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)

Flexible spectral imaging color enhancement plus probe-based confocal laser endomicroscopy for gastric intestinal metaplasia detection

BACKGROUND AND AIM

Probe-based confocal laser endomicroscope (pCLE) has been applied for the early detection and confirmation of many gastrointestinal neoplasms; however, its use in gastric intestinal metaplasia (GIM) detection has not yet been validated. The objective of this study was to assess the diagnostic yield of magnifying flexible spectral imaging color enhancement (ME-FICE) plus pCLE for GIM detection.

METHODS

Sixty patients with previous histology confirmed as GIM underwent a surveillance EGD. Standard and 100× ME-FICE were used as a screening mode to depict GIM by light-blue crest, large long crest, and villous pattern criteria. Then, pCLE was followed to confirm the presence of GIM. In each patient, two biopsies were obtained from one positive area, and the other two were taken from the negative area. All specimens were interpreted by a clinically blinded pathologist. The reading results by ME-FICE and by ME-FICE plus pCLE were assessed for sensitivity, specificity, positive predictive value, negative predictive value (NPV), false-positive rate, false-negative rate, and accuracy.

RESULTS

Of the 59 areas suspicious for GIM in 45 patients, 44 areas were confirmed as GIM by histology. The overall criteria from ME-FICE plus pCLE provided the highest sensitivity, specificity, positive predictive value, NPV, and accuracy at 96%, 90%, 86%, 97%, and 92%, respectively. There were two false-negatives (4%) and seven false-positives (10%). No early gastric cancer was detected in any.

CONCLUSION

Combining ME-FICE with pCLE provides high sensitivity and NPV for GIM detection. The prompt histology reading by this technique may avoid unnecessary biopsy (Clinical trial registration number: NCT01489397).

Narrow-band imaging with magnifying endoscopy is accurate for detecting gastric intestinal metaplasia

AIM

To investigate the predictive value of narrow-band imaging with magnifying endoscopy (NBI-ME) for identifying gastric intestinal metaplasia (GIM) in unselected patients.

METHODS

We prospectively evaluated consecutive patients undergoing upper endoscopy for various indications, such as epigastric discomfort/pain, anaemia, gastro-oesophageal reflux disease, suspicion of peptic ulcer disease, or chronic liver diseases. Patients underwent NBI-ME, which was performed by three blinded, experienced endoscopists. In addition, five biopsies (2 antrum, 1 angulus, and 2 corpus) were taken and examined by two pathologists unaware of the endoscopic findings to determine the presence or absence of GIM. The correlation between light blue crest (LBC) appearance and histology was measured. Moreover, we quantified the degree of LBC appearance as less than 20% (+), 20%-80% (++) and more than 80% (+++) of an image field, and the semiquantitative evaluation of LBC appearance was correlated with IM percentage from the histological findings.

RESULTS

We enrolled 100 (58 F/42 M) patients who were mainly referred for gastro-esophageal reflux disease/dyspepsia (46%), cancer screening/anaemia (34%), chronic liver disease (9%), and suspected celiac disease (6%); the remaining patients were referred for other indications. The prevalence of Helicobacter pylori (H. pylori) infection detected from the biopsies was 31%, while 67% of the patients used proton pump inhibitors. LBCs were found in the antrum of 33 patients (33%); 20 of the cases were classified as LBC+, 9 as LBC++, and 4 as LBC+++. LBCs were found in the gastric body of 6 patients (6%), with 5 of them also having LBCs in the antrum. The correlation between the appearance of LBCs and histological GIM was good, with a sensitivity of 80% (95%CI: 67-92), a specificity of 96% (95%CI: 93-99), a positive predictive value of 84% (95%CI: 73-96), a negative predictive value of 95% (95%CI: 92-98), and an accuracy of 93% (95%CI: 90-97). The NBI-ME examination overlooked GIM in 8 cases, but the GIM was less than 5% in 7 of the cases. Moreover, in the 6 false positive cases, the histological examination showed the presence of reactive gastropathy (4 cases) or H. pylori active chronic gastritis (2 cases). The semiquantitative correlation between the rate of LBC appearance and the percentage of GIM was 79% (P < 0.01).

CONCLUSION

NBI-ME achieved good sensitivity and specificity in recognising GIM in an unselected population. In routine clinical practice, this technique can reliably target gastric biopsies.

