Gastritis staging as a clinical priority

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

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

Analysis of gastrin-17 and its related influencing factors in physical examination results

BACKGROUND

To analyze the difference of serum gastrin-17 (G17) level in healthy people with different sex, age, and body mass index (BMI), to explore the correlation between G17 and pepsinogen, and to study the influences of Helicobacter pylori (H. pylori) infection and various inflammatory factors on G17 secretion level.

METHODS

A total of 531 subjects who received physical examination in our center from April 2019 to December 2019 were enrolled in the study. All subjects were tested for G17, pepsinogen I (PGI), pepsinogen II (PGII), PGI/PGII ratio (PGR), H. pylori, serum amyloid A (SAA), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The difference of G17 secretion in different subjects and its correlation with PG were analyzed to investigate H. pylori infection and expound the effects of inflammatory indicators on G17.

RESULTS

There was no significant difference in G17 secretion level in people with different sex, age and BMI (p > .05). G17 positively correlated with PGI and PGII, but negatively correlated with PGR. The G17 level of H. pylori-positive subjects was 10.16 ± 12.84, and prominently higher than that of H. pylori-negative subjects (3.27 ± 6.65). SAA and H. pylori infection were the greater risk factors for G17 abnormality among various indicators. CRP and ESR had no effect on G17 abnormality.

CONCLUSIONS

G17 secretion is closely related to PG and H. pylori. Combined screening contributes to early screening of gastrointestinal diseases in normal people or groups at high risk for gastric cancer, but the influence of inflammatory indicators on G17 should be excluded to improve the reliability of the results.

Endoscopic scoring system for gastric atrophy and intestinal metaplasia: correlation with OLGA and OLGIM staging: a single-center prospective pilot study in Korea

BACKGROUND/AIMS

We aimed to develop an endoscopic scoring system to evaluate gastric atrophy and intestinal metaplasia using narrow-band imaging (NBI) and near focus mode (NFM) to compare endoscopic scores with the Operative link for gastritis assessment (OLGA) and the Operative link for gastric intestinal metaplasia assessment (OLGIM).

METHODS

A total of 51 patients who underwent diagnostic esophagogastroduodenoscopy were prospectively enrolled and endoscopic scoring using NBI and NFM was performed. Four areas (the lesser and greater curvatures of the antrum and the lesser and greater curvature side of the corpus) were observed and biopsies were taken. The degree of atrophy was scored from 0 to 2 according to the Kimura-Takemoto classification. The degree of intestinal metaplasia was scored from 0 to 4 according to the location and the extent of the intestinal metaplasia.

RESULTS

The correlation coefficient for atrophy between the endoscopic and histologic scores was 0.70 (95% CI: 0.52-0.81 p < .001) and for intestinal metaplasia, it was 0.75 (95% CI: 0.60-0.85; p < .001). For atrophic gastritis, an endoscopic score >1 correlated with OLGA stage III and IV with a sensitivity, specificity, positive predictive value, negative predictive value, and agreement of 88, 74, 75, 87, and 80.4%, respectively, and for intestinal metaplasia, an endoscopic score >1 correlated with high OLGIM stage III and IV with 100, 59, 69, 100, and 78.4%, respectively.

CONCLUSIONS

Endoscopic scoring for gastric atrophy and intestinal metaplasia using NBI-NFM likely correlates with histologic staging in Korea, a high-risk region for gastric cancer.

Gastritis: The clinico-pathological spectrum

The inflammatory spectrum of gastric diseases includes different clinico-pathological entities, the etiology of which was recently established in the international Kyoto classification. A diagnosis of gastritis combines the information resulting form the gross examination (endoscopy) and histology (microscopy). It is important to consider the anatomical/functional heterogeneity of the gastric mucosa when obtaining representative mucosal biopsy samples. Gastritis includes self-limiting and non-self-limiting (long-standing) inflammatory diseases, and the latter are epidemiologically, biologically and clinically linked to the onset of gastric cancer (i.e. "inflammation-associated cancer"). Different biological models of inflammation-associated gastric oncogenesis have been proposed. Helicobacter pylori (H. pylori) gastritis is the most prevalent worldwide, and H. pylori is classified as a first-class carcinogen. On these bases, eradicating H. pylori is mandatory for the primary prevention of gastric cancer. Non-self-limiting gastritis may also be triggered by the immune-mediated destruction of gastric parietal cells, resulting in autoimmune gastritis. In both H. pylori-related and autoimmune gastritis, the non-self-limiting inflammation results in atrophy of the gastric mucosa, which is the main factor promoting gastric cancer. Long-term follow-up studies consistently demonstrate the prognostic impact of the histological staging of gastritis in gastric cancer secondary prevention strategies.

