Significant improvement of atrophy after eradication therapy in atrophic body gastritis

Discussion on the common controversies of Helicobacter pylori infection

BACKGROUND

Helicobacter pylori ( H. pylori ) can persistently colonize on the gastric mucosa after infection and cause gastritis, atrophy, metaplasia, and even gastric cancer (GC).

METHODS

Therefore, the detection and eradication of H. pylori are the prerequisite.

RESULTS

Clinically, there are some controversial issues, such as why H. pylori infection is persistent, why it translocases along with the lesser curvature of the stomach, why there is oxyntic antralization, what the immunological characteristic of gastric chronic inflammation caused by H. pylori is, whether H. pylori infection is associated with extra-gastric diseases, whether chronic atrophic gastritis (CAG) is reversible, and what the potential problems are after H. pylori eradication. What are the possible answers?

CONCLUSION

In the review, we will discuss these issues from the attachment to eradication in detail.

The 'reversibility' of chronic atrophic gastritis after the eradication of Helicobacter pylori

Gram-negative bacterium Helicobacter pylori (H. pylori) infection is lifelong and usually acquired in childhood, which is etiologically linked to gastric cancer (GC). H. pylori gastritis is defined as an infectious disease with varying severity in virtually all infected subjects. Chronic atrophic gastritis (CAG) is the precancerous condition with the decrease or the loss of gastric glands, which can further be replaced by metaplasia or fibrosis. Patients with advanced stages of CAG are at higher risk of GC and should be followed up with a high-quality endoscopy every 3 years. H. pylori infection is the most common cause and its eradication is recommended, which may contribute to the regression of CAG. However, it is controversial whether CAG is reversible after eradication therapy. In the review, we discuss recent studies which provide important insights into whether CAG is 'reversibility' and when it may progress into GC after eradicating H. pylori.

Early diagnosis of early gastric cancer

The prognosis of gastric cancer is closely related to the stage of disease at diagnosis. Early gastric cancer, whereby disease is limited to mucosa and submucosa, confers a survival rate of greater than 90% in 5 years in many centres. Gastric cancer is still a major cause of cancer mortality worldwide. In high incidence areas such as Japan, screening of asymptomatic population has been advocated. However, in Western countries, mass screening is not cost-effective. Hence, strategy has been directed to screen symptomatic individuals who are at higher risk of gastric cancer. Most patients with early gastric cancer present with symptoms indistinguishable from benign peptic ulcer disease. Screening for this group of patients improves detection rate of early gastric cancer and therefore its prognosis. Endoscopy for surveillance of premalignant lesions has been explored with this objective in mind. Serology testing for biomarkers such as pepsinogen, anti-Helicobacter pylori antibody and gastrin has been studied as an alternative to endoscopy. There is compelling evidence for the role of H. pylori in the initiation of Correa's cascade (stepwise progression from chronic active gastritis, atrophic gastritis, intestinal metaplasia, dysplasia and finally adenocarcinoma). Regression of premalignant lesions has been demonstrated with H. pylori eradication. However, it is not known whether this might effectively prevent gastric cancer in either low or high-risk population.

Helicobacter pylori eradication and associated changes in the gastric mucosa

Persistent Helicobacter pylori infection contributes towards the development of chronic gastritis. To clarify the changes in chronic gastritis as a precursor of gastric cancer secondary to H. pylori eradication is an important issue, as it has significant implications for reducing the risk of gastric cancer. Studies published to date, however, are far from consistent with regard to the morphologic changes reported following H. pylori eradication. Of these, some papers reported improvement in gastric atrophy or intestinal metaplasia, versus others reporting no improvement, with the majority of papers published after 2000 reporting improvement in these end points. The inconsistent results concerning the impact of H. pylori eradication on gastric atrophy could be due to the inconsistency of the diagnostic criteria employed for evaluation of the morphology, confounded by the difficulties involved in evaluating atrophic changes in the gastric mucosa. While adherence to the Updated Sydney System available for evaluation of gastritis is primarily required worldwide to ensure consistency in evaluating gastritis, long-term research into the morphologic changes associated with H. pylori eradication is also required to explore strategies for the prevention of gastric cancer with H. pylori eradication.

