Pathology of non-Helicobacter pylori gastritis: extending the histopathologic horizons

RE.GA.IN.: the Real-world Gastritis Initiative-updating the updates

At the end of the last century, a far-sighted 'working party' held in Sydney, Australia addressed the clinicopathological issues related to gastric inflammatory diseases. A few years later, an international conference held in Houston, Texas, USA critically updated the seminal Sydney classification. In line with these initiatives, Kyoto Global Consensus Report, flanked by the Maastricht-Florence conferences, added new clinical evidence to the gastritis clinicopathological puzzle.The most relevant topics related to the gastric inflammatory diseases have been addressed by the Real-world Gastritis Initiative (RE.GA.IN.), from disease definitions to the clinical diagnosis and prognosis. This paper reports the conclusions of the RE.GA.IN. consensus process, which culminated in Venice in November 2022 after more than 8 months of intense global scientific deliberations. A forum of gastritis scholars from five continents participated in the multidisciplinary RE.GA.IN. consensus. After lively debates on the most controversial aspects of the gastritis spectrum, the RE.GA.IN. Faculty amalgamated complementary knowledge to distil patient-centred, evidence-based statements to assist health professionals in their real-world clinical practice. The sections of this report focus on: the epidemiology of gastritis; Helicobacter pylori as dominant aetiology of environmental gastritis and as the most important determinant of the gastric oncogenetic field; the evolving knowledge on gastric autoimmunity; the clinicopathological relevance of gastric microbiota; the new diagnostic horizons of endoscopy; and the clinical priority of histologically reporting gastritis in terms of staging. The ultimate goal of RE.GA.IN. was and remains the promotion of further improvement in the clinical management of patients with gastritis.

Morphological Spectrum of Gastritis in Endoscopic Biopsies and Its Association With Helicobacter pylori Infection

Introduction Helicobacter pylori (H. pylori) infection is the most common cause of gastritis. The consequences of the persistent infection range from acute ulceration to the development of gastric neoplasia. The purpose of the study is to determine the histopathological pattern of gastritis in gastric biopsies and its association with H. pylori. Materials and methods This is a retrospective study of all the gastric biopsies received in the Department of Histopathology, Chughtai Institute of Pathology, Lahore, Pakistan from January 12, 2021 to April 10, 2021. Sections were cut from formalin-fixed, paraffin-embedded (FFPE) tissue blocks. Slides were stained with routine, special and immunohistochemical stains. The cases were then blindly reviewed by two pathologists with a special interest in Gastrointestinal Pathology. Microscopic features based on updated Sydney classification were recorded. The collected data were then analyzed by using SPSS version 20 (IBM Corp., Armonk, NY). Results A total of 429 gastric biopsies were examined. Out of which, 202 (47.1%) were male and 227 (52.9%) were female with a female-to-male ratio of 1.2:1. Their ages ranged from 12 to 100 years and a peak in the fourth decade of life with a mean age of 43 years (median age 49 years). Among gastritis, activity was seen in 194 (45%) and chronicity in 237 (55%) cases. H. pylori was seen in 174 (40.5%) cases and there was a strong statistically significant association between H. pylori infection and severity of gastritis (p<0.001). Other parameters of Sydney classification, such as atrophic changes, were seen in 144 (33%) cases, and intestinal metaplasia in 10 (2.3%) cases. Conclusion H. pylori organism was the most common cause of gastritis in our environment. The severity of gastritis is directly related to the H. pylori infection. If neutrophils are identified on surface epithelium, then H. pylori should be searched with increased attention on morphology and/or on immunohistochemical stain of H. pylori. Chronic inflammation and H. pylori density can also guide treatment which is necessary to avoid complications.

Histopathological Features of Helicobacter pylori Infection in Gastric Mucosa

Objective

To investigate the histopathological characteristics of Helicobacter pylori (Hp) infection in the gastric mucosa in the process from occurrence to intraepithelial neoplasia.

