Eosinophilic Gastroenteritis: Using Presenting Findings to Predict Disease Course

INTRODUCTION

Studies on eosinophilic gastroenteritis have identified broad spectrums of disease. We aimed to characterize subtypes of disease and ascertain outcomes of each group.

METHODS

This is a retrospective cohort study from a large tertiary medical center including 35 patients diagnosed with eosinophilic gastroenteritis from 2007 to 2018. We defined 2 groups of patients based on clinical and laboratory findings at presentation. Severe disease was defined as having weight loss at time of presentation, hypoalbuminemia at presentation, serosal disease involvement, or anemia at diagnosis. The remaining patients were labeled as mild disease group. We collected and compared demographic data, clinical features, laboratory findings, an allergy history, and disease course of both cohorts.

RESULTS

Among 35 patients with eosinophilic gastroenteritis, 18 patients met the criteria for severe disease and 17 patients for mild disease. Of the patients with severe eosinophilic gastroenteritis, 6 (38%) had remission without chronic symptoms, whereas 10 (63%) had chronic symptoms requiring chronic medical therapy. Of the mild group, 12 patients (80%) had disease remission without chronic medications. An allergy history was more common in the severe disease group (83%) compared with the mild disease group (45%). Prednisone and open capsule budesonide were the most commonly used treatment medications in both groups.

DISCUSSION

Patients with eosinophilic gastroenteritis may be characterized into 2 forms. Patients with weight loss at time of presentation, hypoalbuminemia at presentation, serosal disease involvement, or anemia at diagnosis were associated with a chronic disease course requiring chronic medications.

Endoscopic Kyoto classification of Helicobacter pylori infection and gastric cancer risk diagnosis

Recent advances in endoscopic technology allow detailed observation of the gastric mucosa. Today, endoscopy is used in the diagnosis of gastritis to determine the presence/absence of Helicobacter pylori (H. pylori) infection and evaluate gastric cancer risk. In 2013, the Japan Gastroenterological Endoscopy Society advocated the Kyoto classification, a new grading system for endoscopic gastritis. The Kyoto classification organized endoscopic findings related to H. pylori infection. The Kyoto classification score is the sum of scores for five endoscopic findings (atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness with or without regular arrangement of collecting venules) and ranges from 0 to 8. Atrophy, intestinal metaplasia, enlarged folds, and nodularity contribute to gastric cancer risk. Diffuse redness and regular arrangement of collecting venules are related to H. pylori infection status. In subjects without a history of H. pylori eradication, the infection rates in those with Kyoto scores of 0, 1, and ≥ 2 were 1.5%, 45%, and 82%, respectively. A Kyoto classification score of 0 indicates no H. pylori infection. A Kyoto classification score of 2 or more indicates H. pylori infection. Kyoto classification scores of patients with and without gastric cancer were 4.8 and 3.8, respectively. A Kyoto classification score of 4 or more might indicate gastric cancer risk.

Chronic gastritis classifications

Chronic gastritis are inflammatory diseases of the gastric mucosa whose diagnosis depends on  pathological examination. They are frequent and cover a significant part of the daily activity of pathologists. Their origin is often infectious, particularly by Helicobacter Pylori. Several classifications of chronic gastritis were proposed but in order to achieve standardization in the drafting of pathological reports of gastric biopsies, pathologists currently following the recommendations of the revisted Sydney System. OLGA (Operative Link for Gastritis Assessment) and OLGIM (Operative Link for Gastritis Intestinal metaplasia Assessment) stages are increasingly used since they allow the clinicians to select patients with « high risk » chronic gastritis, which require special monitoring. The aim of this paper was to perform a review of the different classifications of chronic gastritis currently available to pathologists.

[KYOTO CONSENSUS - THE NEW ETIOLOGICAL CLASSIFICATION OF CHRONIC GASTRITIS AND ITS DISCUSSION]

The main provisions and headings of the new etiological classification of chronic gastritis are discussed in the context of recent data on the true role of Helicobacter pylori infection in the development of this pathology. The methods and results of the authors ’ investigations into gastric microflora are presented along with information about the frequency of detection of its different forms, concentration of microbial forms in gastric mucosa, their pathogenic properties including urease activity, and possible contribution to chronic gastritis etiology. The possibility of alcoholic and chemical chronic gastritis is discussed along with the role of these conditions in the development of stomach cancer. Special emphasis is laid on the disagreement between the adopted consensuses and principles of evidence-based medicine.

[Topical problems of chronic gastritis]

The authors propose the definition of chronic gastritis with a brief overview of the history of investigation of this diseases and its prevalence with special reference to (1) the bacterial profile and its role in the development of infectious and inflammatory process in gastric mucosa, (2) the modern state of and new trends in the classification of chronic gastritis including their advantages and disadvantages, (3) the relationship between chronic gastritis and functional gastroduodenal dyspepsia syndrome. It is concluded that mucous microflora plays an important factor in the development ofpathology but H.pylori is not its predominant component. Modern classifications of chronic gastritis provide a basis for a deeper insight into evolution of chronic gastritis and its transformation into cancer. The diagnosis of ‘chronic gastritis with functional gastroduodenal dyspepsia syndrome‘ is invalid.

CHRONIC GASTRITIS AND FUNCTIONAL DYSPEPSIA: CURRENT ISSUES IN CLASSIFICATION, DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS IN THE CONTEXT OF THE KYOTO GLOBAL CONSENSUS

Set out the basic problems of classification, diagnostics and differential diagnostics of chronic gastritis and functional dyspepsia in the context of the Kyoto global consensus.

The coeliac stomach: gastritis in patients with coeliac disease

BACKGROUND

Lymphocytic gastritis (LG) is an uncommon entity with varying symptoms and endoscopic appearances. This condition, as well as two forms of H. pylori-negative gastritis [chronic active gastritis (CAG) and chronic inactive gastritis (CIG)], appears to be more common in patients with coeliac disease (CD) based on single-centred studies.

AIM

To compare the prevalence of LG, CAG and CIG among those with normal duodenal histology (or nonspecific duodenitis) and those with CD, as defined by villous atrophy (Marsh 3).

METHODS

We analysed all concurrent gastric and duodenal biopsy specimens submitted to a national pathology laboratory during a 6-year period. We performed multiple logistic regression to identify independent predictors of each gastritis subtype.

RESULTS

Among patients who underwent concurrent gastric and duodenal biopsy (n = 287,503), the mean age was 52 and the majority (67%) were female. Compared to patients with normal duodenal histology, LG was more common in partial villous atrophy (OR: 37.66; 95% CI: 30.16-47.03), and subtotal/total villous atrophy (OR: 78.57; 95% CI: 65.37-94.44). CD was also more common in CAG (OR for partial villous atrophy 1.93; 95% CI: 1.49-2.51, OR for subtotal/total villous atrophy 2.42; 95% CI: 1.90-3.09) and was similarly associated with CIG (OR for partial villous atrophy 2.04; 95% CI: 1.76-2.35, OR for subtotal/total villous atrophy 2.96; 95% CI: 2.60-3.38).

