Nodularity-like appearance in the cardia: novel endoscopic findings for Helicobacter pylori infection

The Diagnostic Performance of Linked Color Imaging Compared to White Light Imaging in Endoscopic Diagnosis of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis

Background/Aims

Recognizing Helicobacter pylori infection during endoscopy is important because it can lead to the performance of confirmatory testing. Linked color imaging (LCI) is an image enhancement technique that can improve the detection of gastrointestinal lesions. The purpose of this study was to compare LCI to conventional white light imaging (WLI) in the endoscopic diagnosis of H. pylori infection.

Methods

We conducted a comprehensive literature search using PubMed, Embase, and the Cochrane Library. All studies evaluating the diagnostic performance of LCI or WLI in the endoscopic diagnosis of H. pylori were eligible. Studies on magnifying endoscopy, chromoendoscopy, and artificial intelligence were excluded.

Results

Thirty-four studies were included in this meta-analysis, of which 32 reported the performance of WLI and eight reported the performance of LCI in diagnosing H. pylori infection. The pooled sensitivity and specificity of WLI in the diagnosis of H. pylori infection were 0.528 (95% confidence interval [CI], 0.517 to 0.540) and 0.821 (95% CI, 0.811 to 0.830), respectively. The pooled sensitivity and specificity of LCI in the diagnosis of H. pylori were 0.816 (95% CI, 0.790 to 0.841) and 0.868 (95% CI, 0.850 to 0.884), respectively. The pooled diagnostic odds ratios of WLI and LCI were 15.447 (95% CI, 8.225 to 29.013) and 31.838 (95% CI, 15.576 to 65.078), respectively. The areas under the summary receiver operating characteristic curves of WLI and LCI were 0.870 and 0.911, respectively.

Conclusions

LCI showed higher sensitivity in the endoscopic diagnosis of H. pylori infection than standard WLI.

Helicobacter pylori intragastric colonization and migration: Endoscopic manifestations and potential mechanisms

After being ingested and entering the human stomach, Helicobacter pylori (H. pylori) adopts several effective strategies to adhere to and colonize the gastric mucosa and move to different regions of the stomach to obtain more nutrients and escape from the harsher environments of the stomach, leading to acute infection and chronic gastritis, which is the basis of malignant gastric tumors. The endoscopic manifestations and pathological features of H. pylori infection are diverse and vary with the duration of infection. In this review, we describe the endoscopic manifestations of each stage of H. pylori gastritis and then reveal the potential mechanisms of bacterial intragastric colonization and migration from the perspective of endoscopists to provide direction for future research on the effective therapy and management of H. pylori infection.

Kyoto classification of gastritis: Advances and future perspectives in endoscopic diagnosis of gastritis

This editorial provides an update of the recent evidence on the endoscopy-based Kyoto classification of gastritis, clarifying the shortcomings of the Kyoto classification, and providing prospects for future research, with particular focus on the histological subtypes of gastric cancer (GC) and Helicobacter pylori (H. pylori) infection status. The total Kyoto score is designed to express GC risk on a score ranging from 0 to 8, based on the following five endoscopic findings: Atrophy, intestinal metaplasia (IM), enlarged folds (EF), nodularity, and diffuse redness (DR). The total Kyoto score reflects H. pylori status as follows: 0, ≥ 2, and ≥ 4 indicate a normal stomach, H. pylori-infected gastritis, and gastritis at risk for GC, respectively. Regular arrangement of collecting venules (RAC) predicts non-infection; EF, nodularity, and DR predict current infection; map-like redness (MLR) predicts past infection; and atrophy and IM predict current or past infection. Atrophy, IM, and EF all increase the incidence of H. pylori-infected GC. MLR is a specific risk factor for H. pylori-eradicated GC, while RAC results in less GC. Diffuse-type GC can be induced by active inflammation, which presents as EF, nodularity, and atrophy on endoscopy, as well as neutrophil and mononuclear cell infiltration on histology. In contrast, intestinal-type GC develops via atrophy and IM, and is consistent between endoscopy and histology. However, this GC risk-scoring design needs to be improved.

