Atrophic gastritis in young children and adolescents

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.

Autophagy-Related Gene ATG7 Polymorphism Could Potentially Serve as a Biomarker of the Progression of Atrophic Gastritis

Cytotoxin-associated gene A (CagA) is an oncoprotein that H. pylori injects into the host's gastric epithelial cells and that induces proinflammatory cytokines, such as interleukin (IL)-18 and IL-1β. As a result, it leads to atrophic gastritis (AG), a precancerous lesion of gastric cancer. On the other hand, host cells degrade CagA using autophagy systems. However, few studies exist about the single nucleotide polymorphisms (SNPs) in MAP1LC3A, MAP1LC3B, ATG4A, ATG4B, ATG4C, ATG7, and ATG13, which belong to the autophagy-related genes concerning AG. This study aimed to detect biomarkers associated with AG. Herein, H. pylori-positive subjects (n = 200) were divided into the AG (n = 94) and non-AG (n = 106) groups. Thirty tag SNPs were selected from the above seven candidate genes. The SNP frequency between the two groups was analyzed. The frequency of the C/T or T/T genotype at rs4683787 of ATG7 was significantly lower in the AG group than in the non-AG group (p = 0.034, odds ratio = 0.535). Based on multivariate analysis, the C/C genotype of rs4684787 and age were independently associated with gastric mucosal atrophy. This finding helps stratify the patients needing timely endoscopic screening or early eradication of H. pylori.

Atrophic gastritis in Helicobacter pylori-infected children

BACKGROUND

Helicobacter pylori infection is the leading cause of peptic ulcer and chronic gastritis and may initiate gastric carcinogenesis following the Correa cascade. Another lineage of metaplasia, spasmolytic peptide-expressing metaplasia (SPEM) has recently been found to be an alternative precursor to gastric cancer. To date, few reports have investigated gastric precancerous lesions among children with H. pylori infection. This study aimed to evaluate the histopathological pattern of H. pylori atrophic gastritis in children and the extent of precancerous lesions.

MATERIALS AND METHODS

This study enrolled pediatric patients with H. pylori infection from 1998 to 2019. During esophagogastroduodenoscopy examinations, biopsy fragments were collected from the gastric antrum and corpus for rapid urease test, culture, and histology evaluation. The presence and degree of chronic inflammation, activity of gastritis, H. pylori density, atrophy, and intestinal metaplasia (IM) were assessed according to the modified Updated Sydney System. Trefoil factor 2 (TFF2) immunohistochemistry was also performed to assess SPEM in the gastric tissues collected from each case using rabbit anti-human TFF2 antibodies.

RESULTS

A total of 92 children with H. pylori infection and adequate gastric mucosa biopsies were enrolled. Esophagogastroduodenoscopy showed that 39 (42.4%) had duodenal ulcers, 11 (12.0%) had gastric ulcers, 41 (44.6%) had gastritis, and 1 (1.1%) had negative findings. Mild-to-moderate IM was identified in 4 patients (4.3%). SPEM was found in 8 patients (8.7%) with a significantly higher incidence among female patients (15.8% vs. 8.7%, p = .031). Gastric glandular atrophy presented in 28 patients (30.4%), and high-grade atrophy was more common in female patients (3.2% vs. 1.9%, p = .031).

CONCLUSIONS

The prevalence rates of atrophic gastritis in the children with H. pylori infection were 30.4% for gastric glandular atrophy, 4.3% for IM and 8.7% for SPEM. SPEM and high-grade atrophy were more common in female patients.

Helicobacter pylori-negative Chronic Gastritis in Children: A Systematic Review

OBJECTIVES

To systematically review the current evidence on Helicobacter pylori-negative chronic gastritis including natural history, available therapies and outcomes.

METHODS

Articles providing data on the prevalence, treatment or outcomes of Helicobacter pylori-negative gastritis were identified through a systematic search in the MEDLINE and EMBASE databases. All original research articles from human studies until October 31, 2021, were included.

RESULTS

A total of 54 studies were included consisted of eosinophilic gastritis (n = 9), autoimmune gastritis (n = 11), collagenous gastritis (n = 16), focally enhanced gastritis (n = 6), lymphocytic gastritis (n = 5) and other causes including idiopathic gastritis and chronic renal failure related (n = 7). Most of the included studies were either cross-sectional or longitudinal cohorts except for collagenous gastritis, which mainly included case reports and case series. The prevalence of paediatric eosinophilic gastritis ranges between 5 and 7/100,000 and patients have generally favourable outcome with 50% to 70% clinical and histological response to either corticosteroids or elimination diets. Autoimmune gastritis and collagenous gastritis are extremely rare entities, commonly present with refractory iron deficiency anaemia, while lymphocytic gastritis is relatively common (10%-45%) in children with coeliac disease. Data on treatments and outcomes of autoimmune, collagenous, and focally enhanced gastritis are lacking with limited data implying poor response to therapy in the former 2 diagnoses.

CONCLUSIONS

Helicobacter pylori-negative gastritis is uncommonly reported, mainly in small cohorts, mixed adult-paediatric cohorts or as sporadic case reports. As common symptoms are not specific, thus not always result in an endoscopic evaluation, the true prevalence of these distinct disorders may be underestimated, and thus under reported.

Cellular Plasticity, Reprogramming, and Regeneration: Metaplasia in the Stomach and Beyond

The mucosa of the body of the stomach (ie, the gastric corpus) uses 2 overlapping, depth-dependent mechanisms to respond to injury. Superficial injury heals via surface cells with histopathologic changes like foveolar hyperplasia. Deeper, usually chronic, injury/inflammation, most frequently induced by the carcinogenic bacteria Helicobacter pylori, elicits glandular histopathologic alterations, initially manifesting as pyloric (also known as pseudopyloric) metaplasia. In this pyloric metaplasia, corpus glands become antrum (pylorus)-like with loss of acid-secreting parietal cells (atrophic gastritis), expansion of foveolar cells, and reprogramming of digestive enzyme-secreting chief cells into deep antral gland-like mucous cells. After acute parietal cell loss, chief cells can reprogram through an orderly stepwise progression (paligenosis) initiated by interleukin-13-secreting innate lymphoid cells (ILC2s). First, massive lysosomal activation helps mitigate reactive oxygen species and remove damaged organelles. Second, mucus and wound-healing proteins (eg, TFF2) and other transcriptional alterations are induced, at which point the reprogrammed chief cells are recognized as mucus-secreting spasmolytic polypeptide-expressing metaplasia cells. In chronic severe injury, glands with pyloric metaplasia can harbor both actively proliferating spasmolytic polypeptide-expressing metaplasia cells and eventually intestine-like cells. Gastric glands with such lineage confusion (mixed incomplete intestinal metaplasia and proliferative spasmolytic polypeptide-expressing metaplasia) may be at particular risk for progression to dysplasia and cancer. A pyloric-like pattern of metaplasia after injury also occurs in other gastrointestinal organs including esophagus, pancreas, and intestines, and the paligenosis program itself seems broadly conserved across tissues and species. Here we discuss aspects of metaplasia in stomach, incorporating data derived from animal models and work on human cells and tissues in correlation with diagnostic and clinical implications.

Serum pepsinogen cut-off values in Helicobacter pylori-infected children

BACKGROUND

The aim of this study was to evaluate the standard values for gender- and age-stratified serum pepsinogen (sPG) in Helicobacter pylori (H. pylori) non-infected children and to determine the optimal cut-off values of sPG for predicting H. pylori-infected gastritis in children.

METHODS

A prospective study for determination of sPG levels was performed in children with epigastric pain who underwent esophagogastroduodenoscopy over the past 16 years. After excluding subjects diagnosed with inflammatory bowel diseases, eosinophilic gastrointestinal disorders, or immunoglobulin A vasculitis, the diagnosis of H. pylori infection was defined by positive tissue culture or concordant-positive results for histology and the rapid urease test.

RESULTS

A total of 405 subjects were diagnosed as being H. pylori-infected (79) or non-infected (326). In the H. pylori non-infected group, there were no significant differences in sPG levels among age groups; males had higher sPG I and sPG II levels than females. In the H. pylori-infected group, sPG I and sPG II levels were significantly higher and the sPG I/II ratio was lower than those in the non-infected group. In receiver operating characteristics analyses in diagnosing H. pylori infection, the areas under the curves for sPG I, sPG II and sPG I/II ratio were 0.896, 0.980, and 0.946, respectively. The optimal cut-off value of sPG II of ≥9.0 ng/mL was considered positive for H. pylori infection (sensitivity: 92.4%, specificity: 93.9%).