3rd Brazilian Consensus on Helicobacter pylori

Signicant progress has been obtained since the Second Brazilian Consensus Conference on Helicobacter pylori Infection held in 2004, in São Paulo, SP, Brazil, and justify a third meeting to establish updated guidelines on the current management of H. pylori infection. The Third Brazilian Consensus Conference on H pylori Infection was organized by the Brazilian Nucleus for the Study of Helicobacter, a Department of the Brazilian Federation of Gastroenterology and took place on April 12-15, 2011, in Bento Gonçalves, RS, Brazil. Thirty-one delegates coming from the five Brazilian regions and one international guest, including gastroenterologists, pathologists, epidemiologists, and pediatricians undertook the meeting. The participants were allocated in one of the five main topics of the meeting: H pylori, functional dyspepsia and diagnosis; H pylori and gastric cancer; H pylori and other associated disorders; H pylori treatment and retreatment; and, epidemiology of H pylori infection in Brazil. The results of each subgroup were submitted to a final consensus voting to all participants. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Seventy per cent and more votes were considered as acceptance for the final statement. This article presents the main recommendations and conclusions to guide Brazilian doctors involved in the management of H pylori infection.

Validation of a fluorescence in situ hybridization method using peptide nucleic acid probes for detection of Helicobacter pylori clarithromycin resistance in gastric biopsy specimens

Here, we evaluated a previously established peptide nucleic acid-fluorescence in situ hybridization (PNA-FISH) method as a new diagnostic test for Helicobacter pylori clarithromycin resistance detection in paraffin-embedded gastric biopsy specimens. Both a retrospective study and a prospective cohort study were conducted to evaluate the specificity and sensitivity of a PNA-FISH method to determine H. pylori clarithromycin resistance. In the retrospective study (n = 30 patients), full agreement between PNA-FISH and PCR-sequencing was observed. Compared to the reference method (culture followed by Etest), the specificity and sensitivity of PNA-FISH were 90.9% (95% confidence interval [CI], 57.1% to 99.5%) and 84.2% (95% CI, 59.5% to 95.8%), respectively. In the prospective cohort (n = 93 patients), 21 cases were positive by culture. For the patients harboring clarithromycin-resistant H. pylori, the method showed sensitivity of 80.0% (95% CI, 29.9% to 98.9%) and specificity of 93.8% (95% CI, 67.7% to 99.7%). These values likely represent underestimations, as some of the discrepant results corresponded to patients infected by more than one strain. PNA-FISH appears to be a simple, quick, and accurate method for detecting H. pylori clarithromycin resistance in paraffin-embedded biopsy specimens. It is also the only one of the methods assessed here that allows direct and specific visualization of this microorganism within the biopsy specimens, a characteristic that allowed the observation that cells of different H. pylori strains can subsist in very close proximity in the stomach.

Precancerous lesions in the stomach: from biology to clinical patient management

Gastric cancer is the final step in a multi-stage cascade triggered by long-standing inflammatory conditions (particularly Helicobacter pylori infection) resulting in atrophic gastritis and intestinal metaplasia: these lesions represent the cancerization field in which (intestinal-type) gastric cancer develops. Intraepithelial neoplasia is consistently recognized as the phenotypic bridge between atrophic/metaplastic lesions and invasive cancer. This paper addresses the epidemiology, pathology, molecular profiling, and clinical management of advanced precancerous gastric lesions.

Screening for gastric premalignant lesions with narrow band imaging, white light and updated Sydney protocol or both?

BACKGROUND

Narrow band imaging (NBI) can accurately discriminate gastritis but premalignant lesions (PMLs) are difficult to detect.

AIMS

The purpose of this study was to compare white light endoscopy (WLE) and histopathologic findings using the updated Sydney protocol (USP) with NBI and targeted biopsies (TB).

METHODS

One hundred nineteen symptomatic patients referred for upper GI endoscopy were included in this prospective open study. All patients were assessed for gastritis and PMLs using WLE and NBI by two endoscopists selected in a random manner. Biopsies were taken according to USP and targeted from any area suspicious for PML. Imaging and histological findings between protocols were compared.

