in the diagnosis of GC was the lowest, and the accuracy of Mg7-Ag and ME-NBI detection was significantly higher than that of PGR and PGI. The sensitivity and accuracy of combined detection of PGI + PGR, PGI + PGR + Mg7-Ag, and PGI + PGR + Mg7-Ag + ME-NBI increased gradually, while there was no significant difference in specificity (P > 0.05). Positive result of PGI + PGR + Mg7-Ag + ME-NBI combined with CEA (-) had significantly higher sensitivity and accuracy than PGI + PGR + Mg7-Ag + ME-NBI (P < 0.05), although there was no significant difference in specificity (P > 0.05).

CONCLUSION

Combined detection of serum Mg7-Ag, PG and CEA plus ME-NBI examination is of great clinical significance for screening early GC in highly suspicious people.

Diagnostic Performance of Magnifying Endoscopy for Helicobacter pylori Infection: A Meta-Analysis

Background

Diagnosis of Helicobacter pylori (H. pylori) infection using magnifying endoscopy offers advantages over conventional invasive and noninvasive tests.

Objective

This meta-analysis aimed to assess the diagnostic performance of magnifying endoscopy in the prediction of H. pylori infection.

Methods

A literature search of the PubMed, Medline, EMBASE, Science Direct and the Cochrane Library databases was performed. A random-effects model was used to calculate the diagnostic efficiency of magnifying endoscopy for H. pylori infection. A summary receiver operator characteristic curve was plotted, and the area under the curve (AUC) was calculated.

Results

A total of 18 studies involving 1897 patients were included. The pooled sensitivity and specificity of magnifying endoscopy to predict H. pylori infection were 0.89 [95% confidence interval (CI) 0.87–0.91] and 0.82 (95%CI 0.79–0.85), respectively, with an AUC of 0.9461. When targeting the gastric antrum, the pooled sensitivity and specificity were 0.82 (95%CI 0.78–0.86) and 0.72 (95%CI 0.66–0.78), respectively. When targeting the gastric corpus, the pooled sensitivity and specificity were 0.92 (95%CI 0.90–0.94) and 0.86 (95%CI 0.82–0.88), respectively. The pooled sensitivity and specificity using magnifying white light endoscopy were 0.90 (95%CI 0.87–0.91) and 0.81 (95%CI 0.77–0.84), respectively. The pooled sensitivity and specificity using magnifying chromoendoscopy were 0.87 (95%CI 0.83–0.91) and 0.85 (95%CI 0.80–0.88), respectively. The “pit plus vascular pattern” classification in the gastric corpus observed by magnifying endoscopy was able to accurately predict the status of H. pylori infection, as indicated by a pooled sensitivity and specificity of 0.96 (95%CI 0.94–0.97) and 0.91 (95%CI 0.87–0.93), respectively, with an AUC of 0.9872.

Conclusions

Magnifying endoscopy was able to accurately predict the status of H. pylori infection, either in magnifying white light endoscopy or magnifying chromoendoscopy mode. The “pit plus vascular pattern” classification in the gastric corpus is an optimum diagnostic criterion.

Evidence based review of the impact of image enhanced endoscopy in the diagnosis of gastric disorders

Gastric cancer is the third most common cause of cancer-related death. Advanced stages of gastric cancers generally have grim prognosis. But, good prognosis can be achieved if such cancers are detected, diagnosed and resected at early stages. However, early gastric cancers and its precursors often produce only subtle mucosal changes and therefore quite commonly remain elusive at the conventional examination with white light endoscopy. Image-enhanced endoscopy makes mucosal lesions more conspicuous and can therefore potentially yield earlier and more accurate diagnoses. Recent years have seen growing work of research in support of various types of image enhanced endoscopy (IEE) techniques (e.g., dye-chromoendoscopy; magnification endoscopy; narrow-band imaging; flexible spectral imaging color enhancement; and I-SCAN) for a variety of gastric pathologies. In this review, we will examine the evidence for the utilization of various IEE techniques in the diagnosis of gastric disorders.