CONCLUSIONS

The optimal cut-off value of sPG II of ≥9.0 ng/mL may be a good predictor of H. pylori-infected gastritis in children.

Systematic Review and Meta-analysis of Histological Gastric Biopsy Aspects According to the Updated Sydney System in Children

OBJECTIVES

A descriptive and comparative study of gastric histological aspects according to the updated Sydney classification (USC), obtained from Helicobacter pylori-positive versus H pylori-negative children referred for upper gastrointestinal endoscopy.

METHODS

The Prisma method was used to perform a systematic review and meta-analysis. Selection criteria were based on following key words USC, H pylori, children, endoscopy, or biopsy. Publication biases were assessed according to the Newcastle-Ottawa Scale, and a meta-regression analysis was done. The study was registered on the PROSPERO platform.

RESULTS

Between 1994 and 2017, 1238 references were found; 97 studies were retained for the systematic review with a total number of 25,867 children; 75 studies were selected for the meta-analysis concerning 5990 H pylori-infected and 17,782 uninfected children.H pylori-positive versus H pylori-negative children, according to the USC, showed significantly higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, and of lymphoid follicles, and gastric mucosa atrophy, whereas, intestinal metaplasia showed a significantly higher RR only in antral biopsies. The meta-regression analysis showed that H pylori-positive versus H pylori-negative children had significantly higher risk only for corpus activity according to age, recurrent abdominal pain, and geographical area of low H pylori prevalence.

CONCLUSIONS

H pylori infection in children was associated with higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, lymphoid follicles, and rare gastric mucosa atrophy, whereas, rare intestinal metaplasia was only significantly higher in the antral area.

Association between Helicobacter pylori antibody-positive status and extragastric diseases in Japanese junior high school students

BACKGROUND

Helicobacter pylori (H. pylori) infection causes various extragastric diseases. Its transmission route has still not been clarified. However, no large-scale studies have examined the extragastric diseases caused by H. pylori in adolescents. This study aimed to examine the association of H. pylori infection with anemia, serum cholesterol levels, physique, and birth delivery method (vaginal or cesarean) in a large number of Japanese adolescents.

METHODS

From 2016 to 2018, we screened 2,399 adolescents (aged 13-15 years) in their second and third years of junior high school using an enzyme-linked immunosorbent assay-based antibody test. Red blood cells, hemoglobin, hematocrit, total cholesterol, high-density lipoprotein (HDL) cholesterol, and serum antibody levels were measured.

RESULTS

Hemoglobin and hematocrit levels were significantly lower in the H. pylori antibody-positive group than in the H. pylori antibody-negative group in both sexes (boys: P = 0.0004 and 0.0022; girls: P = 0.0019 and 0.0005, respectively). Total cholesterol and non-HDL cholesterol levels were significantly higher in the H. pylori-positive group than in the H. pylori-negative group among boys (P = 0.0370 and 0.0293 respectively). There was no significant difference in body mass index percentile and birth delivery method between the H. pylori-positive and H. pylori-negative groups in both boys and girls.

CONCLUSIONS

Among Japanese junior high school students, H. pylori antibody-positive status was associated with anemia in both sexes while total cholesterol and non-HDL cholesterol levels were associated among boys. There was no association between H. pylori antibody status, body mass index percentile, and birth-delivery method.

Gut microbiota changes related to Helicobacter pylori eradication with vonoprazan containing triple therapy among adolescents: a prospective multicenter study

Currently, it is unclear whether treating Helicobacter pylori (H. pylori) infection is safe among adolescents. This study aimed to evaluate the safety of H. pylori eradication therapy by examining gut microbiota changes in adolescents 3 months after the therapy. H. pylori-infected adolescents were enrolled in this study. Their stool samples were collected at the following three time points: before treatment, 1-2 days after completion of treatment, and time of eradication successful judgment. We assessed the relative abundance, alpha-diversity, and beta-diversity of the gut microbiota and adverse events. The number of isolated Actinobacteria decreased immediately after eradication therapy in the 16 students included in the study, and it returned to pretreatment condition at the eradication judgment point. There was no change in the relative abundance at genus level. The alpha-diversity was lost immediately after eradication therapy; however, it recovered at the time of eradication judgment, and it was restored to pretreatment condition. Meanwhile, none of the participants experienced serious adverse events. H. pylori eradication therapy is safe for adolescents with respect to gut microbiota changes associated with H. pylori eradication therapy. Therefore, further long-term evaluations of gut microbiota changes following eradication therapy are warranted.

The updated JSPGHAN guidelines for the management of Helicobacter pylori infection in childhood

The Japan Pediatric Helicobacter pylori Study Group published the first guidelines on childhood H. pylori infection in 1997. They were later revised by the Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition (JSPGHAN). The H. pylori eradication rates, when employing triple therapy with amoxicillin and clarithromycin, currently recommended as the first-line therapy of H. pylori infection in Japan, have substantially decreased, creating an important clinical problem worldwide. In Japanese adults, the "test-and-treat" strategy for H. pylori infection is under consideration as an approach for gastric cancer prevention. However, the combined North American and European pediatric guidelines have rejected such a strategy for asymptomatic children. As risk for gastric cancer development is high in Japan, determining whether the "test-and-treat" strategy can be recommended in children has become an urgent matter. Accordingly, the JSPGHAN has produced a second revision of the H. pylori guidelines, which includes discussion about the issues mentioned above. They consist of 19 clinical questions and 34 statements. An H. pylori culture from gastric biopsies is recommended, not only as a diagnostic test for active infection but for antimicrobial susceptibility testing to optimize eradication therapy. Based upon antimicrobial susceptibility testing of H. pylori strains (especially involving clarithromycin), an eradication regimen including use of the antibiotics to which H. pylori is susceptible is recommended as the first-line therapy against H. pylori-associated diseases. The guidelines recommend against a "test-and-treat" strategy for H. pylori infection for asymptomatic children to protect against the development of gastric cancer because there has been no evidence supporting this strategy.

Prevalence of Helicobacter pylori among children in a training and research hospital clinic in Istanbul and comparison with Updated Sydney Classification Criteria

OBJECTIVE

Helicobacter pylori (H. pylori) is a gram-negative bacterium and one of the reasons for gastritis, peptic and duodenal ulcers. It is a crucial public health problem for both children and adults, especially in developing countries. This study aims to investigate the prevalence of Helicobacter pylori positivity in children and to compare with updated Sydney classification criteria.

METHODS

This study was conducted from January 2015 to June 2017. This study included 885 children aged 0-17 year(s). Endoscopic biopsies were evaluated for the diagnosis of infection due to H. pylori.

RESULTS

The findings showed that 418 (47.2%) of 885 children were positive for H. pylori, and this positivity had a significantly increasing correlation with the presence of chronic inflammation, neutrophilic activity, lymphoid aggregates, and follicles. Erythematous pangastritis and antral nodularity on endoscopic findings had a correlation with H. pylori positivity.

CONCLUSION

In this hospital-based study, the findings suggest that H. pylori infection is a problem for children and more extensive studies are needed to determine the prevalence of H. pylori positivity among children.

Diagnosis: gastric intestinal metaplasia - what to do next?

PURPOSE OF REVIEW

One of the most vexing problems for gastroenterologists is what actions to take after receiving a histological diagnosis of gastric intestinal metaplasia. We approach the problem by starting with suggesting a biopsy protocol that ensures obtaining the biopsies required for diagnosis, assessing the status of the gastric mucosa, and effective communication with the pathologist and patient.

RECENT FINDINGS

The rediscovery and integration of the long history of gastric damage and repair resulting in pseudopyloric metaplasia (called SPEM) into the thinking of investigators working with animal models of gastric cancer has resulted in improved ability to separate changes associated with benign repair from those associated with inflammation-associated gastric carcinogenesis.

SUMMARY

Gastric intestinal metaplasia is a potential reversible product of injury and repair and not directly connected with carcinogenesis. Intestinal metaplasia is a biomarker for prior gastric injury and repair. The risk of gastric cancer is best assessed in relation to the severity, extent, and, most importantly, the cause of the atrophic changes.

Atrophic gastritis and chronic diarrhea due to Helicobacter pylori infection in early infancy: A case report

RATIONALE

Helicobacter pylori infection causes atrophic gastritis in childhood, but atrophic gastritis due to H pylori infection is extremely rare in infancy. The relationship between H pylori infection and chronic diarrhea without protein leakage remains controversial.