Helicobacter pylori Infection in a Pediatric Population from Romania: Risk Factors, Clinical and Endoscopic Features and Treatment Compliance

Background and Objectives: The aim of this study was to investigate the association between H. pylori positivity with specific symptoms, risk factors and endoscopic patterns among the pediatric population in northeastern Romania. Materials and Methods: A prospective study was performed in 18 months on 185 children aged 6−18 years with an indication for upper digestive endoscopy. Demographic, anamnestic, symptomatic, endoscopic and histologic data were recorded. Results: Of 116 H. pylori-positive children, the most affected group was 15−17 years. Most (65.5%) of them were girls, with a significant association (p < 0.001). The majority (66.4%) lived in a rural area and 47.4% of children had an unsafe source of water and lived in overcrowded houses with no basic sanitary comfort. The most frequent symptom was epigastric pain (56.9%), and the main endoscopic appearance was nodularity and hyperemia. Patients diagnosed with H. pylori started triple-therapy treatment for 14 days. Only 13.8% stopped the treatment, mainly because of a misunderstanding of the treatment protocol (9.5%). Conclusions: Romanian teen girls living in rural areas are at high risk for H. pylori infection. Epigastric pain and endoscopic nodularity of the gastric mucosa were associated with the infection. As the resistance of the bacteria is unknown in our country, future research is needed in order to improve the eradication rate.

Consistency between the endoscopic Kyoto classification and pathological updated Sydney system for gastritis: A cross-sectional study

BACKGROUND

Two methods are used to evaluate gastritis: the updated Sydney system (USS) with pathology and Kyoto classification, a new endoscopy-based diagnostic criterion for which evidence is accumulating. However, the consistency of their results is unclear. This study investigated the consistency of their results.

METHODS

Patients who underwent esophagogastroduodenoscopy and were evaluated for Helicobacter pylori infection for the first time were eligible. The association between corpus and antral USS scores (neutrophil activity, chronic inflammation, atrophy, and intestinal metaplasia) and Kyoto classification scores (atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness) was assessed.

RESULTS

Seven-hundred-seventeen patients (mean age, 49.2 years; female sex, 57.9%; 450 H. pylori-positive and 267 H. pylori-negative patients) were enrolled. All endoscopic gastritis cases in the Kyoto classification were associated with high corpus and antral USS scores for neutrophil activity and chronic inflammation. A subanalysis was performed for H. pylori-positive patients. Regarding atrophy and intestinal metaplasia, endoscopic findings were associated with USS scores. Enlarged folds, nodularity, and diffuse redness were associated with high corpus USS scores for neutrophil activity and chronic inflammation, but with low antral USS scores for atrophy and intestinal metaplasia. The Kyoto classification scores were also associated with the pathological topographic distribution of neutrophil activity and intestinal metaplasia.

CONCLUSIONS

Among H. pylori-positive individuals, endoscopic and pathological diagnoses were consistent with atrophy and intestinal metaplasia. Enlarged folds, nodularity, and diffuse redness were associated with pathological inflammation (neutrophil activity and chronic inflammation) of the corpus; however, they were inversely associated with pathological atrophy and intestinal metaplasia. The endoscopy-based Kyoto classification of gastritis partially reflects pathology.

Decreased anti-parietal cell antibody titer in the advanced phase of autoimmune gastritis

BACKGROUND

Autoimmune gastritis (AIG) is histologically classified into three phases according to the severity of oxyntic mucosal atrophy: early, florid, and end phases. This study aimed to clarify the relationship between the AIG phase and the anti-parietal cell antibody titer.

METHODS

Patients who underwent upper gastrointestinal endoscopy were retrospectively reviewed in this study. We enrolled patients who were histologically diagnosed with AIG and serologically tested for anti-parietal cell antibody (APCA). AIG patients were classified into three groups: early, florid, and end phase groups. Clinical characteristics, including APCA titers, were compared among these three groups.

RESULTS

A total of 44 AIG patients were enrolled. There were two patients in the early phase, 11 in the florid phase, and 31 in the end phase. APCA-positive rates were 100% in the early phase, 90.9% in the florid phase, and 90.3% in the end phase. The mean APCA titer was 480 U in the early phase, 220 U in the florid phase, and 150 U in the end phase. There was a stepwise decrease in the APCA titer from the early phase to the end phase. The mean APCA titer for the end phase was significantly lower than that of the early phase or florid phase. Additionally, there was a stepwise decrease in serum gastrin levels from the early phase to the end phase.

CONCLUSION

AIG progresses from the early phase to the end phase, and the APCA titer shows a decrease. The negativity of APCA could occur, especially in the end phase.

Clue of Diagnosis for Autoimmune Gastritis

BACKGROUND

The diagnostic clues for autoimmune gastritis (AIG) can be classified into 2 categories: endoscopic findings and pathological diagnosis. We believe that research on the AIG detection rate by endoscopists could provide a better understanding of the diagnosis of AIG. This study aimed to clarify the ratio of the endoscopic and the pathological diagnoses of AIG.