Confocal laser endoscopy in the diagnosis for abdominal lymph node metastasis of gastric cancer

Confocal laser endoscopy (CLE) diagnostic criteria for lymph node metastasis of gastric cancer was established and evaluated to provide a basis for CLE clinical application in the diagnosis of abdominal lymph node metastasis. CLE scanning (surface scanning and sectional scanning) and pathology examination were conducted in gastric cancer tissues and lymph nodes of 5 cases. Characteristics of lymphatic metastasis in CLE imaging were observed and summarized in combination with pathology. The diagnostic criteria were corroborated in 124 lymph nodes of another 14 cases and CLE detection time needed for diagnosis was recorded. The CLE diagnostic criteria were tested and evaluated, and the effect of lymph node size on the diagnosis accuracy was determined. All the 19 participants were confirmed as gastric cancer. Sectional scanning can get comprehensive observation for internal structures of lymph nodes, in which abnormal large heterocyst appeared with special structural changes. CLE scanning could detect 88.75% of the positive metastasis and 68.18% of the negative metastasis examined by the pathology methods based on the established CLE diagnostic criteria. In comparison with pathological diagnosis, specificity, sensitivity and accuracy of CLE diagnosis were 88.75%, 68.18% and 81.45%, respectively. Accuracies of CLE diagnosis on the lymph nodes grouped by size were 85.29%, 77.78% and 88.89%, respectively, with no significant difference between groups (P > 0.05). Complete internal structures of lymph nodes can be observed clearly by CLE sectional scanning. The size of lymph nodes had no effects on diagnosis accuracy. CLE shows better sensitivity and specificity than traditional pathological diagnosis.

Extracellular ATP induces cell death in human intestinal epithelial cells

BACKGROUND

Extracellular ATP is an endogenous signaling molecule released by various cell types and under different stimuli. High concentrations of ATP released into the extracellular medium activate the P2X7 receptor in most inflammatory conditions. Here, we seek to characterize the effects of ATP in human intestinal epithelial cells and to evaluate morphological changes in these cells in the presence of ATP.

METHODS

We treated human intestinal epithelial cells with ATP and evaluated the effects of this nucleotide by scanning and transmission electron microscopy analysis and calcium measurements. We used flow cytometry to evaluate apoptosis. We collected human intestinal explants for immunohistochemistry, apoptosis by the TUNEL approach and caspase-3 activity using flow cytometry analyses. We also evaluated the ROS production by flow cytometry and NO secretion by the Griess technique.

RESULTS

ATP treatment induced changes characteristic of cell death by apoptosis and autophagy but not necrosis in the HCT8 cell line. ATP induced apoptosis in human intestinal explants that showed TUNEL-positive cells in the epithelium and in the lamina propria. The explants exhibited a significant increase of caspase-3 activity when the colonic epithelial cells were incubated with IFN-gamma followed by ATP as compared to control cells. In addition, it was found that antioxidants were able to inhibit both the ROS production and the apoptosis induced by ATP in epithelial cells.

GENERAL SIGNIFICANCE

The activation of P2X7 receptors by ATP induces apoptosis and autophagy in human epithelial cells, possibly via ROS production, and this effect might have implications for gut inflammatory conditions.

[The Usefulness of the Regular Arrangement of Collecting Venules Pattern for the Determination of Helicobacter pylori Infection]

BACKGROUND/AIMS

In the Helicobacter pylori (H. Pylori)-negative normal stomach, collecting venules are visible over all the gastric body as numerous minute points evaluated with standard endoscopy. This finding was termed regular arrangement of collecting venules (RAC), and its absence suggests H. pylori gastritis. The aim of this study was to evaluate the correlation between the RAC and rapid urease test.

METHODS

Two hundred sixty three consecutive adults undergoing upper digestive endoscopy and rapid urease test were included. The lesser curvature of the lower corpus was evaluated for the RAC pattern using a standard endoscope and different hemoglobin index. Two biopsies from the lesser curvature of the antrum and the greater curvature of the body were collected for rapid urease test.

RESULTS

H. pylori were detected in 51.3% (135/263) patients. Of the 57 patients with H. pylori-negative normal stomachs 53 patients (93%) had RAC. As a determinant of the normal stomach without H. pylori infection, the presence of RAC had 41.4% sensitivity, 97.0% specificity, 93.0% positive predictive value and 63.6% negative predictive value.