PATIENT CONCERNS

An 8-month-old male infant presented to our hospital with severe watery diarrhea, erythema, and failure to thrive from approximately 1 month after birth. Blood, stool, esophagogastroduodenoscopy, total colonoscopy, and H pylori urease analysis results were positive, thereby suggesting atrophic gastritis.

DIAGNOSES

Atrophic gastritis and chronic diarrhea due to H pylori infection.

INTERVENTIONS

We performed H pylori eradication therapy using triple therapy with vonoprazan (6 mg/kg), amoxicillin (300 mg/d), and clarithromycin (120 mg/kg) for 7 days.

OUTCOMES

From approximately 1 week after the H pylori eradication therapy, the frequency of defecation had decreased, stool shape had improved, and body weight had gradually increased.

LESSONS

H pylori infection can cause atrophic gastritis and chronic diarrhea even in infancy. Early eradication therapy for H pylori infection may be useful for prevention of gastric cancer and improvement in growth disorders.

Interactions between Helicobacter pylori and gastroesophageal reflux disease

Interactions between Helicobacter Pylori (HP) and gastroesophageal reflux disease (GERD) are a complex issue. Several pathophysiological factors influence the development and the course of GERD, HP infection might be only one of these. Many studies emphasize the co-existence of these diseases. HP infection could contribute to GERD through both a protective and an aggressive role. Gastric acid secretion is a key factor in the pathophysiology of reflux esophagitis. Depending on the type of gastritis related to HP, acid secretion may either increase or decrease. Gastritis in corpus leads to hypoacidity, while antrum gastritis leads to hyperacidity. In cases of antral gastritis and duodenal ulcers which have hyperacidity, the expectation is an improvement in pre-existing reflux esophagitis after eradication of HP. In adults, HP infection is often associated with atrophic gastritis in the corpus. Atrophic gastritis may protect against GERD. Pangastritis which leads to gastric atrophy is commonly associated with CagA strains of HP and it causes more severe gastric inflammation. In case of HP-positive corpus gastritis in the stomach, pangastritis, and atrophic gastritis, reflux esophagitis occurs frequently after eradication of HP. Nonetheless, as a predisposing disease of gastric cancer, HP should be treated. In conclusion, as the determinative factors affecting GERD involving in HP, detailed data on the location of gastric inflammation and CagA positivity should be obtained by the studies at future.

Rise and fall of peptic ulceration: A disease of civilization?

Humans and Helicobacter pylori have evolved and adapted over tens of thousands of years. Yet peptic ulcer disease appeared to be rare prior to the 19th century. The prevalence of peptic ulcer disease increased between 1850 and 1900 and culminated in a cohort at high risk that was born at the end of the 19th century. This coincided with the provision of safe water and improvements in sanitation and personal hygiene. One hypothesis for the emergence of peptic ulcer disease focuses on the rate of development of atrophic gastritis induced by H. pylori. The hypothesis developed in this article focuses on delay in the age of acquisition of H. pylori to a time when immune and inflammatory responses to the infection were more mature. Whereas the acquisition of H. pylori in infancy usually resulted in mild pangastritis, hypochlorhydria, and a low risk for peptic ulcer disease, delayed acquisition could cause either more severe pangastritis (predisposing to gastric ulceration) or gastritis largely restricted to the antrum of the stomach (predisposing to duodenal ulceration). The decline in the prevalence of peptic ulcer disease over the past 100 years parallels the decline in the prevalence of H. pylori. The epidemic of ulcer disease in the first half of the 20th century seems likely to be an adverse effect of important public health measures undertaken in the latter half of the 19th century.

Accuracy of Endoscopic Diagnosis for Mild Atrophic Gastritis Infected with Helicobacter pylori

Background/Aims

This study examined the accuracy of endoscopic evaluation for determining the Helicobacter pylori infection status in patients with mild atrophy who might not exhibit characteristic endoscopic findings.

Methods

Forty endoscopists determined the H. pylori infection status of 50 randomly presented H. pylori-positive and H. pylori-negative cases on the basis of a list of established findings.

Results

The median clinical endoscopy experience was 7 years (range, 1–35 years), including 22 board-certified endoscopists (55%) of the Japan Gastroenterological Endoscopy Society. The mean accuracy rate of endoscopic diagnosis was 67% and was unrelated to experience status (experienced vs. trainee: 69% vs. 65%, p=0.089) and total years of experience (R² =0.022). The most frequently selected endoscopic findings were regular arrangement of collecting venules (59%), atrophy (45%), and red streak (22%), which had fair accuracy rates of 67%, 65%, and 73%, respectively. By contrast, the accuracy rates of nodularity (89%) and mucosal swelling (77%) were highest. The 20 endoscopists who more frequently identified these findings diagnosed H. pylori infection significantly more accurately than did the other endoscopists (71% vs. 64%, p=0.008).

Conclusions

Careful attention to nodularity and mucosal swelling in patients with mild atrophy may enhance diagnosis, enable prompt treatment, and avoid possible long-term carcinogenesis.

Clinical significance of spasmolytic polypeptide-expressing metaplasia and intestinal metaplasia in Epstein-Barr virus-associated and Epstein-Barr virus-negative gastric cancer

Spasmolytic polypeptide-expressing metaplasia (SPEM) and intestinal metaplasia (IM) have been recognized as neoplastic precursors in gastric carcinogenesis. We explored the relationship between SPEM and IM in Epstein-Barr virus-associated (EBVaGC) and Epstein-Barr virus-negative (EBVnGC) gastric cancer. Sixty-four EBVaGC and one hundred and fifty-four EBVnGC patients were included. EBV positivity was identified using Epstein-Barr virus-encoded RNA-1 in situ hybridization. SPEM was subclassified into absent, early, and advanced SPEM. Acute and chronic inflammation was graded as absent, mild, moderate, and marked. Univariate and multivariate logistic regression analyses were conducted to analyze the correlation between SPEM, IM, and inflammation. Our study revealed that SPEM was detected in 87.5% EBVaGC and 85.1% EBVnGC patients. Distribution of patients according to the SPEM classification was significantly different between EBVaGC and EBVnGC groups (P=.038). IM was observed less frequently in EBVaGC when compared with EBVnGC patients (P<.001). No difference was observed between EBVaGC and EBVnGC in the levels of acute and chronic inflammation. A positive correlation between IM and SPEM status was observed in both EBVaGC and EBVnGC patients. Furthermore, advanced SPEM was an independent influential factor to IM in EBVnGC (P=.013). In conclusion, SPEM was associated with both EBVaGC and EBVnGC more frequently than IM. Moreover, advanced SPEM had a stronger association with IM than early SPEM in EBVnGC. These results suggest that identification of SPEM should be used as a high-risk indicator for detecting early gastric carcinoma, and should be brought to the attention of pathologists and clinicians.

Nodule Regression in Adults With Nodular Gastritis

Background

Nodular gastritis (NG) is associated with the presence of Helicobacter pylori infection, but there are controversies on nodule regression in adults. The aim of this study was to analyze the factors that are related to the nodule regression in adults diagnosed as NG.

Methods

Adult population who were diagnosed as NG with H. pylori infection during esophagogastroduodenoscopy (EGD) at our center were included. Changes in the size and location of the nodules, status of H. pylori infection, upper gastrointestinal (UGI) symptom, EGD and pathology findings were analyzed between the initial and follow-up tests.

Results

Of the 117 NG patients, 66.7% (12/18) of the eradicated NG patients showed nodule regression after H. pylori eradication, whereas 9.9% (9/99) of the non-eradicated NG patients showed spontaneous nodule regression without H. pylori eradication (P < 0.001). Nodule regression was more frequent in NG patients with antral nodule location (P = 0.010), small-sized nodules (P = 0.029), H. pylori eradication (P < 0.001), UGI symptom (P = 0.007), and a long-term follow-up period (P = 0.030). On the logistic regression analysis, nodule regression was inversely correlated with the persistent H. pylori infection on the follow-up test (odds ratio (OR): 0.020, 95% confidence interval (CI): 0.003 - 0.137, P < 0.001) and short-term follow-up period < 30.5 months (OR: 0.140, 95% CI: 0.028 - 0.700, P = 0.017).