Chronic atrophic gastritis: an update on diagnosis

Background and aim

Atrophic gastritis is a precancerous gastric lesion, therefore its early detection is a priority in preventing gastric cancer. The aim of the present paper is to develop a narrative synthesis of the present knowledge on diagnostic methods of chronic atrophic gastritis.

Methods

A literature search was carried out on main databases: PubMed, Hinari, SpringerLink and Scopus (Elsevier) for the period 2000–2020. The searched keywords were: chronic atrophic gastritis, intestinal metaplasia and dysplasia + diagnosis. Inclusion criteria were focused on the articles about the invasive and non-invasive diagnosis of chronic atrophic gastritis and of precancerous gastric lesions, intestinal metaplasia and dysplasia; exclusion criteria were articles published before 2000 and those that did not include the proposed theme.

Results

The search returned 575 papers addressing the topic of precancerous lesions. From these, 60 articles were qualified representative for the materials published on the topic of this synthesis article, being those that met the inclusion criteria. The data emphasize the need to use upper digestive endoscopy with biopsies for the diagnosis of chronic atrophic gastritis. However serological diagnosis is available as alternative mainly recommended in follow up.

Conclusions

There are two main methodological approaches for the evaluation of chronic atrophic gastritis as a precancerous gastric lesions: invasive examination, which requires histological analysis of biopsy samples taken during upper digestive endoscopy, being the “gold standard” for diagnosis, and non-invasive serological examination using markers of gastric function.

PGC-MG7 combination could be used as a follow-up panel for monitoring dynamical progression of gastric precancerous diseases

Objective

The aim of this study was to investigate the value of the combined expression of the gastric mucosal differentiation protein pepsinogen C (PGC) and gastric cancer (GC)-associated antigen MG7 for the diagnosis of GC and prediction of the development from precancerous conditions to GC.

Methods

The gastric mucosal biopsies of 285 subjects enrolled from a region with a high incidence of GC were obtained and histopathologically examined. Subjects testing negative for GC (n=208) were followed up from 1998 to 2015. The levels of PGC and MG7 in the biopsies were determined by immunohistochemistry.

Results

PGC was positive in 91.4% of the non-atrophic gastritis, 26.5% of the atrophic gastritis, and 0% of the GC. MG7 was positive in 15.0% of the non-atrophic gastritis, 82.4% of the atrophic gastritis, and 94.8% of the GC. The non-atrophic gastritis group was predominantly “PGC+MG7−”. The atrophic gastritis and GC groups were predominantly “PGC−MG7+”. The rate of GC in subjects with “PGC−MG7+” staining was 113.4-fold higher [95% confidence interval (95% CI): 15.3−869.4, P<0.001] than that in subjects with other staining patterns. The sensitivity and specificity of the “PGC−MG7+” pattern were 92.2% and 78.8% for the detection of GC and 77.2% and 97.9% for GC and precancerous disease, respectively. In the follow-up cohort of non-GC subjects, the risk of developing GC was higher in those with the “PGC−MG7+” staining pattern.

Conclusions

Our data suggest that the “PGC−MG7+” pattern can be employed as a useful follow-up panel for detecting individuals with a high risk of GC, and the dynamic assessment of the follow-up panel needs multi-centre large-scale validation in the future.

Gastric cancer prevention targeted on risk assessment: Gastritis OLGA staging

Gastric cancer (GC) ranks among the most lethal epithelial malignancies, and its striking mortality rate prompts a global prevention strategy. Helicobacter pylori (H. pylori) gastritis is the main GC promoter, and the 2014 Global Kyoto conference recognized H. pylori gastritis as a (treatable) infectious disease. It is therefore plausible that any large-scale intervention for H. pylori eradication would result in cleansing the world of the fifth cause of cancer-related death. Atrophic gastritis is the cancerization field in which GCs (both intestinal and diffuse histotypes) mainly develop. Discontinuing the inflammatory cascade triggered by H. pylori is tantamount to preventing GC. For patients (still infected or eradicated) who have already developed gastric atrophy, the severity/topography of the atrophic changes correlates with their cancer risk. Gastritis OLGA (Operative Link for Gastritis Assessment) staging consistently ranks the atrophy-associated cancer risk, providing a solid clinical/biological rationale for establishing patient-specific surveillance programs. By combining primary and secondary prevention strategies, gastric cancer is a preventable disease.