CONCLUSIONS

Lymphocytic gastritis is strongly associated with coeliac disease, with increasing prevalence correlating with more advanced villous atrophy. Chronic active gastritis and chronic inactive gastritis are also significantly associated with coeliac disease. Future research should measure the natural history of these conditions after treatment with a gluten-free diet.

[Histopathological Study of the Relationship between Lymphoid Follicles and Different Endoscopic Types of Nodular Gastritis]

Nodular gastritis is characterized histologically by hyperplasia and enlargement of lymphoid follicles in the lamina propria. With the objective of elucidating the relationship between different endoscopic types of nodular gastritis and lymphoid follicles, distributions of lymphoid follicles in the lamina propria were investigated in young gastric cancer patients with nodular gastritis. For the study, whole-mucosal step sectioning of each resected stomach was performed, the densities of lymphoid follicles of all specimens were measured microscopically, and the horizontal and depth distributions were calculated. For assessment in the horizontal direction, density distribution diagrams of lymphoid follicles were created. For assessment in the depth direction, the different endoscopic types of nodular gastritis were compared in the five different analysis sites. In the assessment of the horizontal distribution, no characteristic distribution tendencies were observed in either the granular type group or the scattered type group; however, it was found that areas with relatively high densities of lymphoid follicles generally coincided with the areas where nodular gastritis was observed endoscopically. These results suggested that hyperplasia and aggregation of lymphoid follicles in the lamina propria are involved at the sites where nodular gastritis is observed endoscopically. In the assessment of the depth distribution, lymphoid follicles tended to be more unevenly distributed in the upper lamina propria in the granular type group than in the scattered type at the three different analysis sites where nodular gastritis was observed endoscopically. These results suggested the possibility of a granular type characteristic.

Staging of intestinal- and diffuse-type gastric cancers with the OLGA and OLGIM staging systems

BACKGROUND

Operative link on gastritis assessment (OLGA) and Operative link on gastric intestinal metaplasia assessment (OLGIM) staging systems have been proposed for gastric cancer (GC) risk estimation.

AIM

To validate the OLGA and OLGIM staging systems in a region with high risk of GC.

METHODS

This retrospective study included 474 GC patients and age- and sex-matched health screening control persons in a cancer centre hospital. We classified gastritis patterns according to the OLGA and OLGIM systems using the histological database that a pathologist prospectively evaluated using the updated Sydney system. GC risk according to the OLGA and OLGIM stages was evaluated using logistic regression analysis.

RESULTS

More GC patients had OLGA stages III-IV (46.2%) than controls (26.6%, P < 0.001), particularly among patients with intestinal-type GCs (62.2%) compared with diffuse-type GCs (30.9%). OLGA stages III and IV were significantly associated with increased risk of GC [odds ratios (ORs), 2.09; P = 0.008 and 2.04; P = 0.014 respectively] in multivariate analysis. The association was more significant for intestinal-type (ORs, 4.76; P = 0.001 and 4.19; P = 0.002 respectively), but not diffuse-type GC. OLGIM stages from I to IV were significantly associated with increased risk of both intestinal-type (ORs, 3.64, 5.15, 7.89 and 13.20 respectively) and diffuse-type GC (ORs, 1.84, 2.59, 5.08 and 6.32 respectively) with a significantly increasing trend.

CONCLUSION

As high OLGA and OLGIM stages are independent risk factors for gastric cancer, the staging systems may be useful for risk assessment in high-risk regions, especially for intestinal-type gastric cancer.

Mucosal-type eosinophilic gastroenteritis in Thailand: 12-year retrospective study

OBJECTIVE

To evaluate the clinical features and natural course of disease among patients with mucosal-type eosinophilic gastroenteritis in Thailand.

MATERIAL AND METHOD

The present study was conducted by retrospectively searching for the ICD-10 code for eosinophilic gastroenteritis (EGE) among medical records for the period 2001-2012. Clinical and pathological specimens were reviewed using the same diagnostic criteria. Appropriate tests were conducted to exclude other secondary causes of EGE. All patients had to have either received empirical treatment for parasitic infections or were tested for parasites in the stool. After the diagnosis had been established, each patient received 30-40 mg/day of oral prednisoloneforfour weeks, which was tapered down as clinical status improved. All patients were followed up by monitoring clinical symptoms and relevant laboratory findings. Patients who did not maintain follow-up appointments were contacted by telephone and asked about their clinical symptoms.

RESULTS

Seventeen patients with a diagnosis of mucosal-type E (6 male, 11 female, M:F ratio 1:1.83) were found. Mean age at the time of presentation was 52.5 +/- 13.04 years. Four patients (23.5%) had either allergic or atopic conditions. Chronic diarrhea and weight loss were the most common initial presentation in 16 patients (94.1%). Microscopically and macroscopically, bloody diarrhea was observed in 13 cases (76.5%). Four patients were found to have protein-losing enteropathy. Peripheral eosinophilia was found in 10 patients (58.8%) with absolute eosinophil counts between 744 and 23,550 cells/mm3. Eight of these had an absolute eosinophil count in the hypereosinophilic range (> 1,500 cells/mm3). All patients treated with prednisolone treatment showed symptomatic improvement within four weeks. One patient's symptom resolved spontaneously, without treatment. Thirteen patients relapsed during the tapering-off of prednisolone. Seven patients showed complete remission. Three patients subsequently developed cancer (lung, breast, and bladder) after EGE was diagnosed.

CONCLUSION

EGE, although uncommon, is present in Thailand, where parasitic infections continue to be a significant public-health problem.

[Syndrome of functional dyspepsia and/or chronic gastritis?]

Definition and prevalence of syndrome of functional dyspepsia (SFD) are discussed along with the brief history of the problem, priority works of V.P. Obraztsov and other authors, current views of SFD etiology and pathogenesis with reference to the role of H. pylori infections. Clinical variants of SFD, their diagnostic criteria and principals of differential diagnostics are described. Special attention is given to the debatable relationship between CFD and chronic gastritis. Nosological and syndromal diagnostics, structure-function relationship, goals and methods of SFD treatment and other matters of dispute are considered.

Classification of gastritis in first-degree relatives of patients with gastric cancer in a high cancer-risk area in Italy

BACKGROUND

Screening gastroscopic examinations were performed in a cohort of individuals at high risk for developing gastric carcinoma (GC).

PATIENTS AND METHODS

Five gastric biopsies were obtained following the Houston schema. Five histological parameters of gastritis were investigated: acute gastritis, chronic gastritis, and its sequelae; mucosal atrophy, intestinal metaplasia and pseudopyloric metaplasia.

RESULTS

Out of 134 patients, 50% (n=67) had Helicobacter pylori (HP) infection. The sum of scores for the first four parameters was significantly higher in HP-positive cases than in HP-negative ones (p<0.0001). The frequency of these histological parameters was similar to other series from Northern and Central Italy. Hence, none of the histological parameters of gastritis explain the high GC risk in this borough of Florence, considering that the incidence rate of GC is higher in Central than in Northern Italy.

CONCLUSION

Similarities in the frequency of chronic gastritis and sequelae in Northern and Central Italy substantiate the conviction that the difference in GC risk in these regions might be the result of local environmental or lifestyle factors, rather than HP infection. This knowledge is crucial, considering that environmentally related diseases are theoretically preventable.