Improvement in serum pepsinogens and gastrin in long-term monitoring after eradication of Helicobacter pylori: comparison with H. pylori-negative patients

BACKGROUND

A decrease in pepsinogen and gastrin levels 1-3 months after Helicobacter pylori eradication is well known. However, few data are available on the long-term progression of these decreases beyond 1 year after eradication, and there has been no investigation into whether pepsinogen and gastrin levels return to normal levels as defined by data from H. pylori-negative patients with dyspepsia.

AIM

We studied the effect of H. pylori eradication on pepsinogen and gastrin levels for more than 1 year, and compared levels to those in H. pylori-negative patients with dyspepsia. We also investigated the effect of H. pylori eradication on the course of atrophic corpus gastritis as reflected by histology, and on PGI levels and PG I/II ratio.

METHODS

We enrolled 172 H. pylori-positive patients with dyspepsia who had undergone successful eradication therapy of more than 1 year's duration and 101 non-treated H. pylori-negative patients with dyspepsia. H. pylori status was assessed at entry and at each endoscopy after eradication by culture, histological results, the rapid urease test and the urea breath test. In both groups, patients were evaluated for fasting serum pepsinogen I and II and gastrin using a radioimmunoassay technique, and underwent detailed histological assessment according to the updated Sydney System.

RESULTS

In the H. pylori-negative patients, mean serum pepsinogen I and II, I/II ratio and gastrin levels were 52.6 +/- 20.8 ng/mL, 9.2 +/- 4.2 ng/mL, 6.0 +/- 1.7 and 53.5 +/- 29.2 pg/mL, respectively. In H. pylori-positive patients with long-term eradication, pepsinogen I and II, I/II ratio and gastrin levels were 81.3 +/- 46.6 ng/mL, 25.9 +/- 17.1 ng/mL, 3.4 +/- 1.3 and 131.9 +/- 130.8 pg/mL, respectively, before treatment. At 1-3 months after eradication, serum pepsinogen I and II levels in the H. pylori-positive patients decreased to levels similar to those in the negative patients, whereas pepsinogen I/II ratio and gastrin levels remained lower and higher, respectively, than in the negative patients. Serum pepsinogen I/II ratio and gastrin levels then became similar between the groups at 12-15 months after eradication. In histological findings, inflammation and neutrophil activity decreased by 1-3 months, and atrophy in the corpus and metaplasia in the antrum decreased by 12-15 months.

CONCLUSION

The results suggest that atrophic corpus gastritis and superficial gastritis are reversible, as indicated by both histological and serological findings in a long-term follow-up study.

Improvement of gastric atrophy after Helicobacter pylori eradication therapy

BACKGROUND

It remains controversial whether gastric atrophy is reversible after Helicobacter pylori eradication therapy.

AIM

To clarify whether gastric atrophy improves after H. pylori eradication therapy using a histologic approach.

METHODS

Subjects were 87 H. pylori infection-cured patients (treatment group) and 29 continuously H. pylori-infected patients (control group). The subjects in the treatment and control groups were followed for 10-49 months (mean, 22 months) and 11-50 months (mean, 22 months), respectively. Biopsy specimens were obtained from the greater curvature of the antrum and corpus at the beginning and end of the observation period; histologic analyses of these specimens were performed for detection of activity, inflammation, atrophy, and intestinal metaplasia. Results were scored without any clinical information according to the Sydney system.

RESULTS

In the treatment group, the histologic score for atrophy was improved in the corpus but not in the antrum. Intestinal metaplasia was not improved in either the antrum or the corpus. There were no significant differences during the follow-up in gastric atrophy and intestinal metaplasia in the control group.

CONCLUSION

Gastric atrophy was improved in the corpus approximately 2 years after H. pylori eradication therapy.