RESULTS

In total 45 patients (38 %) had atrophy of whom 39 (32.7 %) were detected with WLE-USP and 28 (23.5 %) with NBI-TB (p = 0.03), 25 (21 %) had intestinal metaplasia (IM) of whom 19 (16 %) were detected with WLE-USP and 18 (15.1 %) with NBI-TB (p = 0.7) and 14 (12 %) had dysplasia of whom 12 (10 %) were detected with WLE-USP and 7 (7 %) with NBI-TB (p = 0.5), and 1 (0.8 %) case of gastric cancer only detected with WLE-USP. Accuracies for atrophy and IM were 93 and 90 % for the WLE-USP and 80 and 82 % for NBI-TB. The NBI-TB detected six cases of atrophy (13 %), 5 (20 %) of IM, and 2 (14 %) of dysplasia missed by WLE-USP as agreement was moderate. Accuracies of the NBI patterns for body and antral gastritis were 80 and 84 %.

CONCLUSIONS

In a non high-risk population NBI-TB has less accuracy in detecting premalignant lesions compared to WLE-USP. However, it may be used as an important and easy-to-use complementary method which increases overall detectability for gastric premalignant lesions.

[Gastric cancer risk estimate in patients with chronic gastritis associated with Helicobacter pylori infection in a clinical setting]

BACKGROUND/AIM

Severity of chronic gastritis associated with Helicobacter pylori infection (CGAHpI) could play a role in evaluating the potential risk to develop gastric cancer. Our aim was to estimate the risk for gastric cancer in a clinical setting, according to histopathologic criteria, by applying the gastric cancer risk index (GCRI) METHODS: Histopathologic study of the gastric biopsies (corpus-antrum) from consecutive adult patients that underwent gastroesophageal duodenoscopy was carried out, and the GCRI was applied in patients presenting with CGAHpI.

RESULTS

One hundred eleven patients (77% female) with a mean age of 38.6±13.1 years were included. Active Helicobacter pylori infection (aHpi) was diagnosed in 77 cases (69.40%). In 45% of the cases with aHpi, pangastritis (23%) or corpus-predominant gastritis (22%) was diagnosed. Nine cases were diagnosed with intestinal metaplasia (8%), 7 of which (77.70%) were in the aHpi group. Twenty one percent of the patients with aHpi had a GCRI of 2 (18.10%) or 3 (2.50%) points (high risk index), while 79.10% accumulated a GCRI of 0 or 1 points (low risk index). Of the patients with no aHpi, none of them had 3 points (p=0.001). Of the 18 patients that accumulated 2 or 3 points, 6 (33.30%) presented with intestinal metaplasia (all with pangastritis and corpus-predominant gastritis), of which 4 cases (66.60%) had aHpi.

CONCLUSIONS

The estimated gastric cancer risk in patients with CGAHpI in the clinical setting studied was relatively low and 5% of the patients had a histopathologic phenotype associated with an elevated risk for developing gastric cancer.

Intestinal metaplasia surveillance: Searching for the road-map

Atrophic gastritis and intestinal metaplasia (IM) of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, a pragmatic management has been performed in Western countries in patients with these premalignant conditions. Recently, formal European guidelines have been delivered on this topic. Basically, it has been recommended that patients with extensive atrophic gastritis (AG) and/or extensive IM should be offered endoscopic surveillance every 3 years. On the contrary, no scheduled endoscopic/histological control has been advised for those patients with precancerous conditions confined to the antrum. In this commentary, we highlighted some potential weaknesses in the management formally recommended by the new guidelines. In detail, we discussed that AG and IM patients do not share the same gastric cancer risk, at least in Western countries, deserving a different approach. Some factors significantly associated with gastric cancer risk, such as IM type, first-degree family history of gastric cancer, and smoking habit have not been considered in tailoring the endoscopic follow-up. Finally, some data would suggest that a 3-year follow-up in patients with extensive gastric precancerous conditions could result in an inadequate secondary prevention.

Utility of subtyping intestinal metaplasia as marker of gastric cancer risk. A review of the evidence

The identification and surveillance of patients with preneoplastic lesions at high risk of progressing to gastric cancer (GC) represents the most effective way of reducing the burden of GC. The incomplete type of intestinal metaplasia (IM) could be considered as the best candidate for surveillance. However, the usefulness of subtyping of IM has been considered by some authors as limited and inconsistent. A search was carried out to identify all cross-sectional (n=14) and follow-up (n=10) studies that assessed the risk of GC among subjects with different types of IM. Out of the 14 cross-sectional studies, 13 reported that the prevalence of incomplete IM was statistically significantly higher in GC than in other gastric lesions. Out of the ten follow-up studies, six found a statistically significant association between incomplete IM and subsequent GC risk. The relative risks of GC were from 4- to 11-fold higher for the presence of incomplete type in comparison to complete type or in comparison to the absence of incomplete type, among the studies that reported the magnitude of the risk. According to this comprehensive review, most of the scientific evidence supports the utility of subtyping IM as a predictor of GC risk. Recognizing its usefulness by gastroenterologists should encourage pathologists to subtype IM.