CONCLUSIONS

RAC-positive finding by standard endoscopy showed high positive predictive value and specificity of H. pylori-negative normal stomach. RAC-positive finding by standard endoscopy could be an useful finding to predict H. pylori negativity.

Predictability of Gastric Intestinal Metaplasia by Mottled Patchy Erythema Seen on Endoscopy

BACKGROUND

Intestinal metaplasia (IM) is regarded as a premalignant lesion. However, endoscopic diagnosis of IM has been considered difficult. Using endoscopy, we found a unique pattern of erythema, "Mottled Patchy Erythema (MPE)," which includes severe IM. Helicobacter pylori (Hp) infection itself can cause erythema, which reflects histologic changes in the gastric mucosa. Therefore we enrolled Hp eradication patients to validate the relation between MPE and pathologic findings.

METHODS

We enrolled patients with chronic gastritis who underwent successful Hp eradication at least 6 months before the study. We defined MPE as multiple flat or depressed erythematous lesions. When encountering MPE on endoscopy, we performed biopsy on both the MPE site and non-MPE site. The non-MPE site was defined as an adjacent mucosa located within 3 cm of the MPE site. All biopsy specimens were evaluated immunohistochemically for IM subtype using MUC2, MUC5AC, MUC6, CD10, and CDX2 stains. The degree of IM was defined according to the Updated Sydney System. The diagnostic accuracy of the MPE findings for pathologic IM was calculated. The relation between MPE and IM subtype was also assessed.

RESULTS

A total of 102 patients were selected for the study. Of these, 55 (54%) patients had MPE. Biopsy specimens were taken from the MPE sites and non-MPE sites from these 55 patients. The IM percentages and median scores of IM were both significantly higher at the MPE sites (P < 0.001) than at the non-MPE sites. The sensitivity and specificity for MPE in the detection of histologic IM were 72.7% and 84.1%, respectively. No significant associations were observed in the expression of MUC2, MUC5AC, MUC6, CD10, and CDX2 between the MPE sites and non-MPE sites. There were no significant differences in the ratios (complete/incomplete) of IM subtypes between the two groups.

CONCLUSIONS

MPE is a useful endoscopic finding to detect histologic IM without the use of chromoendoscopy and magnifying endoscopy. However, the IM subtype is difficult to identify. In the era of Hp eradication, MPE has the potential to become a predictive finding for the risk of gastric cancer.

How to assess the severity of atrophic gastritis

Atrophic gastritis, is the main consequence of long-standing Helicobacter pylori infection, and is linked to the development of gastric cancer. The severity of atrophic gastritis is related to the lifetime risk of gastric cancer development, especially in terms of its degree and extent of mucosal damage. Therefore, it is important for clinicians to assess the severity of atrophic gastritis, interfere with the disease progress, and reverse gastric mucosal atrophy. In the article, we demonstrated some methods (conventional endoscopy, modern endoscopic technology and noninvasive methods) that may help assess the severity of atrophic gastritis and select the reasonable treatment protocols.

Magnifying endoscopic findings of the surface structure of non-cancerous mucosa surrounding differentiated and undifferentiated gastric carcinoma

BACKGROUND

Several reports have described the usefulness of magnifying endoscopy in observing the surface structure in gastric neoplasia. The aim of the present study was to evaluate the characteristics of the surface structure of non-cancerous mucosa surrounding gastric cancer.

METHODS

Sixty Japanese patients with early gastric cancer were enrolled in this study. We observed the non-cancerous gastric mucosa surrounding gastric carcinoma by magnifying endoscopy and classified the magnified view into four patterns: (A) dotted; (B) short-linear; (C) striped; and (D) granular, according to Sakaki's classification.

RESULTS

All patients were diagnosed as having Helicobacter pylori infection, and histological evaluation revealed 46 types of differentiated and 14 types of undifferentiated-type gastric carcinomas. There were significant differences in the gender, age and endoscopic-atrophic-border scale between patients with these two types. In all, the surface structure at 240 points (4 points each in 60 patients) of non-cancerous mucosa was observed by magnifying endoscopy. The prevalences of the surface patterns of the mucosa surrounding differentiated carcinoma were: A, 1.1%; B, 8.1%; C, 28.3%; D, 62.5%, and those of the mucosa surrounding undifferentiated carcinoma were: A, 8.9%; B, 73.2%; C, 14.3%; D, 3.6%. There were significant differences in the surface structure of the non-cancerous mucosa surrounding differentiated and undifferentiated gastric carcinoma.