[The Russian revision of chronic gastritis classification: reproducibility of the pathomorphologic picture]

The estimation of Russian revision reproducibility of the chronic gastritis OLGA system International classification has been spent. The analysis of Russian pathologists-experts work, considered in estimations of an expression level and prevalence of gastric mucosal atrophic changes, as a tumour predictor, for the identification of chronic gastritis stages (0-IV) has been carried out by kappa-statistics. The different levels of experts' consent according to consent criteria calculation have been estimated. The criteria of consent (k) of leading Russian pathologists have been 0.5 (moderate level of the agreement). In the practice of histopathology researchers' classification a consent level has been lower--from 0.27 (satisfactory or tolerable consent level) to 0.42 (moderate or average consent level). A subjective reasons reducing consistency level of pathologists-experts have been discussed.

Exocrine gastric secretion and gastritis: pathophysiological and clinical relationships

Gastric exocrine secretion, both acid and non-acid, is required for micronutrients absorption, such as iron, calcium and vitamin B12, drugs absorption, protein digestion. Clinical presentation of a gastric secretion impairment might be then characterized by the presence of both gastrointestinal and non-gastrointestinal specific symptoms (i.e. anemia) or to a non-response to therapies. The main factor that impairs gastric exocrine secretion homeostasis is mucosal chronic inflammation that principally occurs after colonization by Helicobacter pylori (Hp). The extent and distribution of gastritis ultimately determine the clinical outcome linked to differences in gastric acid secretion status, the involvement of gastric body leading to a decrease in gastric exocrine secretion with possible progression to mucosal atrophy towards cancer. A correct clinical strategy in the management of Hp infected patients should be then to early identify body involvement, a diagnosis generally missed in that body biopsies are not routinely performed. The use of gastric serological markers, gastrin and pepsinogens, are helpful in suspecting the presence of mucosal atrophy but their diagnostic accuracy for non-atrophic chronic gastritis topography is not adequate despite a good specificity due to the low sensitivity, of all the available biomarkers. Gastric serology associated to anemia/iron-deficiency screening might nevertheless been helpful in the framing of patients that undergo endoscopy in order to highlight the need of extensive mucosal biopsies sampling.

[Gastritis and gastropathies]

A review of the different types of gastritis, including features in which the edema and erythema can resemble the picture, but without the typical inflammatory reaction that is called gastropathy. A description of various epidemiological, aetiological, pathogenetic, are proposed. The review describes the diagnoses and treatment recommendations and prognosis of this common disorder.

[Acute erosive gastropathies]

There is a rise in the rates of acute erosive gastropathies in patients with cardiovascular and other somatic diseases. The role of acute erosive gastropathy-induced hemorrhages in the tanatogenesis of these diseases is underestimated; the problems of their prevention, diagnosis, and treatment remained unsolved. Many factors, mainly acute or chronic ischemia of the gastroduodenal mucosa, as well as its age-related involution, Helicobacter pylori infection, reflux gastritis, multiple organ dysfunction, drug-induced damage, etc., which are implicated in the pathogenesis of acute erosive gastropathies in patients with cardiovascular and other somatic diseases, are summarized.

Helicobacter pylori gastritis updated Sydney classification applied in our material

(Full text is available at http://www.manu.edu.mk/prilozi). BACKGROUND. Hp inhabits the stomach of more than 50% of humans and is the most frequent cause of chronic gastritis worldwide. The purpose of this research has been to present the importance of combining topographical, morphological and etiological information of diagnostic evaluation on grading gastritis in our material according to the Updated Sydney Classification, as well as to represent the frequency and the evaluation of Hp gastritis after eradication in order to prevent the development of gastric cancer. MATERIALS AND METHODS. 154 cases of gastric mucosa (endoscopic biopsies) which were fixed in buffered neutral formalin and embedded in paraffin were invwstigated. Tissue sections (5microm thick) were cut and stained with H&E, May Grunwald Giemsa and Silver stain. The biopsy cases were analysed in an attempt to assess the major histopathological features of gastritis. The histopathological major variables were graded on a scale of 3 (mild, moderate and severe). RESULTS. There were 36 (23.37%) cases positive for Hp (22.2%, 72.2%, 5.5%). Atrophy was positive in 23 (14.93%) cases with the scale (47.8%; 47.8%; 4.34%). Dysplasia was positive in 13 (8.44%) cases with the scale (84.6%; 7.6%; 7.6%). Intestinal metaplasia was positive in 25 (16.2%) with the scale (76%; 20%, 4%). There were 6 (3.8%) cases of MZL, which were treated appropriately. CONCLUSIONS. Our data indicate the importannce of early eradication of Helicobacter pylori in order to prevent the eventual development of gastric cancer. These findings should influence the treatment of gastric cancers. Key words: Updated Sydney System of Classification, Hp gastritis, morphology.

[International classification of chronic gastritis: what should be taken and what is in doubt]

The authors review the used classifications of chronic gastritis: Modified Sydney system, Atrophy Club classification, and Operative Link for Gastritis Assessment (OLGA). Their concept apparatus: the grade and stage of gastritis, intestinal metaplasia as a marker of gastric mucosal athrophy is considered. The possibilities of interpreting the pathologist's report and clinicomorphological comparisons are discussed. The OLGA Classification, which is to predict the gastric cancer risk determined by the degree of mucosal atrophy (a stage of chronic gastritis), is noted to have an indubitable merit. A simplified classification, according to which the grade and stage of gastritis are determined by the modified visual analog scale for mucosal changes in the body of the stomach and its antral part, is proposed. Whether the postmortem study protocol for gastric biopsy specimens can be modified is discussed.

OLGA staging for gastritis: a tutorial

Atrophic gastritis (resulting mainly from long-standing Helicobacter pylori infection) is a major risk factor for (intestinal-type) gastric cancer development and the extent/topography of the atrophic changes significantly correlates with the degree of cancer risk. The current format for histology reporting in cases of gastritis fails to establish an immediate link between gastritis phenotype and risk of malignancy. The histology report consequently does not give clinical practitioners and gastroenterologists an explicit message of use in orienting an individual patient's clinical management. Building on current knowledge of the biology of gastritis and incorporating experience gained worldwide by applying the Sydney System for more than 15 years, an international group of pathologists (Operative Link for Gastritis Assessment) has proposed a system for reporting gastritis in terms of stage (the OLGA staging system). Gastritis staging arranges the histological phenotypes of gastritis along a scale of progressively increasing gastric cancer risk, from the lowest (stage 0) to the highest (stage IV). This tutorial aims to provide unequivocal information on how to consistently apply the OLGA staging system in routine diagnostic histology practice.

Gastritis, dyspepsia and peptic ulcer disease

Peptic ulcer disease remains a common problem and it most frequently due to the presence of an Helicobacter pylori infection or use of non-steroidal anti-inflammatory drugs (NSAIDs). Dyspepsia is neither sensitive or specific for diagnosing peptic ulcer disease. The approach to patients with dyspepsia is to arrive at a definitive diagnosis without unnecessary exposure to invasive or costly diagnostic procedures. Non-invasive testing is preferred with endoscopy being reserved for those with alarm markers or above a specified age (e.g., 55 years in Western countries). Patients negative for H. pylori infection should receive an empiric trial of acid suppression for 4 to 8 weeks and if beneficial it can be continued.