Gastric mucosa: long-term outcome after cure of Helicobacter pylori infection

The histopathological changes due to chronic Helicobacter pylori infection are well characterized. Nevertheless, the clinical and pathological outcomes resulting from the cure of this infection remain incompletely described. In particular, the influence of eradication of H. pylori on nonulcer dyspepsia, the long-term effects of H. pylori eradication on gastric atrophy and intestinal metaplasia, and the role of H. pylori eradication in the prevention of gastric cancer are still unclear. We reviewed 38 studies reported between 1993 and 1999 on the outcome of various disorders related to H. pylori infection after successful eradication. There is general agreement concerning the regression of chronic gastritis, lymphoid follicles, and limited-stage low-grade MALT lymphomas of the gastric mucosa after eradication of H. pylori infection. Conversely, there are still major questions on whether H. pylori eradication improves the outcome of premalignant lesions, such as atrophy, intestinal metaplasia, and dysplasia. Finally, some extragastric idiopathic diseases seem to improve in consequence of the eradication of the infection, although there are still no definitive data to support this.

The long-term effects of cure of Helicobacter pylori infection on patients with atrophic body gastritis

BACKGROUND

Helicobacter pylori infection induces atrophic body gastritis, but the long-term effect of its cure on body atrophy is unclear.

AIM

To investigate the long-term effects of H. pylori cure on gastric morpho-functional parameters in patients with atrophic body gastritis.

METHODS

Forty patients with atrophic body gastritis were cured of H. pylori infection. Gastroscopy with biopsies, gastrin and pepsinogen I levels and basal and stimulated acid secretion were evaluated before and 6-12 months after treatment.

RESULTS

At eradication assessment (6-12 months), in eight of the 40 patients, body atrophy was no longer observed, whereas in 32 of the 40 it remained substantially unchanged (2.03 +/- 0.12 vs. 1.83 +/- 0.15). In the eight patients with reversed body atrophy, gastrinaemia decreased significantly with respect to pre-treatment values (265 +/- 59.9 pg/mL vs. 51.8. +/- 6.04 pg/mL), and basal and stimulated acid secretion increased significantly after cure. In the 32 patients still presenting body atrophy, gastrinaemia was similar topre-treatment values (457 +/- 76.04 pg/mL vs. 335.1 +/- 58.8 pg/mL). At follow-up (21-25 and 32-70 months), the eight patients with reversed body atrophy continued with normal gastrinaemia (35.3 +/- 10.1 pg/mL vs. 38.5 +/- 8.8 pg/mL), but in the 19 patients with continued atrophy, both corporal atrophy and intestinal metaplasia remained substantially unchanged.

CONCLUSIONS

Following successful treatment in patients with atrophic body gastritis and H. pylori infection, long-term histological investigations are crucial in order to detect reversed body damage or to confirm continued body atrophy.

The effect of Helicobacter pylori eradication on the natural course of atrophic gastritis with dysplasia

BACKGROUND

There are few data on the natural course of Helicobacter pylori-related atrophic gastritis.

AIM

To investigate the effect of H. pylori eradication on advanced atrophic gastritis in the corpus.

METHODS

Twenty-two elderly men with H. pylori infection and moderate or severe atrophic corpus gastritis formed the study population. These men were under endoscopic surveillance because of the presence of indefinite or definite dysplastic gastric lesions in addition to atrophic corpus gastritis. The men were gastroscopically and bioptically examined four times before they received H. pylori eradication therapy (mean follow-up time, 7.5 years), and once again 2.5 years after eradication therapy. Serum levels of pepsinogen I and H. pylori antibodies were analysed at baseline, immediately before and 2.5 years after eradication therapy.

RESULTS

During the 7.5-year period prior to eradication therapy, no significant changes were observed in the mean atrophy and intestinal metaplasia scores or in the mean serum level of pepsinogen I. However, a significant improvement occurred in the mean histological scores of inflammation (from 2.2 to 0.5), atrophy (from 2.2 to 1.2) and intestinal metaplasia (from 1.6 to 1.1) in the corpus mucosa after H. pylori eradication. In addition, the mean serum level of pepsinogen I increased from 16.3 to 25.7 microg/L (P=0.0071, Wilcoxon signed rank test) after eradication therapy.