Conclusions

In adults with NG, H. pylori eradication is the most significant factor associated with nodule regression. Long-term follow-up period is also correlated with nodule regression, but is less significant than H. pylori eradication. Our findings suggest that H. pylori eradication should be considered to promote nodule regression in NG patients with H. pylori infection.

Association between Gastric pH and Helicobacter pylori Infection in Children

PURPOSE

To assess gastric pH and its relationship with urease-test positivity and histological findings in children with Helicobacter pylori infection.

METHODS

Fasting gastric juices and endoscopic antral biopsy specimens were collected from 562 children and subjected to the urease test and histopathological examination. The subjects were divided into 3 age groups: 0-4, 5-9, and 10-15 years. The histopathological grade was assessed using the Updated Sydney System, while the gastric juice pH was determined using a pH meter.

RESULTS

The median gastric juice pH did not differ significantly among the age groups (p=0.655). The proportion of individuals with gastric pH >4.0 was 1.3% in the 0-4 years group, 6.1% in the 5-9 years group, and 8.2% in 10-15 years (p=0.101). The proportions of moderate and severe chronic gastritis, active gastritis, and H. pylori infiltration increased with age (p<0.005). Urease-test positivity was higher in children with hypochlorhydria (77.8%) than in those with normal gastric pH (31.7%) (p<0.001). Chronic and active gastritis were more severe in the former than the latter (p<0.001), but the degree of H. pylori infiltration did not differ (20.9% vs. 38.9%; p=0.186).

CONCLUSION

Gastric pH while fasting is normal in most children regardless of age. Urease-test positivity may be related to hypochlorhydria in children, and hypochlorhydria is in turn related to H. pylori infection.

Pediatric non-Helicobacter pylori atrophic gastritis: a case series. Am J Surg Pathol. 2015;39:786-792. [PMID: 25602795 DOI: 10.1097/pas.0000000000000378]

Although autoimmune atrophic gastritis is classically a disease of elderly adults, recent studies have described the disease in younger adults, particularly in those with other autoimmune diseases and iron-deficiency anemia. Atrophic gastritis in pediatrics is a rare and possibly underdiagnosed entity that has been primarily reported as single-case reports. This retrospective study of atrophic gastritis not associated with Helicobacter pylori infection was performed to further expand the knowledge of clinical presentation, pathologic findings, and natural history of this disease in the pediatric population. Twelve patients with a histologic diagnosis of atrophic gastritis were identified, with an age range of 8 months to 18 years. Seven had other autoimmune diseases and/or immunodeficiency. Atrophy was confined to the oxyntic mucosa in 10 patients, with intramucosal inflammation in a diffuse or basal-predominant pattern. Active inflammation was present in 7 patients. Pseudopyloric, intestinal, or squamous/mucinous metaplasia was seen at initial biopsy or on follow-up in 8 patients, and enterochromaffin-like cell hyperplasia was seen in 5. One patient developed an adenocarcinoma during the follow-up period of 10 years. Two false-negative diagnoses were retrospectively identified. In the majority of cases, the possibility of atrophic gastritis was not raised by the submitting physician, and the endoscopic findings were not specific. Therefore, accurate diagnosis requires a high degree of suspicion on the part of the pathologist, and the diagnosis should be considered particularly in patients with a clinical history of other autoimmune diseases or iron-deficiency anemia.

Prevalence of Helicobacter pylori in children in eastern Turkey and molecular typing of isolates

The objectives of the present study were to determine Helicobacter pylori via culture, polymerase chain reaction and histopathological diagnosis in 101 children ranging in age from 4 to 18 years, to identify the association among restriction fragment length polymorphism types and clinical disease and to investigate the relationships among different isolates of H. pylori in different age groups. We observed a high prevalence of H. pylori infections in children between the ages of 13 and 18 (75.8%), while children aged 4 to 6 years had the lowest prevalence of infection (40%). H. pylori was detected in 30.7% (31 of 101), 66.3% (67 of 101) and 63.2% (60 of 95) of children as determined by culture methods, PCR and histological examination, respectively. H. pylori isolates with RFLP types I and III were the most common among children with antral nodularity, whereas RFLP types II and IV were the least detected types. Interestingly, all isolates from peptic ulcer patients were type III. Although our results show a high prevalence of H. pylori infections in the pediatric population in eastern Turkey, no association was identified between H. pylori infection with antral nodularity and recurring abdominal pain. In addition, we found low genetic variation among H. pylori isolates from children and no association between RFLP types and antral nodularity (p > 0.05). Additionally, we found that H. pylori isolates with specific RFLP types were predominant in different age groups.

Assessment of p21, p53 expression, and Ki-67 proliferative activities in the gastric mucosa of children with Helicobacter pylori gastritis

BACKGROUND

Helicobacter pylori that is generally acquired in childhood and infects the gastric mucosa is considered to be responsible for many pathobiological changes that are linked to the pathogenesis of gastric cancer. Although the majority of studies on the subject have been carried out in adults, there are a limited number of studies on children that reflect the early period of infection and may be of greater significance.

AIM

We aimed to determine the role of H. pylori infection and/or gastritis in several histopathological changes, p53, p21, and cell proliferation-associated Ki-67 antigen expression in the gastric mucosa.

MATERIALS AND METHODS

We studied 60 patients with a mean age of 7.5 ± 4.5 years at referral. On the basis of endoscopic appearance and the evaluation of the gastric antral specimens, the patients were divided into three groups: patients without gastritis, patients with H. pylori-positive gastritis, and patients with H. pylori-negative gastritis. To determine the expression of p53, Ki-67, and p21 in gastric biopsy specimens, immunohistochemical stains were performed.

RESULTS

The incidence of neutrophil activity, which was one of our histopathologic parameters, was significantly higher in the H. pylori-positive gastritis group than the other two groups. The presence of lymphoid aggregate was more frequent in H. pylori ± gastritis groups than the nongastritis group. p53 expression was found to be significantly higher in the H. pylori-positive gastritis group than the nongastritis group. Ki-67 and p21 expressions were significantly more frequent in the H. pylori-positive gastritis group than the other two groups. When we evaluated the density of H. pylori, as the density of bacteria increases, we found that the expressions of p53, p21, and Ki-67 increased significantly.

CONCLUSION

Expression of the studied precancerous markers in significant amounts indicates the importance of childhood H. pylori infection in the constitution of gastric cancer in adulthood.

Autoimmune gastritis presenting as iron deficiency anemia in childhood

AIM: To characterize clinical, laboratorial, and histological profile of pediatric autoimmune gastritis in the setting of unexplained iron deficiency anemia investigation.

METHODS: A descriptive, observational study including pediatric patients with a diagnosis of autoimmune gastritis (positive parietal cell antibody and gastric corpus atrophy) established in a 6 year period (2006-2011) in the setting of refractory iron deficiency anemia (refractoriness to oral iron therapy for at least 6 mo and requirement for intravenous iron therapy) investigation, after exclusion of other potentially contributing causes of anemia. Helicobacter pylori (H. pylori) infection and anti-secretory therapy were also excluded. Data were retrospectively collected from clinical files, including: demographic data (age, gender, and ethnic background), past medical history, gastrointestinal symptoms, familial history, laboratorial evaluation (Hb, serum ferritin, serum gastrin, pepsinogen I/ pepsinogen II, B12 vitamin, intrinsic factor autoantibodies, thyroid autoantibodies, and anti-transglutaminase antibodies), and endoscopic and histological findings (HE, Periodic Acid-Schiff/Alcian blue, gastrin, chromogranin A and immunochemistry analysis for CD3, CD20 and CD68). Descriptive statistical analysis was performed (mean, median, and standard deviation).

RESULTS: We report a case-series concerning 3 girls and 2 boys with a mean age of 13.6 ± 2.8 years (3 Caucasian and 2 African). One girl had type I diabetes. Familial history was positive in 4/5 cases, respectively for autoimmune thyroiditis (2/5), sarcoidosis (1/5) and multiple myeloma (1/5). Laboratorial evaluation on admission included: Hb: 9.5 ± 0.7 g/dL; serum ferritin: 4.0 ± 0.9 ng/mL; serum gastrin: 393 ± 286 pg/mL; low pepsinogen I/ pepsinogen II ratio in 1/5 patients; normal vitamin B12 levels (analyzed in 3 patients). Endoscopy findings included: duodenal nodularity (2/5) and gastric fold softening (2/5), and histological evaluation showed corpus atrophic gastritis with lymphocytic infiltration (5/5), patchy oxyntic gland mononuclear cell infiltration (5/5), intestinal and/or pseudo-pyloric metaplasia in corpus mucosa (4/5), and enterochromaffin cell hyperplasia (4/5). Immunochemistry for gastrin on corpus biopsies was negative in all cases. Duodenal histology was normal. All biopsies were negative for H. pylori (Giemsa staining and cultural examination).