Methods

Specimens obtained from the endoscopic biopsy and endoscopic submucosal dissection of 2457 cases of gastric Hp infection were observed and assessed in detail using histology and immunohistochemistry techniques. The condition was divided according to the histopathological characteristics of gastric mucosal damage caused by Hp infection. The histopathological characteristics and immunophenotype of each stage were subsequently elucidated.

Results

Helicobacter pylori is initially implanted in the mucus layer covered by the epithelium on the surface of the gastric mucosa. It then selectively adheres to the cytoplasm of the surface mucus cells, which makes the oval and spherical particles containing mucus that is wrapped by the bounded membrane in the cytoplasm on the nucleus of the surface mucus cells disappear, while the cytoplasm undergoes spiderweb-like vacuolar degeneration. This leads to the proliferation and transformation of the surface mucous cells before developing into intraepithelial neoplasia. In the process of histomorphology, mucosal ulcers, mucosal lymphoid tissue proliferation, gland atrophy, intestinal epithelial metaplasia, mucosa-associated lymphoid tissue lymphoma, and adenocarcinoma may occur. In this study, the condition was divided into five stages according to the histopathological characteristics of gastric mucosal damage caused by Hp infection, as well as the degree of gastric mucosal damage and involvement depth as follows: the mucus infection stage, the surface epithelial cell infection stage, the lamina propria lesion stage, the mucosal atrophy stage, and the intraepithelial neoplasia stage.

Conclusion

Understanding the histopathological characteristics of gastric Hp infection in terms of its occurrence and development into intraepithelial neoplasia is conducive to the precise treatment and tracking of malignant cell transformation, and is of great significance in controlling the occurrence and development of gastric cancer.

The potential of dandelion in the fight against gastrointestinal diseases: A review

ETHNOPHARMACOLOGICAL RELEVANCE

Dandelion (Taraxacum officinale Weber ex F. H. Wigg.), as a garden weed grown globally, has long been consumed as a therapeutic herb. Its folkloric uses include treatments of digestive disorders (dyspepsia, anorexia, stomach disorders, gastritis and enteritis) and associate complex ailments involving uterine, liver and lung disorders.

AIM OF THE STUDY

The present study aims to critically assess the current state of research and summarize the potential roles of dandelion and its constituents in gastrointestinal (GI) -protective actions. A focus is placed on the reported bioactive components, pharmacological activities and modes of action (including molecular mechanisms and interactions among bioactive substances) of dandelion products/preparations and derived active constituents related to GI protection.

MATERIALS AND METHODS

The available information published prior to August 2021 was reviewed via SciFinder, Web of Science, Google Scholar, PubMed, Elsevier, Wiley On-line Library, and The Plant List. The search was based on the ethnomedical remedies, pharmacological activities, bioactive compounds of dandelion for GI protection, as well as the interactions of the components in dandelion with the gut microbiota or biological regulators, and with other ingested bioactive compounds. The key search words were "Taraxacum" and "dandelion".

RESULTS

T. coreanum Nakai, T. mongolicum and T. officinale are the most commonly used species for folkloric uses, with the whole plant, leaves and root of dandelion being used more frequently. GI-protective substances of dandelion include taraxasterol, taraxerol, caffeic acid, chicoric acid, chlorogenic acid, luteolin and its glucosides, polysaccharides, inulin, and β-sitosterol. Dandelion products and derived constituents exhibit pharmacological effects against GI disorders, mainly including dyspepsia, gastroesophageal reflux disease, gastritis, small intestinal ulcer, ulcerative colitis, liver diseases, gallstones, acute pancreatitis, and GI malignancy. The underlying molecular mechanisms may include immuno-inflammatory mechanisms, apoptosis mechanism, autophagy mechanism, and cholinergic mechanism, although interactions of dandelion's constituents with GI health-related biological entities (e.g., GI microbiota and associated biological modulators) or other ingested bioactive compounds shouldn't be ignored.