Helicobacter pylori induces increased expression of Toll-like receptors and decreased Toll-interacting protein in gastric mucosa that persists throughout gastric carcinogenesis

BACKGROUND

Toll-like receptors (TLR) are essential for Helicobacter pylori (HP) recognition. Their role in the progression of gastric lesions leading to cancer is not established.

AIM

To evaluate for the first time in humans the expression of TLR2, TLR4, and TLR5, as well as the expression of other related molecules in the entire sequence of gastric lesions.

METHODS

Biopsy samples (n = 80, 48% HP+) from normal mucosa, HP gastritis, metaplasia, dysplasia or adenocarcinoma were obtained from 44 patients. mRNA quantification of TLR2, TLR4, TLR5, Toll-interacting protein (TOLLIP), PPAR-γ, NF-κB, TNF-α, COX-1, COX-2, and CDX-2 was performed by real-time RT-PCR. TLR2, TLR4, and TLR5 protein expression was quantified by immunohistochemistry.

RESULTS

When compared to normal mucosa (1.0 arbitrary unit (AU)), HP gastritis presented higher expression of TLR2 (2.23 ± 0.36 AU), TLR4 (1.92 ± 0.40 AU) and TNF-α (2.14 ± 0.50 AU) and lower TOLLIP and PPARγ expression (0.72 ± 0.12 AU, p < .05 all genes). Metaplasia and dysplasia/carcinoma presented higher expression of TLR2 (1.66 ± 0.46 and 1.48 ± 0.20 AU, respectively, p < .05), lower expression of TOLLIP (0.66 ± 0.09 and 0.52 ± 0.04 AU, p < .05) and PPARγ (0.73 ± 0.12 and 0.63 ± 0.10 AU, p < .05). The significant trend for decrease in TOLLIP and PPARγ was associated with increasing levels of CDX-2 from normal mucosa to carcinoma (p < .05), translating that in diffuse and higher TLRs protein expression (p < .05).

CONCLUSION

Gastric carcinogenesis is associated with decreasing levels of TLRs inhibitors and elevated TLRs levels throughout all the spectrum of lesions. Future studies should investigate if modulation of these receptors activity may influence gastric carcinogenesis and tumor progression.

Systematic review: gastric cancer incidence in pernicious anaemia

BACKGROUND

Pernicious anaemia (PA) has an increased risk for gastric cancer (GC). It is not established whether PA patients need to undergo endoscopic/histological follow-up.

AIM

To provide a systematic overview of the literature on PA and the development of gastric cancer, to estimate the gastric cancer incidence-rate.

METHODS

According to PRISMA, we identified studies on PA patients reporting the incidence of gastric cancer. Quality of studies was evaluated using the Newcastle-Ottawa Quality Assessment Scale. Meta-analysis on annual gastric cancer incidence rates was performed.

RESULTS

Twenty-seven studies met eligibility criteria. 7 studies were of high, 6 of medium, 10 of low and 4 of very low quality. Gastric cancer incidence-rates ranged from 0% to 0.2% per person-years in 7 American, from 0% to 0.5% in 2 Asiatic, from 0% to 1.2% in 11 Northern European studies and from 0% to 0.9% in 7 studies from other European countries. The incidence-rates of gastric cancer ranged from 0% to 1.2% per person-years in studies which used gastroscopy, from 0.1% to 0.9% in those based on International Classification of Disease. Heterogeneity between studies was not statistically significant at the 5% level (Chi-squared test = 17.9, P = 0.08). The calculated pooled gastric cancer incidence-rate was 0.27% per person-years. Meta-analysis showed overall gastric cancer relative risk in PA as 6.8 (95% CI: 2.6-18.1).

CONCLUSIONS

This systematic review shows a pooled gastric cancer incidence-rate in pernicious anaemia of 0.27% per person-years and an estimated nearly sevenfold relative risk of gastric cancer in pernicious anaemia patients. Further high quality studies are needed to confirm this higher risk.

Gastric precancerous lesions in first degree relatives of patients with known gastric cancer: a cross-sectional prospective study in Guilan Province, north of Iran

BACKGROUND AND OBJECTIVES

In patients with gastric cancer, the most frequently reported family history of cancer also involves the stomach. The aim of this study was to assess the presence of gastric precancerous lesions in first-degree relatives of patients with gastric cancer and to compare the obtained results with those of individuals with no such family history.