CONCLUSIONS

The results suggest that advanced atrophic corpus gastritis (and intestinal metaplasia) improves and may even heal after the eradication of H. pylori.

Morphometric evaluation of gastric antral atrophy: improvement after cure of Helicobacter pylori infection

OBJECTIVE

Our purpose was to find out if morphometric techniques can document long term changes in gastric antral atrophy after curing Helicobacter pylori infection with or without dietary supplementation with antioxidant micronutrients.

METHODS

Study subjects were 132 adult volunteers from a Colombian region with high gastric cancer rates. Participants were randomly assigned to ascorbic acid, beta-carotene, and anti-H. pylori treatment, following a factorial design. Gastric biopsies were obtained at baseline and after 72 months of intervention. Atrophy was evaluated by a standard visual analog scale and by morphometry.

RESULTS

Statistically significant changes in antral atrophy were detected with morphometric techniques after intervention in subjects who received anti-H. pylori treatment. A nonsignificant trend was also observed with visual scores. This effect was greater among those who were free of infection at the end of the trial. After accounting for the effect of anti-H. pylori treatment, no significant effect was noted for dietary supplementation with ascorbic acid and/or beta-carotene.

CONCLUSIONS

We conclude that gastric atrophy improves significantly after long term control of H. pylori infection. This effect can be demonstrated both by conventional histological grading and by morphometry.

The dynamics of gastritis

The dynamics of gastritis remain a topic of intense investigation. The results of these investigations have increased our knowledge concerning the development of preneoplastic lesions and cancer of the stomach and given us insight with regard to the interactions among bacterial colonization, chronic inflammation, and carcinogenesis in other organs. The past year has presented us with further data showing that the progression of chronic gastritis to gland loss and gastric cancer is related to the severity of inflammation, which is influenced by the characteristics of the bacterial strain, host genetics, and hypochlorhydria. In contrast, Helicobacter pylori eradication leads to a rapid disappearance of neutrophils in the gastric mucosa. Chronic inflammation with mononuclear cells also improves upon eradication, but at a much slower rate, usually not leading to normalization within the first year after therapy. Whether H. pylori eradication can thus prevent new development of atrophy and metaplasia as well, or lead to regression of pre-existing lesions, has been the topic of many studies by now. Unfortunately, most of these studies have suffered from their case design, limited sample size, and short follow-up. Therefore, the conflict in outcome of these case studies comes as no surprise. The few prospective, randomized, controlled studies, however, strongly confirm that H. pylori eradication leads to healing of gastritis, which can at least halt further development of atrophy and metaplasia. Whether these lesions can truly regress remains to be proven.

Quantitative assessment of gastric corpus atrophy in subjects using omeprazole: a randomized follow-up study

OBJECTIVES

Atrophy of the gastric mucosa most frequently results from chronic Helicobacter pylori infection and is a risk factor for the development of gastric cancer. Profound acid suppression has been suggested to accelerate the onset of gastric mucosal atrophy. The aim of the present study was to evaluate the effects of H. pylori eradication and acid inhibition by omeprazole on gastric atrophy by means of quantitative analysis of tissue morphology.

METHODS

Corpus biopsy specimens were obtained during endoscopy in 71 gastroesophageal reflux disease (GERD) patients at baseline and after 3 and 12 months. A total of 48 subjects were H. pylori positive and 23 were H. pylori negative. All subjects received omeprazole 40 mg once daily after the first endoscopy for 12 months. After randomization, 27 of the 48 H. pylori-positive patients also received eradication therapy. In hematoxylin and eosin-stained slides the volume percentages of glands (VPGL), volume percentages of stroma (VPS), and volume percentages of infiltrate (VPI) were measured in the glandular zone of the mucosa. The results were evaluated by computerized morphometric analysis.