CONCLUSION

The microsurface structure of the gastric mucosa surrounding gastric cancer lesions differed between patients with differentiated and undifferentiated gastric cancer. These findings are expected to be useful for the early detection of gastric carcinoma lesions or for the determination of extensions of carcinoma lesions.

Endomicroscopy of intestinal metaplasia and gastric cancer

In vivo histologic diagnosis of gastric intestinal metaplasia (GIM) and gastric cancer (GC) can be achieved by confocal laser endomicroscopy (CLE). This review describes the endomicroscopic features of GIM and GC and reviews their clinical applications. Differentiation of phenotypes of GIM and GC by using CLE is also discussed.

Web-based system for training and dissemination of a magnification chromoendoscopy classification

AIM: To evaluate the use of web-based technologies to assess the learning curve and reassess reproducibility of a simplified version of a classification for gastric magnification chromoendoscopy (MC).

METHODS: As part of a multicenter trial, a hybrid approach was taken using a CD-ROM, with 20 films of MC lasting 5 s each and an “autorun” file triggering a local HTML frameset referenced to a remote questionnaire through an Internet connection. Three endoscopists were asked to prospectively and independently classify 10 of these films randomly selected with at least 3 d apart. The answers were centrally stored and returned to participants together with adequate feedback with the right answer.

RESULTS: For classification in 3 groups, both intra- [Cohen’s kappa (κ) = 0.79-1.00 to 0.89-1.00] and inter-observer agreement increased from 1st (moderate) to 6th observation (κ = 0.94). Also, agreement with reference increased in the last observations (0.90, 1.00 and 1.00, for observers A, B and C, respectively). Validity of 100% was obtained by all observers at their 4th observation. When a 4th (sub)group was considered, inter-observer agreement was almost perfect (κ = 0.92) at 6th observation. The relation with reference clearly improved into κ (0.93-1.00) and sensitivity (75%-100%) at their 6th observations.

CONCLUSION: This MC classification seems to be easily explainable and learnable as shown by excellent intra- and inter-observer agreement, and improved agreement with reference. A web system such as the one used in this study may be useful for endoscopic or other image based diagnostic procedures with respect to definition, education and dissemination.

External validation of a classification for methylene blue magnification chromoendoscopy in premalignant gastric lesions

BACKGROUND

Conventional endoscopy has low sensitivity, specificity, and interobserver agreement for the diagnosis of gastric atrophy, intestinal metaplasia, and dysplasia. Magnification chromoendoscopy (ME) may optimize the evaluation of premalignant gastric lesions.

OBJECTIVE AND DESIGN

As part of a multicenter trial, we aimed at validating a previously proposed classification for gastric methylene blue ME at a different center. SETTING, PATIENTS, AND INTERVENTIONS: A sample of patients (n = 42) with previously diagnosed chronic atrophic gastritis with or without intestinal metaplasia underwent ME (Pentax EG-3430Z) with 1% methylene blue by 2 endoscopists.

MAIN OUTCOME MEASUREMENTS

A simplified version of a previously published ME classification (group I, group II [further divided into subgroups IIE and IIF], and group III) was used for macroscopic lesions (n = 203) with Sydney-Houston and Vienna classifications being used for histologic analysis (n = 479 biopsy specimens).

RESULTS AND LIMITATIONS

Excellent reproducibility (wK = 0.92 [95% CI, 0.88-0.96]) was observed for classification in groups and substantial reproducibility (wK = 0.78 [95% CI, 0.72-0.84]) was found for classification in subgroups. Global validity was 82% (range 78%-86%), showing no false negatives (sensitivity of 100% [1/1 biopsy]) and a very low rate of false positives (specificity 99% [297/299 biopsies]) for dysplasia detection.

CONCLUSIONS

This classification for methylene blue ME was highly reproducible and valid for the diagnosis of premalignant gastric lesions when used in a center different from that involved in its conception. Despite requiring an unconventional endoscope and a longer procedure, these results could reinforce ME as a valuable technique in the surveillance of patients at risk for gastric cancer.