METHODS

We retrospectively reviewed consecutive patients who underwent esophagogastroduodenoscopy (EGD). During their first EGD, the gastric mucosa with C2 atrophy or more was biopsied for pathological evaluation based on the updated Sydney system. A gastric biopsy was also performed after Helicobacter pylori eradication, obtaining specimens from at least 2 sites, the greater curvature of the corpus and the antrum. We enrolled patients who were positive for the anti-parietal cell antibody and were diagnosed with AIG, histologically and/or endoscopically. The detection rates of AIG were compared between endoscopic diagnosis and pathological diagnosis.

RESULTS

A total of 10,822 patients underwent EGD during the study period. Finally, 41 patients with AIG were enrolled, leading to an AIG prevalence of 0.38% in this study. As for the clue leading to AIG detection, 31.7% (13/41) were diagnosed through endoscopy (proximal-predominant atrophy), and 68.3% (28/41) were diagnosed pathologically. The AIG detection rate by endoscopists in the posteradication group was significantly lower than in the H. pylori-negative group (p < 0.05).

CONCLUSION

Endoscopists frequently overlooked AIG, especially in posteradication cases. Pathological assessment using the updated Sydney system after H. pylori eradication might be a promising strategy to detect AIG better.

Risk Factors for Prolonged Hospital Stay after Endoscopy

Background/Aims

The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients.

Methods

We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis.

Results

We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy.

Conclusions

Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.

Clinical features of cardiac nodularity-like appearance induced by Helicobacter pylori infection

BACKGROUND

We have previously reported that Helicobacter pylori (H. pylori)-associated nodular gastritis could occur in both the antrum and the cardia. Cardiac nodularity-like appearance (hereafter, called as cardiac nodularity) had a high predictive accuracy for the diagnosis of H. pylori infection. In the previous study, we included only the patients who were evaluated for H. pylori infection for the first time, and excluded patients with a history of eradication. Therefore, the prevalence and clinical features of cardiac nodularity remains unknown.

AIM

To perform this cross-sectional study to explore the characteristics of cardiac nodularity.

METHODS

Consecutive patients who underwent esophagogastroduodenoscopy between May, 2017 and August, 2019 in the Toyoshima Endoscopy Clinic were enrolled in this study. We included H. pylori-negative, H. pylori-positive, and H. pylori-eradicated patients, and excluded patients with unclear H. pylori status and eradication failure. H. pylori infection was diagnosed according to serum anti-H. pylori antibody and the urea breath test or histology. Cardiac nodularity was defined as a miliary nodular appearance or the presence of scattered whitish circular small colorations within 2 cm of the esophagogastric junction. Nodularity was visualized as whitish in the narrow-band imaging mode. We collected data on the patients’ baseline characteristics.

RESULTS

A total of 1078 patients were finally included. Among H. pylori-negative patients, cardiac nodularity and antral nodularity were recognized in 0.14% each. Among H. pylori-positive patients, cardiac nodularity and antral nodularity were recognized in 54.5% and 29.5%, respectively. Among H. pylori-eradicated patients, cardiac nodularity and antral nodularity were recognized in 4.5% and 0.6%, respectively. The frequency of cardiac nodularity was significantly higher than that of antral nodularity in H. pylori-positive and -eradicated patients. The frequencies of cardiac nodularity and antral nodularity in H. pylori-eradicated patients were significantly lower than those in H. pylori-positive patients (P < 0.001). The patients with cardiac nodularity were significantly younger than those without cardiac nodularity (P = 0.0013). Intestinal metaplasia score of the patients with cardiac nodularity were significantly lower than those without cardiac nodularity (P = 0.0216). Among H. pylori-eradicated patients, the patients with cardiac nodularity underwent eradication significantly more recently compared with those without cardiac nodularity (P < 0.0001).

CONCLUSION

This report outlines the prevalence and clinical features of cardiac nodularity, and confirm its close association with active H. pylori infection.

Kyoto classification in patients who developed multiple gastric carcinomas after Helicobacter pylori eradication

BACKGROUND

Endoscopic Kyoto classification predicts gastric cancer risk; however, the score in the patients with primary gastric cancer after Helicobacter pylori (H. pylori) eradication therapy is unknown.

AIM

To elucidate the Kyoto classification score in patients with both single gastric cancer and multiple gastric cancers developed after H. pylori eradication.

METHODS

The endoscopist recorded the Kyoto classification at the endoscope and the Kyoto classification score at the time of the first diagnosis of gastric cancer after H. pylori eradication. The score was compared between single gastric cancer group and multiple gastric cancers group.