METHODS

Between 2007 and 2009, 503 consecutive persons more than 30 years old were enrolled in the study covering siblings, parents or children of patients with confirmed adenocarcinoma of stomach. The control group was made up of 592 patients who were synchronously undergoing upper gastrointestinal endoscopy for evaluation of dyspepsia without gastric cancer or any family history. All subjects were endoscopically examined.

RESULTS

The overall prevalence of Helicobacter pylori was 77.7% in the cancer relatives and in 75.7% in the control group. Chronic gastritis was found in 90.4% vs. 81.1% (P<0.001). Regarding histological findings, 37(7.4%) of the study group had atrophy vs. 12(1.7%) in the control group (P<0.001), while no difference was observed for intestinal metaplasia (20.3%vs. 21.6%, P=0.58). Dysplasia were shown in 4% of cancer relatives but only 0.4% of the control group (P<0.001). There was no gender specificity.

CONCLUSIONS

Findings of our study point to great importance of screening in relatives of gastric cancer patients in Iran.

Can the incidence of gastric cancer be reduced in the new century?

Gastric cancer (GC) is one of the most common cancers in the world. The incidence and mortality rate of GC vary among different countries. It is suggested that GC is the result of the interaction between Helicobacter pylori (H. pylori) infection and the genetic and environmental factors in the host. H. pylori infection is the trigger of intestinal gastric adenocarcinoma. The incidence of GC is highest in East Asia and East Europe, but much lower in Africa; however, H. pylori infection is commonly seen in Africa, which is known as the African enigma. The 5-year survival of early GC is far better than that of advanced GC. A high detection rate of early GC could help us to conquer GC. A decreasing trend of GC incidence has been witnessed worldwide. With the improvement of living conditions and the achievements of scientific research, it seems possible that there will be a further reduction in the incidence of GC in the new century.

The endoscopic diagnosis of early gastric cancer

The aim of this article is to demonstrate the basic principles for the endoscopic diagnosis of early gastric cancer. The diagnostic process can be divided into two steps, detection and characterization. Detection requires good endoscopic technique, and thorough knowledge. With regard to technique, we should administer the optimum preparation to patients, including an antiperistaltic agent. Furthermore, in order to map the entire stomach we need to follow a standardized protocol, and we propose a systematic screening protocol for the stomach. With regard to knowledge, we should be able to identify high-risk background mucosa, and we should be aware of the indicators of a suspicious lesion. Chromoendoscopy and magnifying endoscopy are promising image-enhanced endoscopic techniques for characterization. The proposed criteria for a cancerous lesion are as follows: conventional endoscopic findings of 1) a well-demarcated lesion and 2) irregularity in color/surface pattern; vessel plus surface classification using magnifying endoscopy with narrow-band imaging findings of 1) irregular microvascular pattern with a demarcation line or 2) irregular microsurface pattern with a demarcation line. Conventional endoscopy and subsequent image-enhanced endoscopy can both contribute to the detection of early gastric cancer.

Iron deficiency and Helicobacter pylori-induced gastric cancer: too little, too bad

Clinical vignette: A 38-year-old man consults you in the GI clinic because of frequent episodes of epigastric pain, nausea, and tiredness. His blood count shows signs of mild iron deficiency anemia. Upper GI endoscopy was normal, but antral and corpus biopsy specimens show evidence of gastric atrophy and Helicobacter pylori infection. Colonoscopy and capsule endoscopy showed no evidence of lesions in the large or small bowel. He receives a standard one-week course eradication therapy consisting of a proton pump inhibitor (PPI), amoxicillin, and clarithromycin. His symptoms improve, but his infection persists and he remains mildly anemic. He asks you whether the infection must be eradicated, as he read on the Internet that it can cause stomach cancer. He is also concerned about the anemia.