CONCLUSION

The review reveals some in vivo and in vitro studies on the potential of dandelion derived products as complementary and alternative medicines/therapeutics against GI disorders. The whole herb may alleviate some symptoms related GI immuno-inflammatory basing on the abundant anti-inflammatory and anti-oxide active substances. Dandelion root could be a nontoxic and effective anticancer alternative, owing to its abundant terpenoids and polysaccharides. However, research related to GI protective dandelion-derived products remains limited. Besides the need of identifying bioactive compounds/complexes in various dandelion species, more clinical studies are also required on the metabolism, bioavailability and safety of these substances to support their applications in food, medicine and pharmaceuticals.

Safety and long-term outcomes of early gastric cardiac cancer treated with endoscopic submucosal dissection in 499 Chinese patients

AIMS

Early gastric cardiac cancer (EGCC) has a low risk of lymph node metastasis with the potential for endoscopic therapy. We aimed to evaluate the short- and long-term outcomes of endoscopic submucosal dissection (ESD)-resected EGCCs in a large cohort of Chinese patients and compare endoscopic and clinicopathologic features between EGCC and early gastric non-cardiac cancer (EGNC).

METHODS

We retrospectively studied 512 EGCCs in 499 consecutive patients and 621 EGNCs in 555 consecutive patients between January 2011 and March 2018 at our center. We investigated clinicopathological characteristics of EGCC tumors, ESD treatment results, adverse events, and postresection patient survival.

RESULTS

Compared with EGNC patients, EGCC patients were significantly older (average age: 66 years versus 62 years, p < 0.001). The percentage of the gross 0-IIc pattern was higher in EGCCs (46.1%) than in EGNCs (41.5%), while the frequency of the 0-IIa pattern was lower in EGCCs (14.9%) than in EGNCs (22.4%) (p = 0.001). Compared with EGNCs, EGCCs showed smaller size, deeper invasion, fewer ulcerated or poorly differentiated tumors, but more cases with gastritis cystica profunda. The prevalence of ESD-related complications was higher in EGCCs (6.1%) than in EGNCs (2.3%) (p = 0.001). In EGCCs, the disease-specific survival rate was significantly higher in patients of the noncurative resection group with surgery (100%), compared with that (93.9%) without surgery (p < 0.001).

CONCLUSION

Clinicopathological characteristics were significantly different between EGCCs and EGNCs. ESD is a safe and effective treatment option with favorable outcomes for patients with EGCC. Additional surgery improved survival in patients with noncurative ESD resection.

Upper Gastrointestinal Manifestations of Inflammatory Bowel Disease

Although the features of lower gastrointestinal tract inflammation associated with ulcerative colitis and Crohn disease are generally familiar to pathologists, there is less awareness of and familiarity with the manifestations of inflammatory bowel disease in the esophagus, stomach, and duodenum. Nonetheless, their diagnosis has therapeutic and possibly prognostic implications, potentially foretelling severe complications. The recognition that ulcerative colitis can affect gastrointestinal organs proximal to the large intestine and terminal ileum represents a revision of concepts ingrained among generations of physicians. This article reviews the pathologic features and clinical significance of esophagitis, gastritis, and duodenitis associated with inflammatory bowel disease.

Pathologic Features of Infectious Gastritis

This manuscript presents a review of infectious causes of gastritis aimed at the practicing anatomic pathologist. We shall highlight unique histologic findings and clinical attributes that will assist those analyzing endoscopically obtained mucosal biopsies of the stomach or resection specimens.

Patterns of Gastric Injury: Beyond Helicobacter Pylori

Gastric biopsies are routinely obtained from patients with symptoms related to the gastrointestinal tract and, as a result, a variety of histologic changes are observed in patients with or without endoscopic evidence of mucosal injury. Although Helicobacter pylori-related gastritis is still common, several other patterns of mucosal injury are increasingly encountered. These patterns of injury are classified based on the nature and distribution of inflammation, location of epithelial cell injury, presence of crystal or pigment deposition, and/or other unique features. This article discusses each of these patterns and provides a differential diagnosis for each.