CONCLUSION: We highlight autoimmune gastritis as a diagnosis to be considered when investigating refractory iron deficiency anemia in children, particularly in the setting of a personal/familial history of autoimmune disease, as well as the diagnostic contribution of a careful immunohistological evaluation.

Occurrence of Helicobacter pylori and Epstein-Barr virus infection in endoscopic and gastric cancer patients from Northern Brazil

BACKGROUND

Helicobacter pylori (HP) and Epstein-Barr virus (EBV) have been associated with cancer development. We evaluated the prevalence of HP, HP CagA+ and EBV infection in gastric cancer (GC) samples from adults and in gastric tissues from patients who underwent upper endoscopy (UE).

METHODS

Samples from UE and GC were collected to investigate the presence of HP infection and the HP virulence factor CagA by a urease test and PCR. The presence of EBV was detected by Eber-1 in situ hybridization.

RESULTS

In UE, 85.5% of juvenile patients showed some degree of gastritis (45.3% of patients with mild gastritis and 54.7% with moderate/severe gastritis) and patients with mild gastritis were younger than patients with moderate/severe gastritis. Among adults, 48.7% presented mild gastritis and 51.3% moderate/severe gastritis. HP infection was detected in 0% of normal mucosa, 58.5% of juvenile gastritis patients, 69.2% of adult gastritis patients and 88% of GC patients. In these same groups, HP CagA+ was detected in 0%, 37.7%, 61.5% and 67.2% of tissue samples, respectively. In juvenile patients, HP infection was more common in those with gastritis than in normal samples (p = 0.004). The patients with either HP or HP CagA+ were older than patients without these pathogens (p < 0.05). In juvenile patients, HP infection was more frequent in cases of moderate/severe gastritis than in cases of mild gastritis (p = 0.026). Moreover, in patients with GC, HP infection was more frequent in males than in females (p = 0.023). GC patients with HP CagA+ were older than patients with HP CagA- (p = 0.027). HP CagA+ was more common in intestinal-type than diffuse-type GC (p = 0.012). HP CagA+ was also associated with lymph-node (p = 0.024) and distal (p = 0.005) metastasis. No association between EBV infection and HP infection or any clinicopathological variable was detected.

CONCLUSIONS

Our results suggest that HP is involved in the pathophysiology of severe gastric lesions and in the development of GC, particularly when CagA+ is present. EBV was not the primary pathogenic factor in our samples.

OLGA and OLGIM stage distribution according to age and Helicobacter pylori status in the Korean population

BACKGROUND

The Operative Link for Gastritis Assessment (OLGA) and the Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM) staging systems have been suggested to provide risk assessment for gastric cancer. This study aimed to evaluate the distribution of OLGA and OLGIM staging by age and Helicobacter pylori status.

MATERIALS AND METHODS

We studied 632 subjects who underwent esophagogastroduodenoscopy for gastric cancer screening. Helicobacter pylori status and histologic changes were assessed using the updated Sydney system. Stage III and IV OLGA or OLGIM stages were considered as high-risk stages.

RESULTS

The rate of H. pylori infection was 59.0% (373/632). Overall, the proportion of high OLGA and OLGIM stages was significantly increased with older age (p < .001 for both). Old age (OR = 5.17, 6.97, and 12.23 for ages in the 40's, 50's, and 60's, respectively), smoking (OR = 2.54), and H. pylori infection (OR = 8.46) were independent risk factors for high-risk OLGA stages. These risk factors were the same for high-risk OLGIM stages. In the H. pylori-positive subgroup, the proportion of high-risk OLGA stages was low (6.9%) before the age of 40, but increased to 23.0%, 29.1%, and 41.1% for those in their 40s, 50s, and 60s, respectively (p < .001). High-risk OLGIM stages showed a similar trend of 2.8% before the age of 40 and up to 30.1% for those in their 60s. High-risk OLGA and OLGIM stages were uncommon in the H. pylori-negative group, with a respective prevalence of 10.3% and 3.4% even among those in their 60s.

CONCLUSIONS

Because high-risk OLGA and OLGIM stages are uncommon under the age of 40, H. pylori treatment before that age may reduce the need for endoscopic surveillance for gastric cancer.

Prevalence of gastric precancerous conditions: a systematic review and meta-analysis

Several reports of estimates for precancerous conditions for gastric adenocarcinoma can be found in the current literature. Our aim was to systematically review and estimate the prevalence of gastric precancerous conditions. Four databases (PubMed, Scopus, Web of Knowledge and EBSCO Academic Search Complete) were searched for original manuscripts addressing the presence of chronic atrophic gastritis (CAG) or intestinal metaplasia (IM). Subgroup analysis was carried out on methods of diagnosis, type of population, incidence of gastric cancer, sex, Helicobacter pylori status, age and extent of conditions. Overall, 107 studies were included. The worldwide prevalence of CAG in the general population was 33% (95% confidence interval: 26-41%) when considering biopsies (n=20 912) and 24% (19-29%) if serology (n=51 886) was used, whereas IM was found in 25% (19-30%) (n=30 960). Estimates for CAG were higher in countries with a high incidence of gastric cancer (42 vs. 23%), men (32 vs. 28%), H. pylori positive (46 vs. 17%) and if aged 40 years or older (48 vs. 22%). The prevalence of extensive conditions was 16% (12-20%) for CAG and 13% (9.0-17%) for IM. When comparing countries with high versus low to moderate incidence of gastric cancer, significant differences were achieved for CAG: 27% (12-36%) versus 7.3% (5.6-9.0%). Worldwide, one-third and one-fourth of individuals may harbour CAG and IM, respectively. In countries with a high incidence of gastric cancer, the prevalence of extensive conditions may increase up to 27% and these patients represent a high-risk population to whom endoscopic surveillance should be offered according to recent guidelines.

Association between Helicobacter pylori infection and pathological changes in the gastric mucosa in Chinese children

OBJECTIVE

H. pylori infection in children has a high prevalence worldwide. The disease can cause progressive gastric mucosal inflammation, as verified in animal models. However, data from large-scale clinical studies are limited.

METHODS

We examined 1,634 Chinese children with upper gastrointestinal discomfort using endoscopy. The clinical and pathological data of the patients were analyzed.

RESULTS

A total of 524 (32.1%) patients were infected with H. pylori, and the prevalence of H. pylori infection increased with age. The H. pylori-infected patients exhibited a significantly higher prevalence of active inflammation (26.9% vs. 4.1%), lymphoid follicle formation (18.5% vs. 4.6%) and marked lymphocyte infiltration (19.7% vs. 5.6%). The H. pylori-infected patients also exhibited a significantly higher prevalence of moderate to marked chronic superficial gastritis (41.9% vs. 9.2%) and moderate chronic atrophic gastritis (21.7% vs. 2.6%) than the uninfected patients (p<0.01).

CONCLUSION

H. pylori infection is associated with the degree of gastric mucosal inflammation and the severity of different types of chronic gastritis.

Atrophic gastritis: Helicobacter pylori versus duodenogastric reflux

OBJECTIVES

The objective of this study was to asses the prevalence of atrophic gastritis in children. We also wanted to compare the clinical manifestation, endoscopic appearance and the degree of the gastric atrophy in children and to identify the possible causes which determine gastric atrophy.

METHODS

We evaluated 247 children with chronic gastritis (153 female/94 male, mean age 12.32 years). Atrophy was defined as the loss of normal glandular components, including replacement with fibrosis and/or intestinal metaplasia.

RESULTS

The prevalence of the atrophic gastritis was 16.6% (41 cases), mean age 11.59+/-1.75 years, male-to-female ratio 16:25. The clinical manifestations were correlated with the patient age (infants and toddlers were evaluated mostly for weight loss - 4 cases, and older children for abdominal pain - 22 cases). The endoscopic appearance was described as either nodular (15 cases), or erythematous gastritis (10 cases), or normal (10 cases). According to the Sydney System, the degree of atrophy was found to be mild in 3 patients, moderate in 25, and severe in 13 patients; 14 cases were associated with duodenogastric reflux, 5 with Helicobacter pylori and 2 with Helicobacter heilmannii infection, but in 17 cases the etiology was unknown.