RESULTS

In the eradication group, the mean VPGL increased from 63.0% to 67.7% and 71.5% after 3 and 12 months (p < 0.001), respectively. The mean VPS and VPI decreased from 33.1% and 4.0% to 29.3% and 3.0% and to 26.4% and 2.1% (p < 0.001 and p = 0.04), respectively. Patients with the lowest VPGL at baseline showed the largest increases of VPGL after eradication treatment as compared to patients with high a VPGL at baseline. In the H. pylori-persistent group the VPI showed a significant increase (p = 0.01), and in the H. pylori-negative group VPGL increased significantly from 71.9% to 75.2% (p = 0.03) after 12 months.

CONCLUSIONS

Eradication of H. pylori leads to restitution of the volume percentage of glandular epithelium to normal levels, even during treatment with proton pump inhibitors. Whether this effect can also be seen in patients with marked atrophy needs further investigation.

Morphometric assessment of gastric antral atrophy: comparison with visual evaluation

AIMS

As part of a multinational effort to reach a consensus in the definition and evaluation of atrophic gastritis, we applied morphometric techniques to 22 antral biopsy specimens examined visually by 12 experienced gastrointestinal pathologists.

METHODS AND RESULTS

Atrophy was defined as loss of glands. Each pathologist graded atrophy with both non-standardized and standardized approaches. Discriminant function analyses of morphometric measurements were conducted to validate and grade atrophy. Kappa statistics were used to compare the performance of each pathologist against the group mode and against the discriminant functions' grading of atrophy. Three morphometric indexes showed significant differences among categories of atrophy utilizing non-standardized as well as standardized visual atrophy grades: (i) the ratio of glandular length to total mucosal thickness; (ii) the proportion of the secretory compartment area occupied by glands; and (iii) the number of glandular cross sections per 40x microscopic field. The discriminant function analyses verified all cases classified visually as either non-atrophic, or moderately/severely atrophic; it verified as mildly atrophic 40% of the cases classified visually as mildly atrophic; and classified the remaining 60% as moderately or severely atrophic. The kappa statistics were good or excellent for the majority of pathologists.

CONCLUSIONS

The evaluation of antral atrophy, simply defined as loss of glands, can be reliable and reproducible. The visual grading of atrophy as absent, moderate and severe is entirely consistent with objective morphometric observations.

Does eradication of Helicobacter pylori reverse atrophic gastritis or intestinal metaplasia? Data from Japan

In Japan, more reports showing improvement of atrophy or IM after eradication have appeared than reports showing no change. Many authors take biopsy specimens from the lesser and greater curvatures of the antrum and body and incisura angularis and make a histologic assessment using the standardized Updated Sydney System. Sampling errors should be taken into account, however. Interobserver agreement is poor in grading of atrophy. Apart from these problems, it seems almost certain that some patients show improvement or regression of atrophy or IM after eradication. Takizawa et al, evaluating many gastritis specimens, observed that antral IM might regress after eradication in the antral mucosa, where some pyloric glands remained under IM because pyloric glands and IM shared the proliferative zone, and that body IM replacing total fundic glands might hardly regress (T. Takizawa, MD, personal communication). Suto et al showed in an animal model that pseudopyloric glands differentiated into chief and parietal cells. Watanabe et al examined the influence of gastric pH on IM in x-irradiated rats and showed that increased acid secretion was associated with partial disappearance of IM without Paneth cells. Because gastric acid secretion of hypochlorhydric patients with body-predominant gastritis increased into normal range 1 to 6 months after eradication, it is possible that IM may regress in human subjects whose acid-secreting capacity recovers after eradication. The point of no return at which eradication leads to regression of atrophy and IM is not known. It is unknown how long IM takes to regress after eradication. There may be some differences in the characteristics between patients with and without improvement. Factors other than H. pylori (e.g., environmental factors) also should be investigated.