[The problem of chronic gastritis]

Scientific review and own data about chronic gastritis problem: prevalence, short history data, question of aetiology and pathogenesis, clinical features, methods of instrumental and laboratory diagnostics including developed by the author, interrelation between chronic gastritis, gastric ulcer, gastric cancer and functional gastric dyspepsia syndrome are represented. Issues of chronic gastritis classification, principles of treatment and its efficiency are shown.

[Dysbacteriosis of mucosal microflora of the gastroduodenal zone in inflammatory and ulcer lesions: diagnosis and classification]

AIM

To study mucous (parietal) gastroduodenal microflora in healthy persons, patients with ulcer and chronic gastritis, to develop diagnostic criteria and classification of gastroduodenal dysbacteriosis.

MATERIAL AND METHODS

Biopsy specimens were obtained from gastroduodenal mucosa of 134 patients with ulcer, 36--with chronic gastritis and 28 healthy subjects. The mucous microflora agents were isolated microbiologically from biopsy specimens obtained from different compartments of the stomach and duodenum. The spectrum of their enzymatic activity and cytotoxic properties were determined.

RESULTS

Gastroduodenal mucous microflora of healthy subjects was represented with 1-2, less often with 3-4 cultures of 12 species, enzymatic activity spectrum of microorganisms was small, cytotoxicity was absent. In ulcer recurrence and exacerbation of chronic gastritis gastroduodenal zone showed dysbacteriosis characterized by overgrowth of mucous microflora (up to 22 species of microorganisms) with a wide spectrum of enzymatic activity and cytotoxic properties. The criteria of dysbacteriosis diagnosis and classification are proposed.

CONCLUSION

The role of gastroduodenal mucous microflora in ulcer and gastritis course is specified. New approaches to effective treatment of gastroduodenal diseases may be developed with consideration of dysbacteriosis.

Investigations proposed to accurately classify chronic gastritis

Patients of chronic gastritis should be investigated with gastric mucosal biopsy, parietal cell antibody, intrinsic factor antibody, Helicobacter pylori antibody, urea breath test or faecal antigen test for Helicobacter pylori, to accurately classify them. The results of these tests will indicate Helicobacter pylori infection (present or past), the role of hereditary factor (intrinsic factor antibody present or absent) and the success or failure of Helicobacter pylori eradication treatment.

Automated virtual microscopy of gastric biopsies

BACKGROUND

Automated virtual microscopy of specimens from gastrointestinal biopsies is based on cytometric parameters of digitized histological sections. To our knowledge, cytometric parameters of gastritis and of adenocarcinoma have yet to be fully characterized. Our objective was to classify gastritis and adenocarcinoma based on cytometric parameters. We hypothesized that automated virtual microscopy using this novel classification can reliably diagnose gastritis and adenocarcinoma.

METHODS

Routinely processed hematoxylin-and-eosin-stained histological sections from specimens that showed normal mucosa (14 cases), gastritis (35 cases), and adenocarcinoma (30 cases) diagnosed by conventional optical microscopy were scanned and digitized at high resolution. Thirty-eight cytometric parameters based on density and morphometry were applied to glands and superficial epithelium. Twelve cytometric parameters based on cytologic detail were applied to individual cells.

RESULTS

Statistically significant differences in cytometric parameters for normal mucosa, gastritis, and adenocarcinoma were found. The most discriminatory parameter was the ratio of the total number of cells to the number of interstitial cells. These differences correctly classified adenocarcinoma at 100% accuracy and overall correctness was 86%.

CONCLUSIONS

We describe a novel method of analyzing gastric mucosal histology based on cytometric parameters. Automated virtual microscopy can be used to classify gastric mucosa as normal, gastritis, or adenocarcinoma with reasonable accuracy. Further research is necessary to determine whether automated virtual microscopy can subclassify gastric mucosal histology in greater detail.

Assessing risks for gastric cancer: new tools for pathologists

Although the Sydney Systems (original and updated) for the classification of gastritis have contributed substantially to the uniformity of the reporting of gastric conditions, they lack immediacy in conveying to the user information about gastric cancer risk. In this review, we summarize the current understanding of the gastric lesions associated with an increased risk for cancer, and present the rationale for a proposal for new ways of reporting gastritis. In addition to the traditional histopathological data gathered and evaluated according to the Sydney System rules, pathologists could add an assessment expressed as grading and staging of the gastric inflammatory and atrophic lesions and integrate these findings with pertinent laboratory information on pepsinogens and gastrin levels. Such an integrated report could facilitate clinicians' approach to the management of patients with gastric conditions.

Local and systemic immune and inflammatory responses to Helicobacter pylori strains

Colonization with Helicobacter pylori eventuates in varied clinical outcomes, which relate to both bacterial and host factors. Here we examine the relationships between cagA status, serum and gastric juice antibody responses, and gastric inflammation in dyspeptic patients. Serum, gastric juice, and gastric biopsy specimens were obtained from 89 patients undergoing endoscopy. H. pylori colonization and cagA status were determined by histology, culture, and PCR methods, and acute inflammation and chronic inflammation in the gastric mucosa were scored by a single pathologist. Serum and gastric juice antibodies to H. pylori whole-cell and CagA antigens were determined by enzyme-linked immunosorbent assay. Relationships between variables were sequentially analyzed using univariate and multivariate statistical methods. Of the 89 subjects, 62 were colonized by H. pylori. By univariate analyses, levels of serum immunoglobulin G (IgG) and IgA and gastric juice IgA antibodies against whole-cell and CagA antigens each were significantly higher in the H. pylori-positive group than in the H. pylori-negative group (P<0.001). H. pylori and CagA sero-positivities were both significantly associated with enhanced inflammation in gastric antrum and body (P<0.02). The presence of gastric juice antibodies to H. pylori antigens was associated with more severe gastric inflammation. However, in multivariate analyses, only the presence of serum antibodies against CagA and, to a lesser extent, whole-cell antigens remained significantly associated with acute and chronic inflammation in antrum and body (P<0.05). Thus, serum antibody response to CagA correlates with severity of gastric inflammation. Furthermore, given the relationships demonstrated by multivariate analysis, determination of gastric juice antibodies may provide a better representation of serum, rather than secretory, immune response.

Magnifying endoscopy in gastritis of the corpus

Endoscopic diagnosis of Helicobacter pylori infection, before biopsies and serological tests are performed, is possible through careful analysis of the network of superficial vessels in patients with gastritis. At standard endoscopy, a regular arrangement of the collecting venules (RAC) is visible as numerous minute red points in the corpus of the noninfected stomach, and is not visible in H. pylori gastritis. Magnifying endoscopy provides more precise information concerning the collecting venules, the network of capillaries surrounding the gastric pits, the swelling of the surface epithelium between pits, and the enlargement and destruction of the pits. The magnified appearance is classified as Z-0 (noninfected stomach) or as Z-1 to Z-3 for successive degrees of mucosal damage in the infected stomach. Histological controls confirm the reliability of the endoscopic classification. Magnifying endoscopy also proves helpful in the assessment of completeness of eradication of H. pylori.

