Does carditis have two different etiologies?

Follow the Metaplasia: Characteristics and Oncogenic Implications of Metaplasia's Pattern of Spread Throughout the Stomach

The human stomach functions as both a digestive and innate immune organ. Its main product, acid, rapidly breaks down ingested products and equally serves as a highly effective microbial filter. The gastric epithelium has evolved mechanisms to appropriately handle the myriad of injurious substances, both exogenous and endogenous, to maintain the epithelial barrier and restore homeostasis. The most significant chronic insult that the stomach must face is Helicobacter pylori (Hp), a stomach-adapted bacterium that can colonize the stomach and induce chronic inflammatory and pre-neoplastic changes. The progression from chronic inflammation to dysplasia relies on the decades-long interplay between this oncobacterium and its gastric host. This review summarizes the functional and molecular regionalization of the stomach at homeostasis and details how chronic inflammation can lead to characteristic alterations in these developmental demarcations, both at the topographic and glandular levels. More importantly, this review illustrates our current understanding of the epithelial mechanisms that underlie the pre-malignant gastric landscape, how Hp adapts to and exploits these changes, and the clinical implications of identifying these changes in order to stratify patients at risk of developing gastric cancer, a leading cause of cancer-related deaths worldwide.

Characterization of the gastric cardia in volunteers from the general population. Type of mucosa, Helicobacter pylori infection, inflammation, mucosal proliferative activity, p53 and p21 expression, and relations to gastritis

The aim of this research was to characterize the mucosa of the gastric cardia in relation to infection with Helicobacter pylori and the occurrence of chronic gastritis in other parts of the stomach in a sample of the general population. In this study, 80 adult volunteers underwent esophagogastroscopy with biopsies from the gastric cardia, corpus, and antrum. Gastritis was classified according to the Sydney system. Chronic gastritis (cardia excepted) was diagnosed in 35 subjects, 30 with H. pylori infection. Epithelial proliferative activity (Ki-67), p53- and p21 expression were examined quantitatively with cell counting after immunohistochemical stainings. Esophagitis was diagnosed macroscopically. Fourty eight subjects had cardia-type and 32 corpus-type mucosa in the anatomical cardia. The prevalence of esophagitis (nine cases) did not differ between these groups. Carditis was more prevalent among subjects with cardia-type mucosa (73 vs. 28%, P < 0.0001). H. pylori was present in 48% of those with cardia-type and 25% of those with corpus-type mucosa (P = 0.06). Of the 44 subjects with carditis, 31 had H. pylori in this location. The group with H. pylori infection had significantly higher mucosal proliferative activity when compared to uninfected subjects. Among the subjects with H. pylori-associated carditis, more p53-positive epithelial cells were detected compared to both the non-infected group (P = 0.0004) and to subjects with non-H. pylori-associated carditis (P = 0.03). In subjects with cardia-type mucosa, and both carditis and gastritis, the degree of chronic inflammation was higher in the cardia compared to the corpus and antrum and the p53 expression was significantly higher in the cardia compared to the corpus, but similar to that in the antrum. The proliferative activity was significantly higher in the antrum compared to the cardia and corpus, respectively. In conclusion, H. pylori infection, carditis, and increased p53 expression are more common in subjects with cardia- than corpus-type mucosa in the gastric cardia. Carditis is mainly related to H. pylori infection. There are some differences regarding inflammation, proliferative activity, and p53 expression between the cardia and other regions of the stomach, yet the significance of these differences remains to be clarified.