Granulomas in the gastrointestinal tract: deciphering the Pandora's box

Granulomas are organised collection of activated histiocytes induced by a persistent antigen stimulus. A wide variety of antigens encountered by the gastrointestinal tract are of this nature and hence the resulting granulomatous inflammation represents a tissue reaction pattern. The potential causes can be broadly classified as infections or non-infectious immune reactions. There is also a group where a cause is never identified. Granulomas may be of varying morphological appearance, most commonly epithelioid, foreign body type, suppurative and necrotizing. This may provide a clue as to the aetiology; however, in most cases, the cause requires further inquiry. Pathologists may need to cut deeper levels to look for foreign material and apply special stains to look for microorganisms. Pathologists also need to be certain that the process is a true granuloma and not a mimic. The site of occurrence in the gastrointestinal tract and the clinical setting is often paramount in establishing the aetiology. For instance, infections are more likely the cause in developing countries or when there is immunosuppression. Similarly, granulomas in the stomach are usually due to Crohn's disease; however, it is only rarely the cause of granulomas isolated to the appendix.

Helicobacter pylori chronic gastritis updated Sydney grading in relation to endoscopic findings and H. pylori IgG antibody: diagnostic methods

Helicobacter pylori (Hp) inhabits the stomach of > 50% of humans and has been established as a major etiological factor in the pathogenesis of chronic gastritis, gastric atrophy, peptic ulcer disease, gastric adenocarcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. The aim of this study was to provide unequivocal information about Hp-associated gastritis grading according to the Sydney grading system and to compare the histopathological features with the endoscopic findings and anti-Hp immunoglobulin (Ig)G serological status. This analytical study was conducted on 157 patients with dyspeptic gastritis. All patients underwent esophagogastroduodenoscopy, and antrum and corpus biopsies were taken. Blood samples were obtained from all participants. Different stains were performed on formalin-fixed, paraffin-embedded tissue blocks that included hematoxylin and eosin and Giemsa stain for histopathological interpretation. The endoscopic findings of gastritis were observed in 120 patients and most of them showed hyperemia (80 patients), whereas seven patients had normal appearing gastric mucosa. Histologically variable numbers of mononuclear inflammatory cellular infiltrates were seen in 150 cases (95.5%). Most of them showed Grade 1 gastritis (80 patients), whereas Grades 2 and 3 were found in 43 and 27 biopsies, respectively. Hp colonization was observed in most of the examined biopsies (93.7%). Hp-IgG seropositivity was found in 80.9% of cases and 19.1% were seronegative. The relationship between endoscopic and histological findings was significant (p < 0.001).

H. pylori and its modulation of gastrointestinal microbiota

The discovery of Helicobacter pylori (H. pylori) changed the dogma of the stomach as a sterile organ. H. pylori is an obligate pathogen in the human stomach and recognized as a definite carcinogen. Extensive research on the interaction of this bacterium with the gastric mucosa has been performed over the past three decades. The development of new nucleotide sequencing techniques and new biocomputational tools has opened the field for studying the diversity and complexity of the microbiome in the gastrointestinal tract independently of cultural methods. These techniques allow to better characterize further gastric bacteria. However, the differentiation of alive resident and transient microbes requires an analysis beyond the pure detection of bacterial genomic material applying a combination with metabolomic analyses. Currently, the interaction of gastric microbiota with each other, with H. pylori and with the host is addressed by extensive research. This review gives a concise overview on current knowledge on this topic.

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.

Gastric atrophy and oesophageal squamous cell carcinoma: possible interaction with dental health and oral hygiene habit

Background:

Gastric fundal atrophy has been hypothesised to increase the risk of oesophageal squamous cell carcinoma (OSCC), but studies have shown inconsistent results.

Methods:

We measured serum pepsinogen I (PGI) and pepsinogen II (PGII) among 293 incident cases and 524 matched neighbourhood controls in a high-risk area of Northern Iran. Conditional logistic regression model was used to estimate odds ratios (ORs) and their 95% confidence intervals (CIs).