Staging and grading of chronic gastritis

Chronic gastritis is an inflammatory condition of the gastric mucosa that may include structural alterations of the glandular compartment. The semiquantitative scoring systems advocated in the Sydney Systems and the subsequent Atrophy Club Guidelines remain essential for the recognition of the spectrum of the lesions detectable in gastric inflammatory disease. Most practicing pathologists, however, find them too cumbersome to use in their routine diagnostic activities. In this article, we propose a reporting system for chronic gastritis in staging and grading. Staging would convey information on the topography and extension of the gastric atrophic changes, whereas grading should represent the semiquantitative assessment of the combined severity of both mononuclear and granulocytic inflammation. This system could offer gastroenterologists a more immediate perception of the overall condition of the gastric mucosa while also providing useful information about gastric cancer risk.

[Chronic gastritis: last decade's achievements and problems]

Classifications of chronic gastritis and neoplastic gastric diseases, developed in recent years (1996 Houston update of 1990 Sidney classification system, 2002 New Orlean classification of atrophic gastritis according to recommendations of International Group for Atrophy Studies; 1998 Padova classification of gastric displasia, and 1998 Vienna classification of gastrointestinal neoplasia) allow to statandardize international research and perform more objective diagnostics of pathological changes in the gastric mucosa. Studies carried out in recent years have established that morphological manifestations of chronic gastritis caused by Helicobacter pylori infection can be reduced after its eradication. Longterm treatment with proton pump inhibitors have been demonstrated not to cause atrophic changes in the gastric mucosa when undertaken after successful eradicational therapy. It has been established that corporal gastritis intensifies in patients treated with proton pump inhibitors. The studies show that measurement of serum levels of Helicobacter pylori antibodies, gastrine, pepsinogen I and II can be used in non-invasive serologic diagnostics of atrophic gastritis. Achievements in diagnostics and treatment of chronic gastritis create the necessary prerequisites for the development of gastric cancer preventing measures.

Evaluation of cell proliferation and apoptosis in Helicobacter pylori gastritis using an image analysis processor

BACKGROUND

Infection of the gastric mucosa by helicobacter pylori is primarily responsible for gastritis, gastric ulcer, adenocarcinoma, and lymphoproliferative disorders. H. pylori appears to accelerate apoptosis and the proliferation of the gastric epithelium directly or indirectly. To precisely assess the proliferative and apoptotic profile of .H pylori-infected gastric mucosa, a quantitative imaging system is now required.

METHODS

Fifty-two patients with H. pylori gastritis were the subjects of the study. Biopsy materials were taken from at least two sites (usually three to five sites) including the antrum and corpus. The grade of gastritis was evaluated by the updated Sydney System. The proliferative and apoptotic profile was examined by Ki-67 immunohistochemistry and by a terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end-labeling method. In addition, Ki-67-positive cells were quantitated by an image processor for analytical pathology (IPAP) system.

RESULTS

H. pylori density and polymorphonuclear neutrophil activity were significantly decreased after H. pylori eradication ( P< 0.0001). Chronic inflammation (P< 0.0001) and lymphoid follicle numbers ( P < 0.0005) were also significantly decreased after the eradication. Glandular atrophy and intestinal metaplasia were slightly decreased after eradication, but the decrease did not reach the significant level. the Ki-67 labeling index was significantly decreased after the eradication P< 0.0001). The apoptosis index was also decreased after the eradication, but this decrease did not reach the significant level ( P = 0.06).

CONCLUSION

our data suggest that the activation of proliferative cells and induction of apoptosis in the gastric mucosa is a response to H. pylori-induced mucosal damage. Moreover, IPAP may be a useful technology for evaluating the results of immunohistochemistry, and it could provide quantitative and reliable data for studying H. pylori gastritis.

[Operative intervention as a factor provoking the ulcer formation process in patients suffering from chronic gastritis type B]

The article presents 27 cases of ulcer formation in the duodenal bulb that occurred in 8.3 +/- 0.13 days after an operative intervention carried out because of the calculous cholecystitis and coccygeal cyst. The chronic gastritis type B has been detected in all the patients in 100% of cases.

Comparative classification and grading of Helicobacter pylori gastritis in patients with gastric cancer and patients with functional dyspepsia

BACKGROUND

It has previously been shown that corpus-dominant grade and activity of Helicobacter pylori gastritis in combination with intestinal metaplasia in the antrum or corpus are risk markers for the development of stomach cancer. If one point is scored for each of these three parameters, a gastric cancer risk index is obtained that permits prediction of the risk of gastric cancer developing on the soil of H. pylori gastritis. The aim of the present study was to evaluate the accuracy of the gastric cancer risk index based on a large number of patients compared with dyspeptic controls.

METHODS

In 415 biopsied patients with gastric carcinoma, biopsy specimens taken from the antrum and corpus were investigated retrospectively. From this group of patients, 244 patients positive for H. pylori were compared with 244 sex- and age-matched H. pylori-infected patients with functional dyspepsia.

RESULTS

H. pylori gastritis was detected in 395 carcinoma patients (95.2%). The 244 sex- and age-matched patients significantly more frequently had corpus-dominant H. pylori gastritis (compared with NUD controls). The incidence of intestinal metaplasia was also significantly increased. For a gastric cancer risk index score of 3 points (i.e. corpus pronounced grade and activity of gastritis, and intestinal metaplasia in antrum or corpus), a sensitivity of 93% and a specificity of 85% for the presence of gastric carcinoma can be calculated.

CONCLUSION

Using the proposed risk index, the topographic grading of H. pylori gastritis in the antrum and corpus enables the diagnosis of a 'risk gastritis' to be made.

Histologic classification of patients based on mapping biopsies of the gastroesophageal junction

This study consists of 959 consecutive patients in whom endoscopic biopsies were taken according to a protocol that permitted mapping and measurement of epithelial types in the gastroesophageal region. The epithelial types were classified as normal (oxyntic and squamous) and questionably abnormal (oxyntocardiac, cardiac, intestinal) by strict histologic criteria. Patients were classified into four groups based on the length of histologically defined abnormal glandular epithelium in the measured biopsies. A total of 811 (84.6%) patients had 0 to 0.9 cm of questionably abnormal columnar epithelium between normal oxyntic mucosa and squamous epithelium. Of these, 161 (19.9%) patients had no abnormal epithelium, 158 (19.4%) patients had oxyntocardiac mucosa, 372 (45.9%) patients had cardiac mucosa, and 120 (14.8%) patients had intestinal metaplasia. A total of 148 (15.4%) patients had >or=1 cm of abnormal columnar epithelium. All but one patient in this group had cardiac or intestinal epithelia. The prevalence of intestinal epithelium increased progressively with increasing length of abnormal columnar epithelium, being present in 70.4% in the 1- to 2-cm group, 89.5% in the 3- to 4-cm group, and 100% with in the >or=5 cm group. We propose a histologic grading system of biopsies based on these findings.

