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Drnovsek J, Homan M, Zidar N, Smid LM. Pathogenesis and potential reversibility of intestinal metaplasia - a milestone in gastric carcinogenesis. Radiol Oncol 2024; 58:186-195. [PMID: 38643513 PMCID: PMC11165985 DOI: 10.2478/raon-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Non-cardia gastric cancer remains a major cause of cancer-related mortality worldwide, despite declining incidence rates in many industrialized countries. The development of intestinal-type gastric cancer occurs through a multistep process in which normal mucosa is sequentially transformed into hyperproliferative epithelium, followed by metaplastic processes leading to carcinogenesis. Chronic infection with Helicobacter pylori is the primary etiological agent that causes chronic inflammation of the gastric mucosa, induces atrophic gastritis, and can lead to intestinal metaplasia and dysplasia. Both intestinal metaplasia and dysplasia are precancerous lesions, in which gastric cancer is more likely to occur. Atrophic gastritis often improves after eradication of Helicobacter pylori; however, the occurrence of intestinal metaplasia has been traditionally regarded as "the point of no return" in the carcinogenesis sequence. Helicobacter pylori eradication heals non-atrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions. In this article, we discuss the pathogenesis, epigenomics, and reversibility of intestinal metaplasia and briefly touch upon potential treatment strategy. CONCLUSIONS Gastric intestinal metaplasia no longer appears to be an irreversible precancerous lesion. However, there are still many controversies regarding the improvement of intestinal metaplasia after Helicobacter pylori eradication.
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Affiliation(s)
- Jan Drnovsek
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Matjaz Homan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Gastroenterology, Hepatology and Nutrition, University Children’s Hospital, Ljubljana, Slovenia
| | - Nina Zidar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Lojze M Smid
- Department of Gastroenterology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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2
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Ferreira AI, Lima Capela T, Macedo Silva V, Xavier S, Boal Carvalho P, Magalhães J, Cotter J. Gastric dysplasia in random biopsies: the influence of Helicobacter pylori infection and alcohol consumption in the presence of a lesion. Scand J Gastroenterol 2024; 59:125-132. [PMID: 37872792 DOI: 10.1080/00365521.2023.2272563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Gastric dysplasia in the absence of an endoscopically defined lesion is rare, usually either a false positive diagnosis or a previously unidentified precancerous lesion during esophagogastroduodenoscopy (EGD). AIMS Evaluate factors associated with the presence of an endoscopically visible lesion during follow-up in patients with histologic diagnosis of gastric dysplasia in random biopsies. METHODS Retrospective cohort study including patients referred to our institution for gastric dysplasia in random biopsies during Index EGD. Endoscopic evaluation was performed with a high-definition endoscope using narrow band imaging (HD EGD-0). If no lesion was detected, endoscopic surveillance (HD EGD-FU) was conducted within 6 months for high grade dysplasia (HGD) or 12 months for low grade (LGD) or indefinite for dysplasia (IFD). RESULTS From a total sample of 96 patients, 5 (5.2%) presented with an endoscopically visible lesion during HD EGD-0, while 10 lesions (10.4%) were identified during HD EGD-FU. Patients with Helicobacter pylori infection at Index EDG and with regular alcohol consumption (≥25 g/day) were 8 and 4 times more likely to have an endoscopically visible lesion on HD EGD-FU (p = 0.012 and p = 0.047). In binary logistic regression, both factors were independent predictors of the presence of gastric lesion on HD EGD-FU (OR 9.284, p = 0.009 and OR 5.025, p = 0.033). CONCLUSIONS The presence of an endoscopically visible lesion after the histologic diagnosis of gastric dysplasia in random biopsies was more frequent during HD EGD-FU. H. pylori infection at Index EGD and regular alcohol consumption were significant predictors of the presence of gastric lesion on HD EGD-FU.