Gastric and duodenal neuroendocrine tumours

Gastric neuroendocrine neoplasms (NENs) are increasing in frequency and have a varied spectrum with regard to histology, clinicopathologic background, stage, and prognosis. They are usually discovered incidentally, are for the most part benign and are associated with hypergastrinaemia (secondary either to chronic atrophic gastritis or rarely Zollinger-Ellison syndrome; types 1 and 2, respectively) or more rarely sporadic type 3. Applications of recent staging and grading systems - namely using Ki-67 proliferative indices - (from ENETS and WHO 2010) can be particularly helpful in further categorising these tumours. The natural history of Type 1 gastric carcinoids is generally (>95%) favourable and simple surveillance is usually recommended for small (<1 cm) T1 tumours, with local (endoscopic or surgical) resection for larger lesions. Other potential therapies such as somatostatin analogues and gastrin receptor antagonists may offer newer therapeutic possibilities. Rarely, gastric NENs have a malignant course and this is usually confined to Type 2 and especially Type 3 tumours; the latter mimic the biological course of gastric adenocarcinoma and require radical oncological therapies. Most duodenal NENs, apart from gastrinomas (that are not dealt with here) are sporadic and non functional. They are also increasing in frequency probably due to incidental discovery at endoscopy or imaging for other reasons and this may account for their overall good prognosis. Peri-ampullary and ampullary NENs may have a more aggressive outcome and should be carefully appraised and treated (often with surgical resection).

Prevalence of Helicobacter pylori infection and atrophic gastritis in Latvia

OBJECTIVES

Helicobacter pylori infection and atrophic gastritis are related to an increased risk for gastric cancer. There is a decrease in global H. pylori prevalence. We analyzed the prevalence of H. pylori infection in Latvia by the plasma IgG test and the presence of atrophy by means of pepsinogen testing.

METHODS

This subanalysis was carried out on a randomly selected cross-sectional sample of a general population of adults to access cardiovascular risk factors. Plasma samples were screened for H. pylori IgG (cutoff value 24 U/ml), and pepsinogens (Pg) I and II. Pg cutoff values of PgI/PgII ≤ 3 and PgI ≤ 70 ng/ml were used to assess the prevalence of atrophy of any grade and PgI/PgII ≤ 2 and PgI ≤ 30 ng/ml for advanced atrophy.

RESULTS

Altogether, 3564 serum samples were available for the study (2346 women, 1218 men; median age 54 years). Of the tested individuals, 79.21% were H. pylori positive, with no difference between sexes. The prevalence increased with age (P<0.001). Atrophy of any grade was identified in 1444 individuals (40.52%) and advanced atrophy in 475 individuals (13.33%). Linear association with age was present in both response types (P<0.001). The prevalence of atrophy of any grade was higher in women (41.73%) than in men (38.18%; P=0.04); this difference was lost for advanced atrophy (women 13.98%, men 12.07%; P=0.1).

CONCLUSION

The prevalence of H. pylori infection or atrophy remains high in Latvia. Determining the right cutoff value is critically important for pepsinogen-based atrophy detection in Europe in order to objectively stratify gastric cancer risk.

Current pharmacotherapy options for gastritis

INTRODUCTION

Gastritis is a broad term, which is used for different conditions by clinicians, endoscopists and pathologists. Classification strategies have led to more congruence between specialists. The histological evaluation of the gastric mucosa is mandatory for diagnosing and classifying gastritis. Main aetiologic factor is infection with Helicobacter pylori. The clinical importance of gastritis lays in the fact that it predisposes to more pronounced damage to the gastric mucosa, in particular peptic ulcer disease, and eventually atrophic gastritis, intestinal metaplasia and gastric malignancy, both adenocarcinoma and MALT lymphoma.

AREAS COVERED

This review covers the current pharmacotherapy options for different forms of gastritis. The main focus is on H. pylori-induced gastritis. Thereafter, other forms of gastritis like autoimmune gastritis and non-steroidal anti-inflammatory drug (NSAID)-related gastropathy are covered.

EXPERT OPINION

The emerging problem of antibiotic resistance requires an accurate knowledge of local eradication rates. Standard triple therapy should be abandoned in regions with high clarithromycin resistance. In these areas, sequential or quadruple therapy is best initial treatment. Further research should focus on non-invasive and effective techniques of susceptibility testing, making a tailored and cost-effective approach. Primary prevention of NSAID-related gastropathy can be enhanced by better education for clinicians and patients, so that both right prescription of gastroprotective agents as therapy adherence will improve.

Helicobacter pylori: clinical management

PURPOSE OF REVIEW

Progress continues in our understanding of the role of Helicobacter pylori infection in gastroduodenal as well as extragastric disorders. This review gives an overview on selected areas of the H. pylori infection and their clinical implications.