B-cell monoclonality is associated with lymphoid follicles in gastritis

The gold standard for diagnosis of gastric MALT lymphoma is histopathology. Polymerase chain reaction-based assays to detect the expansion of monoclonal B cells have also been used to corroborate the diagnosis. However, there are conflicting data on monoclonal B-cell expansion in gastritis. We asked about its frequency in graded gastritis cases. Lymphocytic infiltration in gastric biopsies was graded according to Wotherspoon in 129 cases. The histologic diagnosis ranged from normal gastric mucosa to suspicious for gastric MALT lymphoma. To search for a monoclonal B-cell population, a semi-nested polymerase chain reaction strategy was used for amplification of rearranged VDJ sequences of the immunoglobulin heavy chain gene. Of 106 evaluable samples, 18 were found to be monoclonal. The detection of a monoclonal B-cell population was strongly associated with the presence of lymphoid follicles. In cases with lymphoid follicles, detection of monoclonality was independent of Wotherspoon grading; there is no significant difference between cases being suspicious for lymphoma and those not. We found B-cell monoclonality to be a more frequent than expected finding in gastritis and to be strongly associated with the presence of lymphoid follicles; thus, its presence is of little significance in patient management.

Ultrastructure and molecular biological changes of chronic gastritis, gastric cancer and gastric precancerous lesions: a comparative study

AIM: To carry out a comparative study on ultrastructure and molecular biological changes of chronic gastritis (CG), gastric cancer (GC) aand gastric precancerous lesions.

METHODS: By the use of histochemical staining, SEM with EDAX, TEM with EDAX, image analysis technique, RIA and chemiluminescence method, gastric mucosa of 168 patients were synchronously analyzed in morphology, trace elements, DNA, cAMP, SOD, ³H-TdR LCT and serum LPO were also done.

RESULTS: The incidence of epithelial nucleoplasmic ratio > 1, lobulated nuclei, inter-chromatin aggregation of granules, nucleolar hypertrophy, and the content of DNA, Zn, Cu in nuclei and serum LPO of each group were showed as belows: normal control group (0.0, 0.0, 6.7, 0.0, 12.6 ± 2.7, 7.6 ± 0.4, 58.4 ± 0.3, 2.6 ± 0.6), CSG group (5.7, 2.9, 7.4, 2.9, 15.2 ± 3.1, 8.1 ± 0.5, 58.9 ± 0.5, 4.2 ± 0.7), CAG group (31.3, 29.7, 45.3, 42.2, 16.5 ± 3.1, 8.6 ± 0.4, 59.3 ± 0.5, 4.5 ± 0.6), CA group (100.0, 100.0, 72.2, 50.0, 30.7 ± 8.2, 8.8 ± 0.3, 59.5 ± 0.4, 6.8 ± 1.6), ATP⁺⁺ group (61.5, 38.5, 23.1, 38.5, 23.5 ± 8.9, 8.3 ± 0.4, 59.1 ± 0.4, 5.1 ± 1.2), IM⁺⁺ + ATP⁺⁺ group (77.8, 55.5, 33.3, 44.4, 25.1 ± 7.2, 8.4 ± 0.5, 59.5 ± 0.4, 6.5 ± 1.1), IM⁺⁺⁺ + ATP⁺⁺ group (100.0, 100.0, 75.0, 62.5, 28.5 ± 9.1, 8.9 ± 0.5, 59.7 ± 0.4, 7.6 ± 0.7), IMII_b group (100.0, 62.5, 75.0, 50.0, 27.3 ± 10.3, 8.6 ± 0.3, 59.5 ± 0.4, 6.1 ± 0.9); whereas the content of Zn, Cu in mitochondria and cAMP, SOD in gastric mucosa, and ³H-TdR LCT of each group were showen as belows: normal control group (9.2 ± 0.5, 58.3 ± 0.3, 15.9 ± 1.5, 170.5 ± 6.1, 1079.7 ± 227.4), CSG group (8.6 ± 0.5, 57.8 ± 0.3, 14.6 ± 1.8, 163.3 ± 5.6, 867.3 ± 240.5), CAG group (8.3 ± 0.4, 57.5 ± 0.3, 13.4 ± 1.8, 161.2 ± 4.3, 800.9 ± 221.8), CA group (8.9 ± 0.4, 57.1 ± 0.3, 10.2 ± 3.9, 152.2 ± 3.8, 325.7 ± 186.8), ATP⁺⁺ group (9.1 ± 0.4, 57.0 ± 0.3, 12.4 ± 1.8, 161.5 ± 3.8, 642.9 ± 174.3), IM⁺⁺ + ATP⁺⁺ group (8.6 ± 0.4, 56.9 ± 0.3, 12.0 ± 2.3, 152.2 ± 2.5, 326.3 ± 160.3), IM⁺⁺⁺ + ATP⁺⁺ group (8.5 ± 0.3, 56.8 ± 0.2, 10.4 ± 0.9, 147.4 ± 2.6, 316.1 ± 170.7), IMII_b group (8.6 ± 0.3, 56.9 ± 0.3, 11.9 ± 1.9, 150.0 ± 2.8, 318.9 ± 145.8), there were significant differences between groups (P < 0.05-0.01).

CONCLUSION: There was a significant difference between CG and GC in their ultrastructure and molecular biology. Only on the condition of changes of internal environment in combination with the harmful effect of external environment, chronic atrophic gastritis can then develop into gastric cancer. Hence it might have similar epithelial cell ultrastructure and molecular biological changes in ATP⁺⁺, IMII_b and cancer, hence there were similar patterns of occurrence, development and transformation. Recognition of this trend might help to explore problems of prevention and cure.

Study on the classification of chronic gastritis at molecular biological level

AIM: To explore the pathophysiologibasis for the fact that patients with digestive tract symptoms do not necessarily have gastric mucosal pathology and those without clinical symptoms do not necessarily have no gastric mucosal pathology.

METHODS: The ultrastructure, trace elements, cAMP, DNA, SOD and LPO in the gastric mucosa and its epithelial cells of 188 patients without organic lesions of heart, lung, liver, gallbladder, pancreas, kidney or intestine and basically histopathological normal persons (F) were detected synchronously by SEM, TEM, EDAX, Image analysis system RIA and ³H-TdR Lymphocyte Transfer Test.