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Affiliation(s)
- Ana Isabel Ferreira
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - Tiago Lima Capela
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - Vítor Macedo Silva
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - Sofia Xavier
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - Pedro Boal Carvalho
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - Joana Magalhães
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Guimarães, Braga, Portugal
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3
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Prakash P, Jain S, Trieu H, Chow K, Karunasiri D, Liang T, Yung E, Mason H, Tan H, Tabibian JH. Clinical epidemiology and outcomes of patients with gastric intestinal metaplasia in the Los Angeles County System. BMC Gastroenterol 2023; 23:165. [PMID: 37208616 DOI: 10.1186/s12876-023-02797-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/02/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Gastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system. METHODS We identified patients with biopsy-proven GIM between 2016-2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ2) tests were used to compare patients with and without multifocal GIM. RESULTS There were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2-3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients. CONCLUSION In a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices.
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Affiliation(s)
- Preeti Prakash
- David Geffen School of Medicine at the University of California Los Angeles (UCLA), Los Angeles, CA, USA.
- Department of Medicine, Massachusetts General Hospital, MA, Boston, USA.
| | - Shailavi Jain
- David Geffen School of Medicine at the University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Harry Trieu
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - Kenneth Chow
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Deepthi Karunasiri
- Department of Pathology, Olive-View-UCLA Medical Center, Sylmar, CA, USA
| | - Tom Liang
- Department of Pathology, Los Angeles County-University of Southern California Medical Center, Los Angeles, CA, USA
| | - Evan Yung
- Department of Pathology, Los Angeles County-University of Southern California Medical Center, Los Angeles, CA, USA
| | - Holli Mason
- Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Hongying Tan
- Department of Pathology, Olive-View-UCLA Medical Center, Sylmar, CA, USA
| | - James H Tabibian
- David Geffen School of Medicine at the University of California Los Angeles (UCLA), Los Angeles, CA, USA
- Division of Gastroenterology, Department of Medicine, Olive-View-UCLA Medical Center, Sylmar, CA, USA
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4
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Ahmad AI, Lee A, Caplan C, Wikholm C, Pothoulakis I, Almothafer Z, Raval N, Marshall S, Mishra A, Hodgins N, Kang IG, Chang RK, Dailey Z, Daneshmand A, Kapadia A, Oh JH, Rodriguez B, Sehgal A, Sweeney M, Swisher CB, Childers DF, O'Connor C, Sequeira LM, Cho W. Gastric intestinal metaplasia development in African American predominant United States population. World J Gastrointest Endosc 2022; 14:597-607. [PMID: 36303812 PMCID: PMC9593516 DOI: 10.4253/wjge.v14.i10.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/01/2022] [Accepted: 09/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastric cancer significantly contributes to cancer mortality globally. Gastric intestinal metaplasia (GIM) is a stage in the Correa cascade and a premalignant lesion of gastric cancer. The natural history of GIM formation and progression over time is not fully understood. Currently, there are no clear guidelines on GIM surveillance or management in the United States.
AIM To investigate factors associated with GIM development over time in African American-predominant study population.
METHODS This is a retrospective longitudinal study in a single tertiary hospital in Washington DC. We retrieved upper esophagogastroduodenoscopies (EGDs) with gastric biopsies from the pathology department database from January 2015 to December 2020. Patients included in the study had undergone two or more EGDs with gastric biopsy. Patients with no GIM at baseline were followed up until they developed GIM or until the last available EGD. Exclusion criteria consisted of patients age < 18, pregnancy, previous diagnosis of gastric cancer, and missing data including pathology results or endoscopy reports. The study population was divided into two groups based on GIM status. Univariate and multivariate Cox regression was used to estimate the hazard induced by patient demographics, EGD findings, and Helicobacter pylori (H. pylori) status on the GIM status.
RESULTS Of 2375 patients who had at least 1 EGD with gastric biopsy, 579 patients were included in the study. 138 patients developed GIM during the study follow-up period of 1087 d on average, compared to 857 d in patients without GIM (P = 0.247). The average age of GIM group was 64 years compared to 56 years in the non-GIM group (P < 0.001). In the GIM group, adding one year to the age increases the risk for GIM formation by 4% (P < 0.001). Over time, African Americans, Hispanic, and other ethnicities/races had an increased risk of GIM compared to Caucasians with a hazard ratio (HR) of 2.12 (1.16, 3.87), 2.79 (1.09, 7.13), and 3.19 (1.5, 6.76) respectively. No gender difference was observed between the study populations. Gastritis was associated with an increased risk for GIM development with an HR of 1.62 (1.07, 2.44). On the other hand, H. pylori infection did not increase the risk for GIM.