OLGA Gastritis Staging for the Prediction of Gastric Cancer Risk: A Long-term Follow-up Study of 7436 Patients

OBJECTIVES

Gastritis OLGA-staging ranks the risk for gastric cancer (GC) in progressive stages (0-IV). This long-term follow-up study quantifies the GC risk associated with each OLGA stage.

METHODS

Consecutive patients (7436) underwent esophagogastroscopy (T-0), with mapped gastric biopsies, OLGA staging, and H. pylori status assessment. Patients with neoplastic lesion (invasive or non-invasive) at the index endoscopy (and/or within 12 months) were excluded. All patients were followed-up (T-1) by combining different sources of clinical/pathological information (Regional Registries of: (i) esophagogastroduodenoscopies; (ii) pathology reports; (iii) cancer, (iv) mortality). The endpoint was histologically documented development of gastric epithelial neoplasia.

RESULTS

At T-0, the patients' distribution by OLGA stage was: Stage 0 = 80.8%; Stage I = 12.6%; Stage II = 4.3%; Stage III = 2.0%; Stage IV = 0.3%; H. pylori infection was detected in 25.9% of patients. At the end of the follow-up (mean/median = 6.3/6.6 years), 28 incident neoplasia were documented (overall prevalence = 0.60 per 10³/person-years; low-grade intraepithelial neoplasia = 17/28; high-grade intraepithelial neoplasia = 4/28; GC = 7/28). By OLGA stage at the enrollment, the rate of incident neoplasia was: Stage 0 = 1 case; rate/10³ person-years = 0.03; 95%CI: 0.004-0.19; Stage I = 2 cases; rate/10³ person-years = 0.34; 95%CI: 0.09-1.36; Stage II = 3 cases; rate/10³ person-years = 1.48; 95%CI: 0.48-4.58; Stage III = 17 cases; rate/10³ person-years = 19.1; 95%CI: 11.9-30.7; Stage IV = 5 cases; rate/10³ person-years = 41.2; 95%CI: 17.2-99.3. Multivariate analysis including gender, age, H. pylori status, and OLGA stage at enrollment only disclosed OLGA stage as predictor of neoplastic progression (OLGA stage III: HR = 712.4, 95%CI = 92.543-5484.5; OLGA stage IV: HR = 1450.7, 95%CI = 166.7-12626.0).

CONCLUSIONS

Among 7436 patients, OLGA stages at the enrollment correlated significantly with different risk for gastric neoplasia. Based on the obtained results, gastritis staging is a critical adjunct in endoscopy follow-up protocols aimed at GC secondary prevention.

Correlation between serum vitamin B12 level and peripheral neuropathy in atrophic gastritis

AIM

To explore the correlation between serum vitamin B12 level and peripheral neuropathy in patients with chronic atrophic gastritis (CAG).

METHODS

A total of 593 patients diagnosed with chronic gastritis by gastroscopy and pathological examination from September 2013 to September 2016 were selected for this study. The age of these patients ranged within 18- to 75-years-old. Blood pressure, height and weight were measured in each patient, and the body mass index value was calculated. Furthermore, gastric acid, serum gastrin, serum vitamin and serum creatinine tests were performed, and peripheral nerve conduction velocity and Helicobacter pylori (H. pylori) were detected. In addition, the type of gastritis was determined by gastroscopy. The above factors were used as independent variables to analyze chronic gastritis with peripheral neuropathy and vitamin B12 deficiency risk factors, and to analyze the relationship between vitamin B12 levels and peripheral nerve conduction velocity. In addition, in the treatment of CAG on the basis of vitamin B12, patients with peripheral neuropathy were observed.

RESULTS

Age, H. pylori infection, CAG, vitamin B9 and vitamin B12 were risk factors for the occurrence of peripheral nerve degeneration. Furthermore, CAG and H. pylori infection were risk factors for chronic gastritis associated with vitamin B12 deficiency. Serum vitamin B12 level was positively correlated with sensory nerve conduction velocity in the tibial nerve (R = 0.463). After vitamin B12 supplementation, patients with peripheral neuropathy improved.

CONCLUSION

Serum vitamin B12 levels in patients with chronic gastritis significantly decreased, and the occurrence of peripheral neuropathy had a certain correlation. CAG and H. pylori infection are risk factors for vitamin B12 deficiency and peripheral neuropathy. When treating CAG, vitamin B12 supplementation can significantly reduce peripheral nervous system lesions. Therefore, the occurrence of peripheral neuropathy associated with vitamin B12 deficiency may be considered in patients with CAG. Furthermore, the timely supplementation of vitamin B12 during the clinical treatment of CAG can reduce or prevent peripheral nervous system lesions.