RESULTS: The content of Zn, Cu, cAMP and ³H-TdR LCT in gastric mucosa and the content of Zn, Cu, DNA and LPO in gastric mucosa epithelial nuclei of each group were shown as belows: Normal control (4.1 ± 1.0, 5.2 ± 0.8, 15.9 ± 1.5, 1079.7 ± 227.4, 7.6 ± 0.4, 58.4 ± 0.3, 12.6 ± 2.7, 2.6 ± 0.6); CSG without symptoms group (3.7 ± 1.2, 5.1 ± 1.8, 15.6 ± 0.9, 924.5 ± 234.9, 7.8 ± 0.3, 58.6 ± 0.4, 13.0 ± 3.1, 2.9 ± 0.4); CAG without symptoms group (3.3 ± 1.0, 4.8 ± 0.9, 14.9 ± 0.7, 887.7 ± 243.6, 7.8 ± 0.3, 58.7 ± 0.3, 14.3 ± 2.8, 3.1 ± 0.4); F type with symptoms group (3.5 ± 1.4, 4.5 ± 1.0, 15.7 ± 1.4, 932.1 ± 2449.3, 7.9 ± 0.4, 58.7 ± 0.5, 13.5 ± 4.6, 2.9 ± 0.7); CSG with symptoms group (2.8 ± 1.9, 4.0 ± 1.5, 14.2 ± 1.8, 867.3 ± 240.5, 8.1 ± 0.5, 58.9 ± 0.5, 15.2 ± 3.2, 4.2 ± 0.7); CAG with symptoms group (2.0 ± 1.8, 3.4 ± 1.5, 13.4 ± 1.8, 800.9 ± 221.8, 8.6 ± 0.4, 59.3 ± 0.5, 16.5 ± 3.1, 4.5 ± 0.6). The contents of Zn, Cu in mitochonondria and SOD in gastric mucosa of each group were shown as belows: Normal control group (9.2 ± 0.5, 58.3 ± 0.3, 170.5 ± 6.1), CSG without symptoms group (8.9 ± 0.5, 58.2 ± 0.3, 167.2 ± 5.3), CAG without symptoms group (8.8 ± 0.4, 57.5 ± 0.2, 166.1 ± 4.2); F type with symptoms group (8.9 ± 0.5, 58.0 ± 0.3, 167.9 ± 5.7), CSG with symptoms group (8.6 ± 0.5, 57.8 ± 0.3, 163.3 ± 5.6); CAG with symptoms group (8.3 ± 0.4, 57.5 ± 0.3, 161.2 ± 4.3). There were significant differences in these cases, P < 0.05-0.001. There were synchronous changes of gastric mucosa epithelial cellular ultrastructure. The “background lesions” (focal atrophic gastritis, focal intestinal metaplasia, micro-ulcer) in nonfocal gastric mucosa of all groups had significant differences (P < 0.05-0.001).

CONCLUSION: Disease with symptoms, disease without symptoms, nondisease with symptoms occur on the basis of the quantitative changes of gastric mucosa epithelial cellular ultrastructure and related bioactive substances.

Gastritis and carditis

Dyspepsia is a common clinical problem. Its causes include peptic ulcer disease, gastroesophageal reflux, and functional (nonulcer) dyspepsia. A detailed clinical description of pain does not reliably differentiate the cause. Approximately 80% of gastroscopies are performed for the investigation of dyspepsia. "Gastritis" is diagnosed endoscopically in 59% of all stomachs, although in only 3% are the changes severe. Pathologic examination of unselected gastric biopsy specimens reveals that abnormalities are present in 62-73%, but there is only a weak correlation between endoscopic and histologic findings. For these reasons, it is recommended that endoscopic examination should always be accompanied by biopsy. Ideally, biopsies should be taken in a systematic fashion to include sampling of antrum and corpus. Recent evidence suggests that gastric infection by Helicobacter pylori initially presents as a superficial gastritis. Later it may become atrophic with development of intestinal metaplasia. The onset of atrophic changes may be related to the duration of infection, the strain of the infecting organism, associated dietary factors, or as-yet undefined host factors related to immunity. Persistent superficial gastritis predisposes to duodenal ulcer and gastric mucosa-associated lymphoid tissue lymphoma. Atrophic gastritis predisposes to gastric ulcer and adenocarcinoma. Evidence is accumulating that in some patients, pernicious anemia may be an end result of H. pylori-induced atrophic gastritis. Reactive gastropathy is a relatively common finding in gastric biopsies; in most instances it is associated with either reflux of duodenal contents or therapy with nonsteroidal anti-inflammatory drugs. Lymphocytic gastritis, eosinophilic gastritis, and the gastritis associated with Crohn's disease are distinct morphologic entities. Lymphocytic gastritis and eosinophilic gastritis have a variety of clinical associations. Carditis is a controversial topic: currently opinions are divided as to whether it is the result of gastroesophageal reflux or a proximal extension of H. pylori infection from the remainder of the stomach.

[Hemomotorodynamic disturbances in various types of chronic gastritis]

The investigation of gastric hemomotorodynamics in 23 patients with various types of gastritis and 10 practically healthy patients have been carried out in the clinic of general surgery of Izhevsk State Medical Academy. The method of investigation was transillumination hemomotorodynamic monitoring, which was carried out simultaneously with fibrogastroscopy. The findings received testify to hemomotorodynamic disturbances in chronic gastritises. The character and severity of hemodynamic and motility disturbances in chronic gastritis depend on the etiological factor, the impairment of the acid-producing function, localization and morphology of the pathological process. Hemomotorodynamic disturbances are an important link of pathogenesis and stipulate the clinical picture of various types of chronic gastritis.

Diagnostic yield of gastric biopsy specimens when screening for preneoplastic lesions

The Sydney system recommends sites and numbers of stomach biopsies (mapping) for evaluation of Helicobacter pylori-associated lesions. The diagnostic yield of the recommended mapping technique in populations at high risk for gastric preneoplastic lesions has not been established. We evaluated pathology data from 733 endoscopies performed as part of an intervention study that assessed the effects of H. pylori treatment on preneoplastic conditions. Two pathologists assessed whether the mapping sequence of the 7 biopsy specimens obtained during each endoscopy was correctly followed and graded the specimens using the Sydney classification for gastritis. If the mapping sequence was followed, then we evaluated whether the amount of information obtained from 3 biopsy samples approximated that obtained from 5 and 7 biopsy samples. The mapping sequence was followed in only 239 (33%) endoscopies, indicating that experienced endoscopists can inadvertently misidentify sites in the stomach when obtaining specimens. When data from 7 specimens were used, H. pylori was found in 205 endoscopies, atrophy in 152, metaplasia in 135, and dysplasia in 22. When data from 3 specimens were used, the sensitivity was 99% for presence of H. pylori, 82% for atrophy and metaplasia, and 81% for dysplasia. When data from 5 specimens were used, the sensitivity was 100% for H. pylori, 96% for atrophy, and 95% for metaplasia and dysplasia. Although site-specific biopsy mapping is difficult in practice, the recommendations of the Sydney system as to the location and number of gastric biopsy specimens can adequately identify significant gastric histopathology.

[Morphology of gastritis and Helicobacter pylori infection]

Helicobacter pylori infection almost invariably results in chronic gastritis. The Sydney System (1990) emphasised the importance of combining topographical, morphological and etiological aspects in attempt to make clinical useful diagnosis of chronic gastritis. The aims of revised Sydney System in Houston (1994), Texas, were to improve terminology of chronic gastritis emphasising distinction between nonatrophic and atrophic gastritis, and in addition to determinate special forms of gastritis. The special forms of gastritis were described and diagnostic criteria were provided. Principles and grading of histological division of Sydney System were only slightly modified, grading being improved by the provision of a visual scale. Endoscopy and histological findings of 1062 patients from University Hospital Merkur were compared to evaluate the value of endoscopic division of Sydney System, and the modified grading proposed by Houston classification. There was no correlation between endoscopic and histological findings. Localisation of inflammatory cells was either 1) superficial or 2) diffuse in the mucosa, respectively. In Helicobacter pylori positive patients the most common finding was chronic active gastritis, and in Helicobacter pylori negative superficial and inactive chronic gastritis.