[Histopathology of Helicobacter pylori infections]

Helicobacter pylori (H.p.) infection is associated in essentially all patients with a chronic active gastritis. According to the Houston-update of the Sydney classification grade and activity of the gastritis, the occurrence of intestinal metaplasia and atrophy as well as the density of H.p. colonization have to be semiquantitatively determined by the pathologists. Gastric acid production influences the severity of gastritis in antrum and body mucosa. In a subgroup of patients other forms of gastritis, such as lymphocytic gastritis, giant fold gastritis and atrophic gastritis may develop. After eradication plasma cells may persist in the lamina propria for years.

Cure of Helicobacter pylori infection in atrophic body gastritis patients does not improve mucosal atrophy but reduces hypergastrinemia and its related effects on body ECL-cell hyperplasia

BACKGROUND

The effects of H. pylori eradication on atrophic body gastritis are controversial.

AIM

To investigate the effect of triple therapy on atrophic body gastritis in H. pylori-positive patients and its effect on morpho-functional gastric parameters.

METHODS

Thirty-five consecutive atrophic body gastritis patients with histological/serological evidence of H. pylori infection were treated. Before and 6 and 12 months after H. pylori eradication the patients were evaluated for fasting gastrinemia and pepsinogen I, basal and peak acid output, and detailed histological assessment including the ECL cell proliferative patterns.

RESULTS

Six months after treatment, 25 out of 32 patients were cured (78%). Cure of infection was associated with improvement in both basal (basal acid output mean 0.23 +/- 0.14 mmol/h vs. 1.75 +/- 0.7 mmol/h, P < 0.005) and stimulated acid secretion (peak acid output mean 3.0 +/- 1.06 mmol/h vs. 16.6 +/- 4.1 mmol/h, P=0.0017) as well as with reduction in hypergastrinemia (mean gastrin levels 444.1 +/- 110.7 pg/mL vs. 85.3. +/- 28 pg/mL; P < 0.005). In contrast, the eradication had no effect on body corporal atrophy and intestinal metaplasia, or pepsinogen I levels (mean 16.6 +/- 2.9 ng/mL vs. 14.2 +/- 2.1 ng/mL, N.S.). These results were confirmed at 12 months after eradication. A statistical inverse correlation was obtained (r=-0.3635, P < 0.05) between the corporal chronic infiltrate score and peak acid output values. A total of 53% of atrophic body gastritis patients showed a regression in severity of body ECL cell hyperplastic change.

CONCLUSION

Cure of H. pylori infection in patients with atrophic gastritis reverses some adverse effects on gastric function and ECL cell hyperplasia. H. pylori infection may be cured in atrophic body gastritis patients with partial reversion of its negative consequences on acid secretion and body ECL cell hyperplasia.

Role of antigastric autoantibodies in chronic Helicobacter pylori infection

In recent studies a significant association between H. pylori infection and antigastric autoimmunity has been reported. Antigastric autoantibodies can be found in more than 30% of infected patients. Two distinct binding patterns of these autoantibodies have been described, first at the luminal membrane of the foveolar epithelium, and second at the canaliculi membranes of the parietal cells in the body mucosa. The latter type of autoantibodies correlates with histologic and clinical parameters of gastric mucosa atrophy. The gastric H,K-ATPase, which is known to be the autoimmune target in classical autoimmune gastritis, also represents a major autoantigen in atrophic H. pylori gastritis. Molecular mimicry between H. pylori and the host does not seem to be responsible for the generation of this type of autoreactivity. The development of antigastric autoantibodies may be a relevant host factor which contributes to the final clinical outcome of chronic H. pylori gastritis.

Decrease of antigastric autoantibodies in Helicobacter pylori gastritis after cure of infection

H. pylori infection leads to the formation of autoantibodies against canalicular structures with human parietal cells in about 30% of all patients. This type of autoreactivity is associated with gastric mucosa atrophy. This study aimed to analyse the effect of cure of infection on anticanalicular autoantibodies. H. pylori infection was cured in 34 patients. Sera of these patients were screened for anticanalicular autoantibodies using an immunohistochemical method before, 10 weeks after and one year after cure of infection. Prevalence of anticanalicular autoantibodies significantly decreased from 26% before treatment to 9% after one year. The data presented in this study add new information to the possible reversibility of gastric mucosa atrophy.