Results:

After controlling for age, sex, residence area and other potential confounders, gastric atrophy (defined by a validated criterion, PGI <55 μg dl⁻¹) was associated with a two-fold increased risk (OR=2.01, 95% CI: 1.18, 3.45) of OSCC in the absence of nonatrophic pangastritis (defined as PGII <11.8 μg dl⁻¹). Stratification by PGII decreased the misclassification errors due to cancer-induced gastritis. Presence of both poor dental health, indicated by higher than median sum of decayed, missing, and filled teeth (DMFT score), and gastric atrophy further increased the risk of OSCC (OR=4.15, 95% CI: 2.04, 8.42) with relative excess risk due to interaction (RERI) of 1.47 (95% CI: −1.15, 4.1). Coexistence of poor oral hygiene habit with gastric atrophy elevated OSCC risk eight times (OR=8.65, 95% CI: 3.65, 20.46) and the additive interaction index was marginally statistically significant (RERI=4.34, 95% CI: −1.07, 9.76).

Conclusion:

Gastric atrophy is a risk factor for OSCC, and poor dental health and oral hygiene habit may act synergistically in increasing the risk.

Gastritis: the histology report

Gastritis is defined as inflammation of the gastric mucosa. In histological terms, it is distinguishable into two main categories, i.e. non-atrophic and atrophic. In the gastric mucosa, atrophy is defined as the loss of appropriate glands. There are several etiological types of gastritis, their different etiology being related to different clinical manifestations and pathological features. Atrophic gastritis (resulting mainly from long-standing Helicobacter pylori infection) is a major risk factor for the onset of (intestinal type) gastric cancer. The extent and site of the atrophic changes correlate significantly with the 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. Building on current knowledge of the biology of gastritis, an international group of pathologists [Operative Link for Gastritis Assessment (OLGA)] has proposed a system for reporting gastritis in terms of its stage (the OLGA Staging System): this system places the histological phenotypes of gastritis on a scale of progressively increasing gastric cancer risk, from the lowest (Stage 0) to the highest (Stage IV). The aim of this tutorial is to provide unequivocal information on how to standardize histology reports on gastritis in diagnostic practice.

Chronic gastritis in the setting of autoimmune pancreatitis

Autoimmune pancreatitis (AIP) is a recently recognized disease entity. In some patients, this disease is associated with other inflammatory diseases. In this study, we aimed to elucidate the pathologic characteristics of AIP-associated gastritis (AIP-G). We evaluated and compared the pathologic findings and immunohistochemical expressions of immunoglobulin G (IgG)4 and IgG in gastric biopsy specimens from 13 AIP-G patients with those from patients of 2 control groups. We divided the AIP-G patients who did not receive steroid therapy [AIP-G-ST(-)] into the following 2 groups: without Helicobacter pylori (HP) infection [AIP-G-HP(-)] and with HP infection [AIP-G-HP(+)]. The control groups comprised 19 patients who were diagnosed with chronic active gastritis associated with HP infection and 7 patients with nonsteroidal anti-inflammatory drug-induced gastritis. We classified the findings for the gastric mucosa into those for the upper and the lower lamina propria. The characteristic finding of AIP-G groups was diffusely lymphoplasmacytic infiltration in the lamina propria. The IgG4-positive plasma cell/IgG-positive plasma cell ratios (IgG4/IgG ratios) in both the upper and lower lamina propria in the AIP-G-ST(-) groups were predominantly higher than the corresponding values in the other groups. In the AIP-G-ST(-) groups, the IgG4/IgG ratio in the lower lamina propria was predominantly higher than that in the upper lamina propria, irrespective of the HP status. In conclusion, diffuse lymphoplasmacytic infiltration in the lamina propria and increased IgG4/IgG ratio in the gastric mucosa (notably in the lower lamina propria) may be the characteristic findings of AIP-G.