Classification of gastric pit patterns by confocal endomicroscopy

BACKGROUND

Confocal endomicroscopy is a newly developed endoscopic imaging technology that produces 1000-fold magnification cross-sectional images of the GI surface and subsurface tissue during routine endoscopy. The gastric pit patterns identified by confocal endomicroscopy and correlation with histopathologic examination have not yet been established.

OBJECTIVE

Our purpose was to explore the appearance of various kinds of gastric pits and clarify the relationship between gastric pit patterns and the histopathologic findings.

DESIGN

Descriptive study.

SETTING

Qilu Hospital, Shandong University, Jinan, China.

PATIENTS

A total of 132 consecutive patients underwent confocal endomicroscopy after 7 healthy volunteers had been examined in vivo and 10 samples resected from 10 patients with gastric cancer had been examined ex vivo by use of confocal endomicroscopy. The confocal images obtained from the 132 patients were compared with the histopathologic findings of the biopsy specimens from the corresponding confocal imaging sites in a prospective and blinded fashion.

MAIN OUTCOME MEASUREMENTS

The relationship between the pit patterns and the histopathologic findings.

RESULTS

Gastric pit patterns were classified into 7 types. Normal mucosa with fundic glands mainly showed type A (round pits), and corporal mucosa with histologic gastritis showed type B (noncontinuous short rod-like); normal mucosa with pyloric glands mainly showed type C (continuous short rod-like), and antral mucosa with histologic gastritis showed type D (elongated and tortuous branch-like). Goblet cells were easily distinguished by confocal endomicroscopy in intestinal metaplasia mucosa, which showed type F. The sensitivity and specificity of the type E pattern for predicting gastric atrophy were 83.6% and 99.6%, respectively. Corresponding values of the type G pattern for predicting gastric cancer were 90.0% and 99.4%.

LIMITATIONS

No data on interobserver and intraobserver variability.

CONCLUSIONS

The patterns of gastric pits identified by confocal endomicroscopy correlate well with the histopathologic findings. Confocal endomicroscopy may prove useful in predicting histopathologic diagnoses during routine endoscopic procedures.

Prevalence and distribution of gastric intestinal metaplasia and its subtypes

BACKGROUND AND STUDY AIMS

Intestinal metaplasia, especially type III intestinal metaplasia is considered to be a precursor of gastric cancer and because of this it is suggested that these patients should be followed up by gastroscopy. Our aim was to find out the prevalence of intestinal metaplasia and its subtypes, the appearance of intestinal metaplasia in different parts of the stomach, and the correlation of intestinal metaplasia with other histological and endoscopic findings.

PATIENTS AND METHODS

A total of 505 consecutive patients, with a mean age+/-S.D. of 54+/-16 years, had two biopsies taken from the antrum, two from the corpus, and, in 272 cases, two from the angulus of the stomach during routine upper gastrointestinal endoscopy. Histological specimens were examined according to the updated Sydney system and the ones with incomplete intestinal metaplasia were further stained for sulphomucin visualisation to divide these into types II and III.

RESULTS

The overall prevalence of intestinal metaplasia was 19%. The prevalence of type III intestinal metaplasia was 2.8%, type II intestinal metaplasia was 4.4%, and complete intestinal metaplasia was 11%. Intestinal metaplasia was found most frequently in the antrum and also in the angulus. There was no type III intestinal metaplasia in the corpus. Intestinal metaplasia was found more frequently in patients with atrophic gastritis than in other patients (p < 0.01). The patients with type III intestinal metaplasia were older than the patients without intestinal metaplasia (mean age of 73 versus 51 years). None of the patients with a totally normal appearing stomach in upper gastrointestinal endoscopy had type II or type III intestinal metaplasia.

CONCLUSION

The relatively high overall prevalence of intestinal metaplasia was found in patients referred for gastroscopy in a region of low prevalence of Helicobacter pylori infection and low incidence of gastric cancer. Intestinal metaplasia was most often found in the antrum and angulus. Type III intestinal metaplasia was more prevalent in older patients and intestinal metaplasia was more frequently found in patients with atrophic gastritis. Normal appearing endoscopic finding seems to exclude type II and III intestinal metaplasia.