The pathology of gastric cardia: a prospective, endoscopic, and morphologic study

"Carditis" (inflammation of the gastric cardiac mucosa) may be associated with gastroesophageal reflux disease (GERD), whereas other studies argue that Helicobacter pylori could play a significant role in the chronic cardiac damage. We examined prospectively histologic features of gastric cardia, esophagitis, and H. pylori status in 204 consecutive subjects with GERD symptoms (57.3% male, 42.7% female mean age 49.2 y) undergoing upper gastrointestinal endoscopy with multiple biopsies in the distal esophagus, cardiac region, and stomach. These were assessed for esophagitis landmarks [Ismail Beigi grading (g0-3)], gastritis, and H. pylori infection (Sydney classification). The average symptom duration was 10.8 months. Endoscopy showed no erosive disease in 54.5% patients, grade "A" esophagitis in 37.6%, "B" in 8%, and "C" in 1 case. Histologic examination disclosed g0 in 8.3% patients, g1 in 78.4%, g2 in 12.8%, and g3 in 1; analysis of the cardia showed oxyntic mucosa in 27.9% patients and chronic cardiac mucosa inflammation in 72.1%. Carditis was significantly related to macroscopic esophagitis (P=0.044) and heartburn score (P=0.001). H. pylori cardiac infection was present in 27.4% cases (73.2% associated with cardiac mucosa). Gastric H. pylori infection was demonstrated in 35% patients. H. pylori in the cardiac region was associated with gastric H. pylori infection (P=0.001) and with paucity of GERD symptoms (P=0.05). A good correlation between carditis and GERD, concerning symptoms and macroscopic esophagitis was found in this study. H. pylori-related carditis is likely to be differently compared with the GERD-related type.

Carditis is related to Helicobacter pylori infection in dyspeptic children and adolescents

BACKGROUND

Etiology of gastric cardia inflammation is still controversial.

AIMS

To evaluate the association between carditis and Helicobacter pylori infection and the correlation among inflammatory changes observed in biopsies taken from cardia, corpus, and antrum in a well-defined group of patients.

PATIENTS

The mean age of 45 dyspeptic patients was 10.4 years (range 5.1-17.0 years); gender F/M rate: 1.6/1.

METHODS

A total of 450 specimens from esophagus (2), cardia (2), corpus (3), and antrum (4) were collected for biopsy. The presence of H. pylori was assessed by histology and a rapid urease test. The types of glandular epithelium of cardia found in specimens were identified and both inflammatory changes and H. pylori density were graded.

RESULTS

Carditis was present in specimens of 30/45 (66.7%) of the patients. Presence of H. pylori in specimens was detected in the antrum (26/45; 57.8%), in the corpus (19/45; 42.2%), and in the cardia (14/45; 31.1%). There was a strong association between carditis and presence of H. pylori infection (OR=27.08) by multivariate analysis. The scores for inflammation and activity in the cardia, corpus and antrum have shown a relationship except for both cardia and antrum H. pylori density and corpus and cardia activity. The intensity of gastritis and degree of colonization with H. pylori were significantly higher in the antrum than in both the corpus and the cardia. Pangastritis was highly associated to H. pylori infection in 22/25 (88%) of the patients.

CONCLUSIONS

1. Carditis is associated to H. pylori infection in children with symptoms of dyspepsia; 2. The degrees of gastritis found at the cardia were correlated to those at the antrum and body except for both cardia and antrum H. pylori density and corpus and cardia activity.

Cancer of the gastric cardia

Current evidence indicates that cardia cancers are of at least two distinct and disparate aetiologies. One type resembles cancer of the more distal stomach (Type A), being a consequence of atrophic gastritis due to Helicobacter pylori infection or more rarely autoimmune atrophic gastritis. Another type (Type B) resembles oesophageal adenocarcinoma and is likely to be a consequence of short-segment gastro-oesophageal reflux disease. The two cancers are themselves indistinguishable but examination of the gastric phenotype indicates the aetiology: Type A occurring in patients with evidence of atrophic gastritis whereas Type B occurs in subjects with healthy acid secreting stomachs. In subjects with healthy acid secreting stomachs the cardia has a specific luminal chemistry remaining highly acidic and unbuffered following a meal and having very active nitrosative chemistry due to the acidification of nitrite in saliva. This luminal chemistry may contribute to the high incidence of metaplasia and neoplasia at this anatomical site.