RECENT FINDINGS

Indications for therapy have been extended and now include idiopathic thrombocytopenic purpura, iron deficiency anemia, and vitamin B12 deficiency. New data are presented on the role of H. pylori in neurodegenerative disorders and in the metabolic syndrome. H. pylori is associated with a (small) increase in the risk for colorectal adenoma and colon cancer. The biggest challenge is the selection of new therapies and treatment strategies because of the increasing failure of standard triple therapies. The best option in high clarithromycin resistance areas is bismuth-based quadruple therapy. Probiotic bacteria and yeasts reduce adverse effects of standard H. pylori eradication regimens. In gastric cancer prevention, screening programs based on the serological detection of preneoplastic conditions may prove useful.

SUMMARY

New algorithms for preventing H. pylori-induced disease and eradicating the organism should be individualized.

Early gastric cancer: an update on endoscopic management

PURPOSE OF REVIEW

The review focuses on the latest endoscopic techniques that are emerging in the management of early gastric cancer.

RECENT FINDINGS

Improved sensitivity and specificity in the diagnosis of early gastric cancers has been demonstrated in a number of studies by narrow band imaging (92.7 and 94.5%), confocal laser endomicroscopy (90.2 and 98.5%), and magnification chromoendoscopy (88.6 and 93.2%), respectively. In early gastric cancer, endoscopic submucosal dissection (ESD) has been shown to be superior to endoscopic mucosal resection (EMR) with curative resection rate at 79.5% for ESD vs. 59% for EMR, and a lower local recurrence rate at 0.82% for ESD vs. 5.03% for EMR.

SUMMARY

Advanced diagnostic and therapeutic endoscopic techniques are changing the paradigm of care in patients with early gastric cancers.

Argon plasma coagulation is safe and effective for treating smaller gastric lesions with low-grade dysplasia: a comparison with endoscopic submucosal dissection

BACKGROUND AND AIMS

The best therapeutic modality has not been established for gastric low-grade adenomas or dysplasia (LGD), which can progress to invasive carcinoma despite a low risk. This study aims to investigate the clinical efficacy, safety, and local recurrence after argon plasma coagulation (APC) treatment of gastric LGD compared with endoscopic submucosal dissection (ESD).

PATIENTS AND METHODS

A total of 320 patients with gastric LGD ≤ 2.0 cm treated with APC or ESD between 2004 and 2011 were retrospectively analyzed. We compared local recurrence rate, complication rate, procedure time, and admission to hospital between APC and ESD groups.

RESULTS

Of the 320 patients, 116 patients were treated with APC and 204 with ESD. During follow-up, local recurrence was more common in the APC group (3.8 %, 4/106) than the ESD group (0.5 %, 1/188; log-rank test P = 0.036). However, all patients with local recurrence (n = 5) were treated by additional APC, and followed up without further recurrences. ESD was complicated by two perforations (1.0 %, 2/204) compared with no perforations in the APC group (0 %, 0/116). Bleeding complications were not different between the APC (1.7 %, 2/116) and ESD (2.0 %, 4/204) groups. Procedure time was shorter in the APC (7.8 ± 5.1 min) than the ESD (53.1 ± 38.1 min) group (P < 0.001). The proportion of hospitalization was less in the APC group (31.0 %, 36/116) than the ESD group (100.0 %, 204/204) (P < 0.001).

CONCLUSIONS

APC can be a good treatment option for patients with LGD ≤ 2.0 cm.

Quality assurance for gastrointestinal endoscopy

PURPOSE OF REVIEW

This review concerns quality assurance for gastrointestinal endoscopic procedures, especially colonoscopy and will emphasize research and guidelines published since January 2011. Important articles from previous years have been included for background.

RECENT FINDINGS

Critical lapses in endoscope processing and administration of intravenous sedation alerted us to the infection risk of endoscopy. Increases in cost of colonoscopy, evidence for overuse and studies demonstrating missed cancers have led some to question the value of endoscopy. Despite these setbacks, the National Polyp Study (NPS) consortium published their long-term follow-up of the original NPS patients and confirmed that colonoscopy with polyp removal can reduce the risk of colorectal cancer for an extended period. In this article, we will focus on ways to improve the value of outpatient colonoscopy.

SUMMARY

The United States national quality improvement agenda recently became organized into a more coordinated effort spearheaded by several public and private entities. They comprise the infrastructure by which performance measures are developed and implemented as accountability standards. Understanding wherein a gastroenterology (GI) practice fits into this infrastructure and learning ways we can improve our endoscopic practice is important for physicians who provide this vital service to patients. This article will provide a roadmap for developing a quality assurance program for endoscopic practice.