CONCLUSIONS

Atrophic gastritis is present in childhood, even at very young ages (infants, toddlers). The endoscopic appearance is not characteristic for the presence of atrophy. The degree of the atrophy is not correlated with the age of the children. Because of the relatively high number of duodenogastric reflux associated with gastric atrophy, further studies need to evaluate the potential causes and clinical course.

Upper gastrointestinal histopathological findings in children and adolescents with nonulcer dyspepsia with Helicobacter pylori infection

OBJECTIVES

The aim of the study was to investigate the histopathological lesions in the upper gastrointestinal mucosa associated with Helicobacter pylori infection in children with nonulcer dyspepsia.

METHODS

A cross-sectional case-control study was performed on 185 Brazilian children and adolescents (4-17 years, mean 9.5 ± 2.7 years), 63.2% girls, submitted to upper gastrointestinal endoscopy. The histopathological lesions of the esophageal and gastric mucosa were analyzed in biopsy samples.

RESULTS

H pylori infection was identified in 96 children (51.8%). Moderate to severe chronic active gastritis was present in antrum (70.5%) and corpus (45.2%), with higher grading in antrum than in corpus (P < 0.05). The topographic distribution of inflammation was pangastritis (61.9%), followed by antral (32.1%) and corpus (5.9%). H pylori density was higher in antrum than in corpus. Intestinal metaplasia was not found in the H pylori-infected group, nor was significant gastric atrophy. The scores for esophagitis were significantly higher (P < 0.05) in the noninfected group (1.4 ± 0.8) than in the H pylori-infected group (1.07 ± 0.9), with significant negative correlation (r = 0.29; P < 0.05) with the scores of gastric inflammation.

CONCLUSIONS

The prevalence of H pylori infection was high among children with dyspepsia and associated with moderate/severe degrees of gastric inflammation. The high scores of esophagitis in the noninfected group point to 2 distinct groups of pathological conditions sharing similar clinical patterns.

Correlation of serum antibody titres with invasive methods for rapid detection of Helicobacter pylori infections in symptomatic children

Helicobacter pylori (H. pylori) is causally associated with peptic ulcer disease and gastric carcinoma. Typically, children get infected during the first decade of life, but diseases associated with H. pylori are seen mainly in adults. Multiple diagnostic methods are available for the detection of H. pylori infection. The aim of this study was to evaluate the correlation and diagnostic accuracy of three invasive methods [rapid urease test (RUT), histology and bacterial culture] and one non-invasive method (IgG serology) for diagnosis of H. pylori infection in a prospective cohort study conducted on 50 symptomatic children between two and eighteen years of age. Endoscopies with gastric biopsies were performed for RUT, culture and histopathological examination, respectively. IgG antibodies were measured in patient sera using a commercially available enzyme-linked immunosorbent assay (ELISA). RUT and positive H. pylori IgG antibodies were concordant in 88% (44/50) of patients. Both tests were negative in 32% (16/50), and both were positive in 56% (28/50). Disagreement occurred in 12% (6/50) of the patients: three of them (6%) had positive RUT and negative H. pylori IgG, and another three (6%) had negative RUT and positive H. pylori IgG. A combination of RUT with non-invasive serology constituted the optimum approach to the diagnosis of H. pylori infection in symptomatic children. The non-invasive serological test (ELISA) could not be used alone as the gold standard because it cannot distinguish between active and recently treated infection; and bacterial culture could not be used alone because of its low sensitivity.

First-degree relatives of patients with early-onset gastric carcinoma show even at young ages a high prevalence of advanced OLGA/OLGIM stages and dysplasia

BACKGROUND

First-degree relatives (FDRs) of early-onset gastric carcinoma (EOGC) patients are at increased risk of cancer development. OLGA/OLGIM (Operative Link on Gastritis/Intestinal Metaplasia Assessment) classifications have been proposed for the identification of individuals at high risk of gastric cancer development.

AIM

To estimate the prevalence and severity of premalignant conditions and lesions in FDRs of EOGC patients.

METHODS

A case-control study was conducted encompassing 103 FDRs of EOGC patients (cases) and 101 age- and gender-matched controls, all submitted to upper GI endoscopy and OLGA and OLGIM used for staging as well as modified versions with exclusion of the biopsies from incisura angularis in the analysis.

RESULTS

Helicobacter pylori infection was present in 82% of cases (P = 0.001). Atrophy was present in 70% of cases (OLGA stages I-IV). High-risk stages (III-IV) were identified only in cases (19%) (P < 0.001). Dysplasia was diagnosed only in cases (n = 7, P = 0.007). The application of OLGIM, modified OLGA and modified OLGIM classifications led to downgrade of stages in comparison with the original OLGA classification (27%, 15% and 30% respectively). In all classification systems, dysplastic lesions clustered (86%) in high-risk stages.

CONCLUSIONS

FDRs of EOGC patients have, even at young ages, a high prevalence of H. pylori infection, high-risk OLGA and OLGIM stages and dysplasia. These patients should undergo accurate endoscopic observation with at least four biopsies in antrum and corpus to allow adequate staging and follow-up of premalignant conditions and lesions scored in high-risk stages, in accordance with international guidelines recently proposed.

The significance of small intestinal epithelium in gastric antral biopsies in children

Intestinal metaplasia of the gastric antrum is common in adults with chronic gastritis and occurs in Helicobacter -associated gastritis in children. This study examined the frequency and clinical correlates of intestinal epithelium in 1690 consecutive antral biopsies obtained from children over a 2-year period in a tertiary pediatric care facility. Intestinal epithelium in gastric glands not associated with overlying villi was present in 22 (1.3%) biopsies. These came from 20 patients, 2-17 years of age, none of whom had clinical or histologic evidence of Helicobacter infection or significant chronic gastritis. Eight (40%) had an antral pancreatic rest, 8 had some other localized antral abnormality, and 4 were endoscopically normal. Four additional patients with a pancreatic rest had no intestinal epithelium. Six surgically resected rests and 2 rests found at autopsy were also reviewed. Heterotopic intestinal epithelium was present in 1 of the 2 postmortem specimens but was absent from all 6 surgically resected lesions. No intestinal epithelium was present in 67 antral biopsies with Helicobacter gastritis observed during this same period. Although the intestinal epithelium in these patients could be metaplastic, it more likely represents inadvertent sampling of the gastroduodenal junction induced by a lesion in the distal antrum or a focus of heterotopic epithelium and might best be addressed in the surgical pathology report by a comment to this effect. The distinction from metaplasia is more than semantic, because a diagnosis of intestinal metaplasia can have adverse clinical implications and should be made with caution in a child.

Serum pepsinogen and Helicobacter pylori infection--a Japanese population study

The decreased ratio of serum pepsinogen (PG) I and II has good correlation with the presence of atrophic gastritis. A total of 1,540 residents aged 30-89 years were enrolled into this study to investigate which serum PG level of residents with Helicobacter pylori infection would represent an adjunct to the diagnosis and progression of atrophic gastritis. All participants received esophagogastroduodenoscopy. Serum antibody to H. pylori (anti-H. pylori) was measured by an enzyme-linked immunosorbent assay (ELISA). Serological atrophic gastritis was defined as serum PG I isozyme level ≤70 ng/ml and a PG I/II ratio of ≤3.0. Of the 1,540 participants, 923 (59.9%) were positive for anti-H. pylori. Serological atrophic gastritis was found significantly more often in anti-H. pylori-positive participants (40.8%) than in anti-H. pylori-negative participants (7.9%) (p ≤ 0.0001). The endoscopic findings of anti-H. pylori-positive participants with serological atrophic gastritis were significantly more frequent by 4.06 times for atrophic gastritis (p ≤ 0.0001) than anti-H. pylori-negative participants without serological atrophic gastritis. Eight anti-H. pylori-positive participants were diagnosed with gastric cancer, but no cancer was found in anti-H. pylori-negative participants without serological atrophic gastritis. Serum PG testing is clinically useful for the prediction of gastric lesions in H. pylori-infected persons.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED)

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.