Comparison of immunohistochemical and modified Giemsa stains for demonstration of Helicobacter pylori infection in an African population

BACKGROUND

Modified Giemsa staining has been favoured by many researchers because it is easy to perform but, like many other stains, demonstration of the bacteria depends on its morphology. It has been arged in some research circles that some of the organisms in the gastric mucosa may not be true H.pylori. Immunohistochemical techniques have been developed and make use of anti H.pylori antibody, which reacts, with somatic antigens of the whole bacteria and have been found to correlate well with the presence of the bacteria.

OBJECTIVE

To ascertain the efficacy of modified Giemsa stain in an African setting where H.Pylori seems quite prevalent.

STUDY DESIGN

A laboratory-based study of two diagnostic tests in which modified Giema stain was compared with immunohistochemistry.

METHODS

A total of 48 consecutive autopsy cases with no upper gastro intestinal diseases had their gastric mucosa stained for demonstration of H.pylori using both modified Giemsa and immunohisto chemical staining techniques.

RESULTS

Twenty-seven cases of H.pylori were demonstrated by both techniques and 14 cases were not identified by the two staining methods. In 2 cases immunostain could not demonstrate the bacteria but they were identified with modified Giemsa stain while in 5 cases the bacteria were identified by immunostain but not with modified Giemsa stain. The sensitivity of modified Giemsa stain was 85% (CI 66.5-98.8) while the specificity was 89% (CI 60.4 - 97.8). The positive predictive value of modified Giemsa stain was 93% CI 75 - 98.8%) while the negative predictive value was 74% (CI 48.6 - 89.9). The kappa statistic comparing the 2 stains was 0.69 (p value 0.00001) giving a good agreement between the two tests.

CONCLUSION

With the above results the modified Giemsa stain, which is readily available in most African laboratories, is recommenced for diagnosis of H.pylori, a prevalent infection in Africa.

[Classification of gastroesophageal reflux disease and gastritis]

The gastroesophageal reflux disease (GORD) is frequent and causes by retrograde flow of the gastric content through incompetent gastroesophageal junction. Epidemiological studies have proved that GORD is associated with hearburn in high prevalence. In western countries several studies reported that 20-40% of adult population experience heartburn symptoms at least once in the year, approximately 10% have symptoms weekly and 5% daily. Esophagitis was objectively defined as a mucosal damage and it was endoscopically verificated in 25% of patients. Indeed, GORD symptoms and esophagitis are in poor correlation and less than half of patients with heartburn symptoms had esophagitis on endoscopy. From 1989, Savary Monniér and Metaplasia-Ulcer-Stricture-Erosion (MUSE) endoscopically classification is in use. From 1994, LA (Los Angeles) classification of reflux disease is also in use by endoscopists. During its life cycle, gastric mucosa is exposed to different harmful agents and its response is restitution "ad integrum" on the beginning and at the end of process. First line defence is mucuse barrier which prevent contact between epithelial cell and possible irritant. Important role in mucuse layer plays prostaglandins. After several classification systems previously used, in 1991 Price introduced Sydney system gradation and gastritis classification. Pointing out importance of topographical differences in gastritis distribution, system has introduced 5 histological variations in its Morphological section: chronic inflammation, neutrophylic activity, glandular atrophy, intestinal metaplasy and H. pylori colonisation, with 4 points grading.

A unique early gastric tubular adenocarcinoma arising from a pre-existent carcinoid tumor in a patient with a more than 20-year history of type A gastritis: an immunohistochemical and ultrastructural study

A unique early gastric tubular adenocarcinoma developed from a pre-existent carcinoid tumor in a patient with a more than 20-year history of type A gastritis, multiple endocrine cell micronests, hypergastrinemia, and a high level of serum antiparietal cell autoantibody. The patient was a 60-year-old Japanese man. The background gastric mucosa around the tumor showed marked atrophy with intestinal metaplasia, in which endocrine cell micronests were frequently observed, and was consistent with type A gastritis. The mass was composed of both adenocarcinoma and carcinoid tumor. The adenocarcinoma was restricted to the lamina mucosa and submucosal area, and constituted a minor component of the tumor mass. The carcinoid tumor was the dominant constituent of the tumor, that invaded continuously the subserosa and muscularis propria. Based on this examination together with the detailed immunohistochemical and ultrastructural studies, the adenocarcinoma was presumed to have developed from the pre-existent carcinoid tumor. Ultrastructurally there were no amphicrine cells in the tumor, containing both endocrine granules and mucin droplets.

Quantitative correlation of Helicobacter pylori stool antigen (HpSA) test with 13C-urea breath test (13C-UBT) by the updated Sydney grading system of gastritis

BACKGROUND/AIMS

Helicobacter pylori (H. pylori) infection has a causative relationship with various gastrointestinal disorders. 13C-urea breath test and H. pylori stool antigen test are two valuable noninvasive tests for detecting H. pylori infection. Since the bacterial load of H. pylori in the stomach and the resulting severity of gastritis are important in validating the status of H. pylori infection, we would like to investigate the relative diagnostic accuracy of 13C-urea breath test and H. pylori stool antigen test with respect to the severity of gastritis.

METHODOLOGY

The H. pylori statuses of 62 consecutive patients were evaluated by five tests, i.e., culture, histology, biopsy urease test, 13C-urea breath test, and H. pylori stool antigen test. Gastritis was graded by the updated Sydney system. H. pylori status was defined as positive when the culture was positive or the concordance of positivity of two of the other four tests.

RESULTS

Thirty-five patients (56%) were H. pylori positive. The accuracy of H. pylori stool antigen test and 13C-urea breath test were 92.6% and 100%, respectively. There was a positive correlation between the level of delta 13CO2 of the 13C-urea breath test and the optical density value of enzyme immunoassay of the H. pylori stool antigen test (Rho = 0.758, P < 0.001). Both the level of delta 13CO2 of 13C-UBT and the optical density value of enzyme immunoassay of the H. pylori stool antigen test correlated well with the separate score of the density of H. pylori (P < 0.001, each) and the inflammatory activity (each P < 0.001).

CONCLUSIONS

Both the 13C-urea breath test and H. pylori stool antigen test are effective non-invasive methods to detect the status of H. pylori infection with respect to correlation with the density of H. pylori and inflammatory activity of gastritis.

The updated Sydney system: classification and grading of gastritis as the basis of diagnosis and treatment

In recent years, the importance of the histological diagnosis of gastritis on the basis of routinely obtained antral and corpus biopsies has increased enormously, which is owed not least of all to the discovery of Helicobacter pylori. The introduction of the Sydney system made it possible, for the first time, to grade histological parameters, identify topographical distribution and, finally, make a statement about the etiopathogenesis of the gastritis. Of pathogenetic importance is, in the first instance, the differentiation between gastritis with and gastritis without H pylori infection. The group of H pylori-associated gastritis can be further subdivided into forms of gastritis whose morphological distribution patterns usually identify them as sequelae of H pylori infection, while the group of gastritis unassociated with H pylori, can be differentiated into autoimmune, chemically induced reactive gastritis, ex-H pylori gastritis, Helicobacter heilmannii gastritis, Crohn's gastritis and a number of special forms of gastritis.