Carditis in patients with gastro-oesophageal reflux disease: results of a controlled study based on both endoscopy and 24-h oesophageal pH monitoring

BACKGROUND

There are conflicting reports on the role of gastro-oesophageal reflux disease (GERD) and Helicobacter pylori infection in the aetiology of carditis.

AIM

The role of reflux and H. pylori infection in causing carditis was assessed in 113 consecutive patients with GERD and in 25 controls.

METHODS

All subjects underwent endoscopy and pH test and carditis was diagnosed on biopsies taken across the squamocolumnar junction. Helicobacter pylori was assessed by histology and rapid urease test. GERD was diagnosed by endoscopic oesophagitis or abnormal pH test.

RESULTS

Carditis was detected in 53 of 71 GERD patients and in 15 of 20 controls. Among patients, 18 showed absent, 39 mild and 14 marked cardia inflammation and their H. pylori infection rates were 17, 23 and 57%, respectively (P < 0.025). Most patients with carditis (68%) lacked H. pylori infection. pH-metry was abnormal in 15 of 18 patients with normal cardia, 33 of 39 with mild carditis and 12 of 14 with marked inflammation.

CONCLUSIONS

Carditis is a frequent finding in GERD and controls. Mild, non-active carditis is frequent in GERD patients. Marked inflammation is associated with both H. pylori and abnormal pH testing. Thus, both GERD and H. pylori infection may play a role in inducing carditis.

Carditis at the interface between GERD and Helicobacter pylori infection

Inflammation of the gastric cardia ('carditis') is a histological diagnosis. It seems reasonable to transfer histological criteria of the updated Sydney classification from the distal stomach to the cardia as long as a special classification of inflammation of the esophagogastric junction is lacking. The two best characterized causes of carditis are Helicobacter pylori infection and gastroesophageal reflux disease (GERD). However, the causal contribution and interference of these two factors are highly controversial, as is the clinical relevance of carditis in terms of eliciting symptoms or conferring an increased cancer risk. Variability of studies on carditis is based on conflicting concepts of the normal anatomy of the esophagogastric junction. Cardia-type mucosa (CM) apparently exists at birth as a tiny circular area, and extends to a larger area in adulthood. This implies that cardia-type mucosa is largely metaplastic. Metaplastic CM may evolve in the lower esophagus as a consequence of GERD. It is a general phenomenon that H. pylori-induced gastritis also involves the gastric cardia, irrespective whether the cardia is lined by fundus-type mucosa or CM. The contribution of GERD to inflammation of CM in H. pylori-negative individuals is, however, highly controversial. Prevalence of carditis in GERD patients fluctuates between 10 and 97%. Hence, because of its high frequency and low specificity, carditis can currently not be considered as a clinical entity. The role of carditis for the increasing incidence of cancer of the esophagogastric junction requires careful studies that include accurate description of the area with adequate biopsy protocols.

Carditis is associated with Helicobacter pylori-induced gastritis and not reflux esophagitis

Pathogenesis of chronic inflammation at the gastric cardia is not yet clear. It is controversial whether cardiac-type mucosa is normal structure at the cardiac region. Therefore, we studied the existence of correlations between carditis, infection, and gastroesophageal reflux disease, and determined the prevalence of cardiac mucosa at the endoscopically defined cardiac region. Gastric biopsy specimens were analyzed from 27 patients with reflux esophagitis and 30 subjects without reflux esophagitis. Carditis was not associated with reflux esophagitis, but with infection. Moreover, the degree of gastritis and atrophy at the cardia were closely related to those of the antrum and body. Cardiac mucosa was not always present in the endoscopically defined cardiac region, and its prevalence was positively correlated with gastritis and atrophy grade of the cardia and age. In conclusion, -induced pangastritis may lead to the development of carditis, which is associated with occurrence of cardiac-type mucosa at the cardiac region.