Chronic gastritis associated with Helicobacter pylori in Mexican children: histopathological patterns

The objective of this study was to analyze the histopathological patterns of inflammation, distribution, severity, and degree of gastric mucosa of Helicobacter pylori (Hp)-infected children in Northern Mexico, as well as the correlation between colonization density and inflammation intensity. We carried out a cross-sectional study of gastric biopsies performed on children ranging from 2 to 17 years of age who underwent upper gastrointestinal endoscopy for diverse gastroduodenal disorders. This study includes only children who were found to be Hp carriers, with positive results for tests of Hp antigens in feces and in gastric biopsy studies. We studied 107 patients (age 8.2 ± 3.7 years). In 47.7% of patients, the density of Hp colonization was low; only 21.5% had a marked density. Mononuclear leukocyte infiltration showed a similar distribution. Thirty-seven percent of patients had follicular gastritis. An acute inflammatory response was absent in 65% and mild in 20.6% of patients. When inflammation was present, it was primarily located in the antrum (79%). There were no cases of intestinal metaplasia or atrophy. A link was found between Hp density and age, infiltration by mononuclear cells, the presence of follicular gastritis, and the level of neutrophil infiltration (P  =  0.001). Despite the high rates of Hp infection in the region, the histopathological findings in these children were mild and were limited primarily to the antral mucosa. These data indicate the need to study the behavior of this disease in children in diverse study populations to provide localized prevention and treatment strategies.

Low Levels of Pepsinogen I and Pepsinogen I/II Ratio are Valuable Serologic Markers for Predicting Extensive Gastric Corpus Atrophy in Patients Undergoing Endoscopic Mucosectomy

BACKGROUND/AIMS

The levels of pepsinogen (PG) I and the PGI/II ratio are useful serologic markers for chronic atrophic gastritis. This study evaluated the performance and clinical implications of these markers in patients undergoing endoscopic mucosectomy.

METHODS

We enrolled 142 consecutive patients with early gastric tumors and Helicobacter pylori infection who were eligible for mucosectomy. Chronic gastritis and atrophy were assessed using four defined biopsy procedures. Serum PGs were measured by an enzyme immunoassay. Optimal diagnostic cut-offs and performance were determined using receiver operating characteristic curves.

RESULTS

The PGI level and the PGI/II ratio decreased with corpus-dominant gastritis and as atrophy advanced toward the corpus greater curvature (GC). For the presence of corpus GC atrophy, the areas under the PGI and PGI/II-ratio curves were 0.82 and 0.77, respectively. The optimal cut-off levels were 59.3µg/L for PGI (sensitivity, 83.3%; specificity, 78.4%) and 3.6µg/L for PGI/II ratio (sensitivity, 70.0%; specificity, 78.4%). Using these serologic cut-off levels, we found that the frequency of corpus tumor location differed significantly (32.9% vs 11.1% for PGI <59.3 and ≥59.3µg/L, respectively; and 31.1% vs 14.8% for PGI/II ratio <3.5 and ≥3.5, respectively; p<0.05).

CONCLUSIONS

A low PGI level and PGI/II ratio are valuable serologic markers for predicting corpus GC atrophy, and have clinical implications with respect to the corpus location of tumors in mucosectomy patients.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Evaluation of gastric histology in children and adolescents with Helicobacter pylori gastritis using the Update Sydney System

CONTEXT

Although Helicobacter pylori infection is prevalent in our country, there are few studies evaluating the associated histological abnormalities in children.

OBJECTIVE

To evaluate the histological features of the gastric mucosa in children and adolescents with Helicobacter pylori gastritis.

METHODS

One hundred and thirty two gastric biopsies from 22 symptomatic patients infected with H. pylori (14F/8M, median age 10 y 5 mo, age range 2 y 11 mo to 16 y 9 mo) were evaluated. Evaluated gastric regions included: antrum (lesser and greater curvature), corpus (lesser and greater curvature), incisura angularis and fundus. Histological examination was performed according to the Updated Sydney System, and regional scores for polymorphonuclear and mononuclear cell infiltrate as well as bacterial density were generated.

RESULTS

Fifteen (68.2%) patients presented H. pylori-chronic active gastritis, six (27.3%) presented antrum-predominant H. pylori-chronic active gastritis, and one (4.5%) presented corpus-predominant H. pylori-chronic active gastritis. Polymorphonuclear cell infiltrate and mononuclear cell infiltrate were observed in 93.9% and 98.5% of the biopsy specimens, respectively. Higher histological scores for polymorphonuclear infiltrate, mononuclear infiltrate, and bacterial density were observed in the gastric antrum. Intestinal metaplasia and gastric atrophy were not identified in any patient. Lymphoid aggregates and lymphoid follicles were observed in the gastric antrum of three (13.6%) and seven (31.8%) patients, respectively, but they were not related to antral nodularity.

CONCLUSIONS

Chronic active gastritis was observed in all patients with H. pylori infection. However, antral or corporeal predominance was not observed in most patients.

Primary antimicrobial resistance of Helicobacter pylori in children during the past 9 years

BACKGROUND

Antimicrobial resistance of Helicobacter pylori is a growing problem in clinical practice, particularly clarithromycin resistance. The aim of the present study was therefore to investigate the prevalence of H. pylori resistance to antimicrobial agents in Japanese children.

METHODS

A total of 61 H. pylori strains isolated from children (mean age, 12.6 years; range, 4-18 years) between 1999 and 2007 were studied for primary antimicrobial resistance, using a microdilution method. In addition, the eradication rate with lansoprazole-based triple regimens was determined.

RESULTS

The overall resistance rate of clarithromycin, amoxicillin and metronidazole was 36.1%, 0% and 14.8%, respectively. Resistance to both clarithromycin and metronidazole was detected in 6.6% of the strains. The rate of clarithromycin-resistant strains was 32.4% from 1999 to 2002 and 40.7% from 2003 to 2007, and clarithromycin minimum inhibitory concentration at which 90% of the isolates were inhibited (MIC(90)) increased fourfold from 1999-2002 to 2003-2007, with all clarithromycin-resistant strains showing low-level resistance. Metronidazole resistance rates were not different between these two study periods. Regimens involving amoxicillin and clarithromycin (n= 49) had a higher eradication rate in clarithromycin-susceptible strains (97.1%) than in the resistant strains (57.1%; P < 0.001). There was no difference in the eradication rate between 7 day and 10 or 14 day courses of the regimens (P= 0.53). The regimen with amoxicillin and metronidazole produced successful eradication in all nine patients with clarithromycin-resistant strains.

CONCLUSIONS

Clarithromycin resistance of H. pylori is high, and triple regimen treatment containing clarithromycin should be decided based on susceptibility to the agent.

Interobserver variations in histopathological assessment of gastric pathology

AIM

Considering the fact that histology and its grading systems are accepted gold standards in diagnosis of diverse clinical disorders, assessing the accuracy and reliability of this method of diagnosis is of utmost importance. Thus, this study was performed to measure the agreement values between four independent histopathology readings for identical indices under one scoring guideline using three different approaches.

METHODS

Four independent pathologists participated in this study and were blinded to the clinical diagnosis of patients. Various histological features were examined on gastric tissue specimens according to the updated Sydney system.

RESULTS

Statistical analysis revealed that our null hypothesis about the existing agreement between different histopathological observations is rejected for chronic gastritis, the presence of inflammatory activity, atrophy and Helicobacter pylori, whereas there were significant inter-observation agreements in regard to the presence of lymphoid follicles, intestinal metaplasia and dysplasia. Pairwise analysis showed that different grading scales resulted in different kappa values ranging from poor to excellent agreements. The best kappa values were observed for the evaluation of dysplasia between two independent pathologists.

CONCLUSIONS

This assessment has demonstrated that standardisation of less quantitative grading scales resulting in consistent readings is essential for affirmative clinical diagnosis and devising effective treatment strategies.

Helicobacter pylori diagnostic tests in children: review of the literature from 1999 to 2009

The array of tests that can be used for diagnosis of Helicobacter pylori infection is large, and it can be confusing to define which test to use particularly in children where results may not be comparable to those obtained in adult patients. Using PubMed, we reviewed the English literature from January 1999 to May 2009 to identify articles that determined sensitivity and specificity of H. pylori invasive and non-invasive diagnostic tests in children. We excluded articles that presented a review of the literature, abstracts, case reports, or series where children's results could not be separated from adult populations. Of the tissue based methods, rapid urease tests have better sensitivity than histology to detect presence of H. pylori; however, histology can detect the pathology associated with disease including gastritis, intestinal metaplasia, and other conditions that could be the cause of the child's symptoms. Culture of gastric tissues or stool has 100% specificity but sensitivity is low. Of the serologic tests, immunoblot has the best sensitivity. The urea breath tests have >75% sensitivity for detection of H. pylori before and after treatment. Immunoassays in stool using monoclonal antibodies have >95% sensitivity for detection of H. pylori before and after treatment. PCR testing can be performed in tissue and stool samples and can detect genes associated to antibiotic resistance. In summary, the current commercial non-invasive tests have adequate sensitivity and specificity for detecting the presence of H. pylori; however, endoscopy with histopathology is the only method that can detect H. pylori and lesions associated with the infection.