Helicobacter pylori: gastric cancer and extragastric intestinal malignancies

The greatest challenge in Helicobacter pylori-related diseases continues to remain prevention of gastric cancer. New evidence supports the beneficial effect of H. pylori eradication not only on prevention of gastric cancer but also on the regression of preneoplastic conditions of the gastric mucosa. Concerning early detection of gastric cancer there are still no adequate means and there is urgent need to define appropriate markers, for example, by genome-wide research approaches. Currently, the best available method is the "serologic" biopsy based on pepsinogen I and the pepsinogen I/II ratio for identification of patients with severe gastric atrophy at increased risk for gastric cancer development. The treatment of early gastric cancer by endoscopic techniques can be performed safely and efficiently, but patients need meticulous follow-up for detection of metachronous lesions. In case of advanced disease, laparoscopically assisted surgical procedures are safe and favorable compared to open surgery. Two phase III trials support the role of adjuvant systemic treatment with different regimens. Unfortunately, there is still only slow progress in the development of palliative treatment regimens or modification of the existing therapy protocols. There is accumulating evidence for a role of H. pylori infection also in colorectal carcinogenesis. Seropositive individuals are at higher risk for the development of colorectal adenomas and consequently adenocarcinomas of this anatomical region. This phenomenon can partly be attributed to the increase of serum gastrin as response to atrophic changes of the gastric mucosa.

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.

Risk for gastric neoplasias in patients with chronic atrophic gastritis: A critical reappraisal

Chronic atrophic gastritis (CAG) is an inflammatory condition characterized by the loss of gastric glandular structures which are replaced by connective tissue (non-metaplastic atrophy) or by glandular structures inappropriate for location (metaplastic atrophy). Epidemiological data suggest that CAG is associated with two different types of tumors: Intestinal-type gastric cancer (GC) and type I gastric carcinoid (TIGC). The pathophysiological mechanisms which lead to the development of these gastric tumors are different. It is accepted that a multistep process initiating from Helicobacter pylori-related chronic inflammation of the gastric mucosa progresses to CAG, intestinal metaplasia, dysplasia and, finally, leads to the development of GC. The TIGC is a gastrin-dependent tumor and the chronic elevation of gastrin, which is associated with CAG, stimulates the growth of enterochromaffin-like cells with their hyperplasia leading to the development of TIGC. Thus, several events occur in the gastric mucosa before the development of intestinal-type GC and/or TIGC and these take several years. Knowledge of CAG incidence from superficial gastritis, its prevalence in different clinical settings and possible risk factors associated with the progression of this condition to gastric neoplasias are important issues. This editorial intends to provide a brief review of the main studies regarding incidence and prevalence of CAG and risk factors for the development of gastric neoplasias.

Serological assessment of gastric mucosal atrophy in gastric cancer

Background

Non-invasive tools for gastric cancer screening and diagnosis are lacking. Serological testing with the detection of pepsinogen 1 (PG1), pepsinogen 2 (PG2) and gastrin 17 (G17) offers the possibility to detect preneoplastic gastric mucosal conditions. Aim of this study was to assess the performance of these serological tests in the presence of gastric neoplasia.

Methods

Histological and serological samples of 118 patients with gastric cancer have been assessed for tumor specific characteristics (Laurén type, localisation), degree of mucosal abnormalities (intestinal metaplasia, atrophy) and serological parameters (PG1, PG2, PG1/2-ratio, G17, H. pylori IgG, CagA status). Association of the general factors to the different serological values have been statistically analyzed.

Results

Patients with intestinal type gastric cancer had lower PG1 levels and a lower PG1/2-ratio compared to those with diffuse type cancer (p = 0.003). The serum levels of PG2 itself and G17 were not significantly altered. H. pylori infection in general had no influence on the levels of PG1, PG2 and G17 in the serum of gastric cancer patients. There was a trend towards lower PG1 levels in case of positive CagA-status (p = 0.058). The degree of both intestinal metaplasia and atrophy correlated inversely with serum levels for PG1 and the PG1/2-ratio (p < 0.01). Laurén-specific analysis revealed that this is only true for intestinal type tumors. Univariate ANOVA revealed atrophy and CagA-status as the only independent factors for low PG1 and a low PG1/2-ratio.

Conclusions

Glandular atrophy and a positive CagA status are determinant factors for decreased pepsinogen 1 levels in the serum of patients with gastric cancer. The serological assessment of gastric atrophy by analysis of serum pepsinogen is only adequate for patients with intestinal type cancer.