RESULTS

The Kyoto score at the time of diagnosis of 45 cases of gastric cancer after H. pylori eradication was 4.0 points in average. The score was 3.8 points in the single gastric cancer group, and 5.1 points in the multiple gastric cancers group. The multiple group had a significantly higher score than the single group (P = 0.016). In the multiple gastric cancers group, all the patients (7/7) had 5 or higher Kyoto score, while in single gastric cancer group, the proportion of patients with a score of 5 or higher was less than half, or 44.7% (17/38).

CONCLUSION

Patients diagnosed with gastric cancer after H. pylori eradication tended to have advanced gastritis. In particular, in cases of multiple gastric cancers developed after H. pylori eradication, the endoscopic Kyoto classification score tended to be 5 or higher in patients with an open type atrophic gastritis and the intestinal metaplasia extended to the corpus.

Endoscopy-based Kyoto classification score of gastritis related to pathological topography of neutrophil activity

BACKGROUND

Endoscopy-based Kyoto classification for gastritis and pathological topographic distribution of neutrophil infiltration are correlated with gastric cancer risk.

AIM

To investigate the association between Kyoto classification and the topographic distribution of neutrophil activity.

METHODS

Kyoto classification score, ranging from 0 to 8, consisted of atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness. Neutrophil activity was scored according to the updated Sydney System using biopsy samples obtained from the greater curvature of the corpus and the antrum. The participants were divided into four categories, inactive stomach, antrum-predominant gastritis, pangastritis, and corpus-predominant gastritis, based on the topographic distribution of neutrophil activity. Effects of sex, age, body mass index, drinking habit, smoking habit, family history of gastric cancer, serum Helicobacter pylori (H. pylori) antibody, and Kyoto score on topography of neutrophil infiltration were analyzed.

RESULTS

A total of 327 patients (comprising 50.7% women, with an average age of 50.2 years) were enrolled in this study. H. pylori infection rate was 82.9% with a mean Kyoto score of 4.63. The Kyoto score was associated with the topographic distribution of neutrophil activity. Kyoto scores were significantly higher in the order of inactive stomach, antrum-predominant gastritis, pangastritis, and corpus-predominant gastritis (3.05, 4.57, 5.21, and 5.96, respectively). Each individual score of endoscopic findings (i.e., atrophy, intestinal metaplasia, enlarged folds, nodularity, and diffuse redness) was correlated with the topographic distribution of neutrophil activity. On multivariate analysis, the Kyoto score, age, and serum H. pylori antibody were independently associated with the topographic distribution of neutrophil activity.

CONCLUSION

The Kyoto classification score was associated with the topographic distribution of neutrophil activity.

Helicobacter pylori eradication improved the Kyoto classification score on endoscopy

Background and Aim

Endoscopy‐based Kyoto classification predicts the risk of Helicobacter pylori infection and gastric cancer; however, the change in score following H. pylori eradication remains unknown. We retrospectively compared the Kyoto score before and after H. pylori eradication.

Methods

H. pylori‐positive patients who underwent baseline esophagogastroduodenoscopy (EGD), successful H. pylori eradication, and surveillance EGD were enrolled. The Kyoto score is a sum of scores for atrophy (Kimura‐Takemoto atrophic‐border classification none or C1: 0, C‐II or C‐III: 1, O‐I to O‐III: 2), intestinal metaplasia (none: 0, antrum: 1, corpus and antrum: 2), enlarged folds (absence: 0, presence: 1), nodularity (absence: 0, presence: 1), and diffuse redness (none: 0, mild: 1, severe: 2) and ranges from 0 to 8.

Results

Eighty‐three patients (mean age: 54.9 years; 65.1% women) were enrolled. The mean duration from successful eradication to surveillance EGD was 256 days. The Kyoto score significantly decreased from 3.90 to 2.78 following H. pylori eradication (P < 0.001). Scores for endoscopic atrophy (from 1.43 to 1.46, P = 0.638) and endoscopic intestinal metaplasia (from 0.53 to 0.47, P = 0.543) did not change; however, there was significant improvement in the scores for enlarged folds (from 0.14 to 0.00, P = 0.002), nodularity (from 0.18 to 0.04, P = 0.002), and diffuse redness (from 1.61 to 0.82, P < 0.001).

Conclusion

The Kyoto classification score decreased following H. pylori eradication. A decrease in the scores for enlarged folds, nodularity, and diffuse redness contributed to the decrease in Kyoto score.