Prevalence and time trend of intestinal metaplasia in Hong Kong

BACKGROUND AND METHODS

Upper endoscopy records from 1998 to 2003 were reviewed. The demographic data, endoscopic diagnosis, results of rapid urease test and the absence or presence of intestinal metaplasia (IM) in histology were reviewed, to evaluate the prevalence of IM and Helicobacter pylori (Hp) infection over time in Hong Kong.

RESULTS

Among 1805 endoscopies performed, 1751 had both rapid urease test and histology available. A significant drop in the prevalence of duodenal ulcers from 17.9% in 1998 to 9.8% in 2003 was found (P = 0.015). Prevalence of IM was 13.9%, 5.9% and 9.4% in Hp positive, Hp negative and overall respectively (P < 0.05). The prevalence of IM increased with age, and the patterns were similar amongst subjects in 1998-2000 and those in 2001-2003. There was progressive decrease in Hp prevalence from 58% in 1998 to 40% in 2001 (P = 0.014), but no further decrease was seen in 2002-3. There was no corresponding decrease in IM prevalence. Instead IM prevalence in 2002-2003 was significantly higher than the prevalence in previous few years (P = 0.04).

CONCLUSION

The prevalence of IM did not change in the period from 1998 to 2003 despite a drop in the prevalence of Hp infection since 1994.

Endoscopic and histopathologic findings associated with H. pylori infection in very young children

Most of the individuals infected with H. pylori acquire the infection early in life. However, there is limited data regarding endoscopic and histopathologic findings of H. pylori infection when it is acquired during infancy. The aim of this study was to investigate the H. pylori-related endoscopic and histopathological findings in children younger than 2 years of age. One hundred and fifty-two infants who underwent upper gastrointestinal endoscopy were included in the study. The diagnosis of H. pylori infection was based on histopathology and a positive rapid urease test. Forty of 152 (26.3%) infants were infected with H. pylori, and 65% of the infected infants had histopathologic gastritis. There were no clinical or endoscopic findings suggestive of H. pylori infection. No correlation could be found between the density of H. pylori and the severity of gastritis. H. pylori infection is associated with various degrees of gastritis in more than half of the infected infants. Since the likelihood of normal histopathology is rare in H. pylori-infected infants, its long-term complications should be cautiously followed up in endemic areas.

Gastritis and gastric atrophy

PURPOSE OF REVIEW

The majority of problems in interpreting gastritis remain Helicobacter related, but their nature has changed. The present review covers gastritis historically through cancer risk staging systems.

RECENT FINDINGS

Key points to remember are: Helicobacter is associated with several forms of gastritis; in the present review, I am focusing on the two ends of the disease, 'Helicobacter pylori infection', that starts with antral predominant gastritis but can continue to oxyntic predominant disease with atrophy; the role Helicobacter pylori plays in autoimmune gastritis with pernicious anemia remains unresolved; gastritis staging systems for cancer risk, namely Baylor and Operative Link on Gastritis Assessment, are currently available.

SUMMARY

As most gastric carcinomas arise on a background of atrophic gastritis, and the risk increases with the extent of atrophy, an index of atrophy location and extent could be useful in predicting patients at greatest risk for carcinoma. It is now possible to stage patients for cancer risk. Nonetheless, in a field such as gastritis in which many issues remain unresolved, a classification or staging system that is more descriptive will likely prove more useful.

When does gastric atrophy develop in Japanese children?

BACKGROUND

Long-term Helicobacter pylori infection causes inflammatory sequelae such as atrophy and intestinal metaplasia in the stomach, which is thought to increase the risk of developing gastric malignancy. We previously reported that gastric atrophy can develop in Japanese children with H. pylori infection, predominantly in the antrum. However, detailed data about the age of children with atrophy are largely lacking.

METHODS AND RESULTS

In the present study, 131 children (79 boys) with H. pylori infection were re-analyzed for an association between age and the grade of gastric atrophy. The gastric antrum was histologically evaluated in all 131 patients and the corpus in 46 patients. Grade 2 and 3 antral atrophy was observed in 13 and one patients, respectively: the mean age was 12.1 years. Two patients (11 and 14 years old) had grade 2 corpus atrophy but no patients had grade 3. No significant difference was found in age among patients with grade 0, 1 and 2 or 3 atrophy in the antrum (p = .97) and in the corpus (p = .59). None of the patients with grade 2 or 3 atrophy had intestinal metaplasia either in the antrum or in the corpus.

CONCLUSIONS

The results of the present study require a careful interpretation because of the retrospective analysis. In high-risk countries of gastric cancer, however, eradicating H. pylori in childhood could prove more effective in preventing gastric atrophy, ultimately, the development of cancer.

Peptic ulcers and erosions are common in Israeli children undergoing upper endoscopy

BACKGROUND

Peptic ulcers and erosions (PU&E) are thought to be uncommon in children. Patients with early exposure to Helicobacter pylori may be at a higher risk for early onset PU&E. Children in Israel have a high prevalence and early acquisition of Helicobacter pylori (H. pylori) and have easy access to pediatric gastroenterologists and endoscopy. Our aim was to describe the prevalence and characteristics of PU&E in this population referred by Pediatric Gastroenterologists for an upper endoscopy.

METHODS

We conducted a retrospective study over the years January 2003-May 2006. Over these years we had information on 751 diagnostic upper endoscopies. PU&E was regarded as erosive gastritis/duodenitis or ulcer in either the stomach or duodenum. H. pylori status was assessed using rapid urease test and gastric biopsies.

RESULTS

PU&E was detected in 169 (22.5%) patients (ulcers 51 (6.8%), erosions 118 (15.7%)). One hundred twenty-four had gastric PU&E and 58 had duodenal PU&E. H. pylori was positive in 112 (66.3%). H. pylori-associated PU&E becomes common after age 10 years, with gastric PU&E presenting much earlier than duodenal disease. Most of the H. pylori-negative PU&E were idiopathic and improved symptomatically on PPI treatment. Interestingly, 43% of patients with PU&E in our cohort were either immigrants from the former Soviet Union or of Israeli Arab origin.

CONCLUSIONS

PU&E appears to be common in this selected population with a relatively high incidence of gastric PU&E. H. pylori associated PU&E becomes common after age 10 years with gastric PU&E presenting much earlier than duodenal disease. Non H. pylori PU&E in children comprises approximately a third of all PU&E, are mostly idiopathic and appear earlier than H. pylori associated PU&E.

Helicobacter pylori infection, but not genetic polymorphism of CYP2E1, is highly prevalent in gastric cancer patients younger than 40 years

BACKGROUND

Gastric cancers in young adults are thought to be associated with risk factors that include Helicobacter pylori infection and genetic polymorphism. The objective of this study was to elucidate the roles of these risk factors in patients younger than 40 years by analyzing clinicopathological data and H. pylori infection, and using molecular epidemiologic techniques.

METHODS

Clinicopathological features, the presence of H. pylori infection, endoscopic characteristics of gastritis, genetic polymorphism of P4502E1 (CYP2E1), and family history of cancer in patients with gastric cancer treated surgically at Nippon Medical School Hospital from 1991 to 2004 were analyzed, based on our medical database.

RESULTS

Gastric cancer in those younger than 40 years was characterized by a predominance of female patients with poorly differentiated adenocarcinoma who had undergone total gastrectomy with extended lymphadenectomy. H. pylori infection had a higher prevalence in patients with gastric cancer than in patients with normal endoscopic results or chronic gastritis, especially in those younger than 40 years (odds ratio, 13.7). Atrophic gastritis, nodular gastritis, and rugal hyperplastic gastritis were observed by endoscopy as H. pylori-associated gastritis. No difference in the incidence of either CYP2E1 genetic polymorphism or a family history of cancer was observed among different age groups.

CONCLUSION

Gastric cancer in patients younger than 40 years is closely associated with H. pylori infection, but not with genetic characteristics. Eradication therapy for H. pylori and endoscopic examination of H. pylori-positive young adults may be anticipated to be adopted as a strategy for the prevention and/or early detection of cancer.