CONCLUSION An increase in age and non-Caucasian race/ethnicity are associated with an increased risk of GIM formation. The effect of H. pylori on GIM is limited in low prevalence areas.
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Affiliation(s)
- Akram I Ahmad
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Arielle Lee
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Claire Caplan
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Colin Wikholm
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Ioannis Pothoulakis
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Zaynab Almothafer
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Nishtha Raval
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Samantha Marshall
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Ankit Mishra
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Nicole Hodgins
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - In Guk Kang
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Raymond K Chang
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Zachary Dailey
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Arvin Daneshmand
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Anjani Kapadia
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Jae Hak Oh
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Brittney Rodriguez
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Abhinav Sehgal
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Matthew Sweeney
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Christopher B Swisher
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Daniel F Childers
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Corinne O'Connor
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Lynette M Sequeira
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
| | - Won Cho
- Department of Internal Medicine, Georgetown University School of Medicine, Washington, DC 20007, United States
- Department of Gastroenterology and Hepatology, INOVA Medical System, Leesburg, VA 20176, United States
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Atiyah NS, Fadhil HY, Ad’hiah AH. Toll-like receptor 10 gene polymorphism and risk of multiple sclerosis among Iraqi patients. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Toll-like receptors (TLRs) are a family of 10 pattern recognition receptors (TLR1–TLR10) involved in the regulation of inflammatory and immune responses besides their role in the pathogenesis of autoimmune diseases including multiple sclerosis (MS). TLR10 is the least studied TLR in MS, and data for single nucleotide polymorphisms (SNPs) of the TLR10 gene are limited. Therefore, a case–control study was performed on 85 patients with relapsing–remitting MS and 86 healthy controls (HC) to explore SNPs in the promoter region of TLR10 gene. A 927-bp region was amplified, and Sanger sequencing identified 10 SNPs with a minor allele frequency ≥ 10% (rs200395112 T/A, rs201802754 A/T, rs201228097 T/A, rs113588825 G/A, rs10004195 T/A, rs10034903 C/G, rs10012016 G/A/C, rs10012017 G/T, rs33994884 T/Deletion [Del] and rs28393318 A/G).
Results
Del allele and T/Del genotype of rs33994884, as well as AG genotype of rs28393318, showed significantly lower frequencies in MS patients compared to HC. Allele and genotype frequencies of the 10 SNPs showed no significant differences between MS patients classified according to the Expanded Disability Status Scale. Haplotype analysis revealed that haplotype A-T-A-G-A-G-G-T-A showed a significantly increased frequency in MS patients compared to HC (odds ratio [OR] = 9.70; 95% confidence interval [CI] = 1.28–73.31; corrected probability [pc] = 0.03), while frequency of A-T-A-G-T-C-A-T-G haplotype was significantly decreased (OR = 0.10; 95% CI = 0.01–0.85; pc = 0.05).
Conclusions
The study indicated that two SNPs may influence susceptibility to MS (rs33994884 and rs28393318), but haplotype analysis of TLR10 gene SNPs was more informative.
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Esposito G, Dottori L, Pivetta G, Ligato I, Dilaghi E, Lahner E. Pernicious Anemia: The Hematological Presentation of a Multifaceted Disorder Caused by Cobalamin Deficiency. Nutrients 2022; 14:nu14081672. [PMID: 35458234 PMCID: PMC9030741 DOI: 10.3390/nu14081672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Pernicious anemia is still a neglected disorder in many medical contexts and is underdiagnosed in many patients. Pernicious anemia is linked to but different from autoimmune gastritis. Pernicious anemia occurs in a later stage of autoimmune atrophic gastritis when gastric intrinsic factor deficiency and consequent vitamin B12 deficiency may occur. The multifaceted nature of pernicious anemia is related to the important role of cobalamin, which, when deficient, may lead to several dysfunctions, and thus, the proteiform clinical presentations of pernicious anemia. Indeed, pernicious anemia may lead to potentially serious long-term complications related to micronutrient deficiencies and their consequences and the development of gastric cancer and type 1 gastric neuroendocrine tumors. When not recognized in a timely manner or when pernicious anemia is diagnosed with delay, these complications may be potentially life-threatening and sometimes irreversible. The current review aimed to focus on epidemiology, pathogenesis, and clinical presentations of pernicious anemia in an attempt to look beyond borders of medical specialties. It aimed to focus on micronutrient deficiencies besides the well-known vitamin B12 deficiency, the diagnostic approach for pernicious anemia, its long-term complications and optimal clinical management, and endoscopic surveillance of patients with pernicious anemia.
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7
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Yang H, Yang WJ, Hu B. Gastric epithelial histology and precancerous conditions. World J Gastrointest Oncol 2022; 14:396-412. [PMID: 35317321 PMCID: PMC8919001 DOI: 10.4251/wjgo.v14.i2.396] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/08/2021] [Accepted: 01/05/2022] [Indexed: 02/06/2023] Open
Abstract
The most common histological type of gastric cancer (GC) is gastric adenocarcinoma arising from the gastric epithelium. Less common variants include mesenchymal, lymphoproliferative and neuroendocrine neoplasms. The Lauren scheme classifies GC into intestinal type, diffuse type and mixed type. The WHO classification includes papillary, tubular, mucinous, poorly cohesive and mixed GC. Chronic atrophic gastritis (CAG) and intestinal metaplasia are recommended as common precancerous conditions. No definite precancerous condition of diffuse/poorly/undifferentiated type is recommended. Chronic superficial inflammation and hyperplasia of foveolar cells may be the focus. Presently, the management of early GC and precancerous conditions mainly relies on endoscopy including diagnosis, treatment and surveillance. Management of precancerous conditions promotes the early detection and treatment of early GC, and even prevent the occurrence of GC. In the review, precancerous conditions including CAG, metaplasia, foveolar hyperplasia and gastric hyperplastic polyps derived from the gastric epithelium have been concluded, based on the overview of gastric epithelial histological organization and its renewal.
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Affiliation(s)
- Hang Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wen-Juan Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Is intestinal metaplasia the point of no return in the progression of gastric carcinogenesis? Chin Med J (Engl) 2021; 134:2965-2967. [PMID: 34874672 PMCID: PMC8710313 DOI: 10.1097/cm9.0000000000001889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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9
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Shah SC, Piazuelo MB, Kuipers EJ, Li D. AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology 2021; 161:1325-1332.e7. [PMID: 34454714 PMCID: PMC8740554 DOI: 10.1053/j.gastro.2021.06.078] [Citation(s) in RCA: 145] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/09/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this Clinical Practice Update Expert Review is to provide clinicians with guidance on the diagnosis and management of atrophic gastritis, a common preneoplastic condition of the stomach, with a primary focus on atrophic gastritis due to chronic Helicobacter pylori infection-the most common etiology-or due to autoimmunity. To date, clinical guidance for best practices related to the diagnosis and management of atrophic gastritis remains very limited in the United States, which leads to poor recognition of this preneoplastic condition and suboptimal risk stratification. In addition, there is heterogeneity in the definitions of atrophic gastritis, autoimmune gastritis, pernicious anemia, and gastric neoplasia in the literature, which has led to confusion in clinical practice and research. Accordingly, the primary objective of this Clinical Practice Update is to provide clinicians with a framework for the diagnosis and management of atrophic gastritis. By focusing on atrophic gastritis, this Clinical Practice Update is intended to complement the 2020 American Gastroenterological Association Institute guidelines on the management of gastric intestinal metaplasia. These recent guidelines did not specifically discuss the diagnosis and management of atrophic gastritis. Providers should recognize, however, that a diagnosis of intestinal metaplasia on gastric histopathology implies the diagnosis of atrophic gastritis because intestinal metaplasia occurs in underlying atrophic mucosa, although this is often not distinctly noted on histopathologic reports. Nevertheless, atrophic gastritis represents an important stage with distinct histopathologic alterations in the multistep cascade of gastric cancer pathogenesis. METHODS The Best Practice Advice statements presented herein were developed from a combination of available evidence from published literature and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out. These statements are meant to provide practical advice to clinicians practicing in the United States. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Atrophic gastritis is defined as the loss of gastric glands, with or without metaplasia, in the setting of chronic inflammation mainly due to Helicobacter pylori infection or autoimmunity. Regardless of the etiology, the diagnosis of atrophic gastritis should be confirmed by histopathology. BEST PRACTICE ADVICE 2: Providers should be aware that the presence of intestinal metaplasia on gastric histology almost invariably implies the diagnosis of atrophic gastritis. There should be a coordinated effort between gastroenterologists and pathologists to improve the consistency of documenting the extent and severity of atrophic gastritis, particularly if marked atrophy is present. BEST PRACTICE ADVICE 3: Providers should recognize typical endoscopic features of atrophic gastritis, which include pale appearance of gastric mucosa, increased visibility of vasculature due to thinning of the gastric mucosa, and loss of gastric folds, and, if with concomitant intestinal metaplasia, light blue crests and white opaque fields. Because these mucosal changes are often subtle, techniques to optimize evaluation of the gastric mucosa should be performed. BEST PRACTICE ADVICE 4: When endoscopic features of atrophic gastritis are present, providers should assess the extent endoscopically. Providers should obtain biopsies from the suspected atrophic/metaplastic areas for histopathological confirmation and risk stratification; at a minimum, biopsies from the body and antrum/incisura should be obtained and placed in separately labeled jars. Targeted biopsies should additionally be obtained from any other mucosal abnormalities. BEST PRACTICE ADVICE 5: In patients with histology compatible with autoimmune gastritis, providers should consider checking antiparietal cell antibodies and anti-intrinsic factor antibodies to assist with the diagnosis. Providers should also evaluate for anemia due to vitamin B-12 and iron deficiencies. BEST PRACTICE ADVICE 6: All individuals with atrophic gastritis should be assessed for H pylori infection. If positive, treatment of H pylori should be administered and successful eradication should be confirmed using nonserological testing modalities. BEST PRACTICE ADVICE 7: The optimal endoscopic surveillance interval for patients with atrophic gastritis is not well-defined and should be decided based on individual risk assessment and shared decision making. A surveillance endoscopy every 3 years should be considered in individuals with advanced atrophic gastritis, defined based on anatomic extent and histologic grade. BEST PRACTICE ADVICE 8: The optimal surveillance interval for individuals with autoimmune gastritis is unclear. Interval endoscopic surveillance should be considered based on individualized assessment and shared decision making. BEST PRACTICE ADVICE 9: Providers should recognize pernicious anemia as a late-stage manifestation of autoimmune gastritis that is characterized by vitamin B-12 deficiency and macrocytic anemia. Patients with a new diagnosis of pernicious anemia who have not had a recent endoscopy should undergo endoscopy with topographical biopsies to confirm corpus-predominant atrophic gastritis for risk stratification and to rule out prevalent gastric neoplasia, including neuroendocrine tumors. BEST PRACTICE ADVICE 10: Individuals with autoimmune gastritis should be screened for type 1 gastric neuroendocrine tumors with upper endoscopy. Small neuroendocrine tumors should be removed endoscopically, followed by surveillance endoscopy every 1-2 years, depending on the burden of neuroendocrine tumors. BEST PRACTICE ADVICE 11: Providers should evaluate for iron and vitamin B-12 deficiencies in patients with atrophic gastritis irrespective of etiology, especially if corpus-predominant. Likewise, in patients with unexplained iron or vitamin B-12 deficiency, atrophic gastritis should be considered in the differential diagnosis and appropriate diagnostic evaluation pursued. BEST PRACTICE ADVICE 12: In patients with autoimmune gastritis, providers should recognize that concomitant autoimmune disorders, particularly autoimmune thyroid disease, are common. Screening for autoimmune thyroid disease should be performed.
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Affiliation(s)
- Shailja C. Shah
- Gastroenterology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California,Division of Gastroenterology, University of California, San Diego, La Jolla, California
| | - M. Blanca Piazuelo
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ernst J. Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Dan Li
- Department of Gastroenterology, Kaiser Permanente Northern California, Santa Clara, California,Division of Research, Kaiser Permanente Northern California, Oakland, California
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10
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Dilaghi E, Baldaro F, Pilozzi E, Conti L, Palumbo A, Esposito G, Annibale B, Lahner E. Pseudopyloric Metaplasia Is Not Associated With the Development of Gastric Cancer. Am J Gastroenterol 2021; 116:1859-1867. [PMID: 34313623 DOI: 10.14309/ajg.0000000000001390] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/24/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Corpus atrophic gastritis (CAG) is associated with intestinal metaplasia (IM) and pseudopyloric metaplasia (PPM). Prospective data on corpus mucosa PPM and its link to the development of gastric cancer (GC) are lacking. This study aimed to investigate the relationship between the presence of corpus mucosa PPM at baseline and the development of GC at follow-up in patients with CAG. METHODS A longitudinal cohort study was conducted on patients with consecutive CAG adhering to endoscopic-histological surveillance. Patients were stratified for the presence/absence of corpus PPM without concomitant corpus IM at baseline, and the occurrence of gastric neoplastic lesions at the longest available follow-up was assessed. RESULTS A total of 292 patients with CAG with a follow-up of 4.2 (3-17) years were included. At baseline, corpus PPM without corpus IM was diagnosed in 62 patients (21.2%). At the follow-up, GC was detected in 5 patients (1.7%) and gastric dysplasia (GD) in 4 patients (1.4%). In all these 9 patients with GC/GD at the follow-up, corpus IM was present at baseline and follow-up. Age <50 years (odds ratio [OR] 2.5), absence of pernicious anemia (OR 4.3), and absence of severe corpus atrophy (OR 2.3) were associated with corpus PPM without corpus IM. DISCUSSION At the 4.2-year follow-up, in patients with CAG characterized at baseline with corpus PPM without corpus IM, GC or GD was not observed because these lesions were consistently associated with corpus IM. Corpus PPM without corpus IM was associated with younger age, absence of pernicious anemia, and severe corpus atrophy, suggesting a lower stage of disease progression. Corpus PPM alone seems not to be associated with GC, whose development seems to require the presence of corpus IM as a necessary step.
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Affiliation(s)
- Emanuele Dilaghi
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Francesca Baldaro
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Emanuela Pilozzi
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Laura Conti
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Antonio Palumbo
- Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Gianluca Esposito
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
| | - Edith Lahner
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, University Sapienza, Rome, Italy
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Jonaitis P, Kupcinskas L, Kupcinskas J. Molecular Alterations in Gastric Intestinal Metaplasia. Int J Mol Sci 2021; 22:ijms22115758. [PMID: 34071181 PMCID: PMC8199079 DOI: 10.3390/ijms22115758] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 02/07/2023] Open
Abstract
Gastric cancer (GC) remains one of the most common causes of mortality worldwide. Intestinal metaplasia (IM) is one of the preneoplastic gastric lesions and is considered an essential predisposing factor in GC development. Here we present a review of recent most relevant papers to summarize major findings on the molecular alterations in gastric IM. The latest progress in novel diagnostic methods allows scientists to identify various types of molecular alterations in IM, such as polymorphisms in various genes, changes in the expression of micro-RNAs and long noncoding RNAs, and altered microbiome profiles. The results have shown that some of these alterations have strong associations with IM and a potential to be used for screening, treatment, and prognostic purposes; however, one of the most important limiting factors is the inhomogeneity of the studies. Therefore, further large-scale studies and clinical trials with standardized methods designed by multicenter consortiums are needed. As of today, various molecular alterations in IM could become a part of personalized medicine in the near future, which would help us deliver a personalized approach for each patient and identify those at risk of progression to GC.
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