Two Atypical Cases of Nodular Gastritis: A Poorly Differentiated Gastric Adenocarcinoma and a Pseudo-Low Grade Gastric MALT Lymphoma

Endoscopic findings of Helicobacter pylori gastritis in children and young adults based on the Kyoto classification of gastritis and age-associated changes

Background and Aim

We aimed to evaluate endoscopic findings of Helicobacter pylori (H. pylori)-positive children and young adults based on the Kyoto classification, and to examine if there are age-associated changes in H. pylori-positive gastritis.

Methods

H. pylori-positive patients under 40 years old who underwent upper gastrointestinal endoscopy from 1 April 2009 to 15 February 2017 were included. Subjects were classified into the Pediatric (<20 years) and Young adult groups (20-39 years). The patients' endoscopic photographs were retrospectively re-evaluated based on the Kyoto classification. We compared endoscopic findings between the two groups and examined alterations in the findings of H. pylori-associated gastritis in 5-year age groups.

Results

Forty-three and 163 subjects were classified into the Pediatric and Young adult groups, respectively. In the Pediatric group, nodularity was seen in the majority (93.0%); other endoscopic findings in order of decreasing frequency included mucosal swelling (32.6%), spotty redness (25.6%), diffuse redness (18.6%), and atrophy (9.3%). In the Young adult group, endoscopic findings included atrophy (66.9%), mucosal swelling (49.7%), spotty redness (39.3%), nodularity (31.9%), and diffuse redness (30.3%). The difference in prevalence of nodularity or atrophy between the two groups reached statistical significance (P < 0.0001 each). The rate of nodularity decreased with increasing age in the Young adult group. The rate of atrophy was 33% in young adult patients aged 20-24, and the rate increased to >65% in patients over age 25.

Conclusion

H. pylori-positive children had endoscopic findings besides nodularity based on the Kyoto classification. The prevalence of atrophy increased in patients over age 20.

Two cases of gastric mucosa-associated lymphoid tissue (MALT) lymphoma masquerading as follicular gastritis

In this report, we describe two cases of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach, which presented with multiple small, whitish nodules in the gastric body. The endoscopic appearance was similar to that of lymphoid follicular hyperplasia found in follicular gastritis or nodular gastritis. Both patients were positive for Helicobacter pylori, and the eradication treatment resulted in complete remission of the lymphoma. However, recurrence was noted in one patient. These cases indicate that, although infrequent, gastric MALT lymphoma can show a nodular appearance resembling that of follicular gastritis.

Nodule Regression in Adults With Nodular Gastritis

Background

Nodular gastritis (NG) is associated with the presence of Helicobacter pylori infection, but there are controversies on nodule regression in adults. The aim of this study was to analyze the factors that are related to the nodule regression in adults diagnosed as NG.

Methods

Adult population who were diagnosed as NG with H. pylori infection during esophagogastroduodenoscopy (EGD) at our center were included. Changes in the size and location of the nodules, status of H. pylori infection, upper gastrointestinal (UGI) symptom, EGD and pathology findings were analyzed between the initial and follow-up tests.

Results

Of the 117 NG patients, 66.7% (12/18) of the eradicated NG patients showed nodule regression after H. pylori eradication, whereas 9.9% (9/99) of the non-eradicated NG patients showed spontaneous nodule regression without H. pylori eradication (P < 0.001). Nodule regression was more frequent in NG patients with antral nodule location (P = 0.010), small-sized nodules (P = 0.029), H. pylori eradication (P < 0.001), UGI symptom (P = 0.007), and a long-term follow-up period (P = 0.030). On the logistic regression analysis, nodule regression was inversely correlated with the persistent H. pylori infection on the follow-up test (odds ratio (OR): 0.020, 95% confidence interval (CI): 0.003 - 0.137, P < 0.001) and short-term follow-up period < 30.5 months (OR: 0.140, 95% CI: 0.028 - 0.700, P = 0.017).

Conclusions

In adults with NG, H. pylori eradication is the most significant factor associated with nodule regression. Long-term follow-up period is also correlated with nodule regression, but is less significant than H. pylori eradication. Our findings suggest that H. pylori eradication should be considered to promote nodule regression in NG patients with H. pylori infection.

Current progress toward eradicating Helicobacter pylori in East Asian countries: Differences in the 2013 revised guidelines between China, Japan, and South Korea

New 2013 guidelines on Helicobacter pylori (H. pylori) infection have been published in China, Japan, and South Korea. Like the previous ones, these new guidelines differ between the three countries with regard to the indications for H. pylori eradication, diagnostic methods, and treatment regimens. The most profound change among all of the guidelines is that the Japanese national health insurance system now covers the expenses for all infected subjects up to second-line treatment. This makes the Japanese indications for eradication much wider than those in China and South Korea. With regard to the diagnosis, a serum H. pylori antibody test is not recommended in China, whereas it is considered to be the most reliable method in Japan. A decrease relative to the initial antibody titer of more than 50% after 6-12 mo is considered to be the most accurate method for determining successful eradication in Japan. In contrast, only the urea breath test is recommended after eradication in China, while either noninvasive or invasive methods (except the bacterial culture) are recommended in South Korea. Due to the increased rate of antibiotics resistance, first-line treatment is omitted in China and South Korea in cases of clarithromycin resistance. Notably, the Japanese regimen consists of a lower dose of antibiotics for a shorter duration (7 d) than in the other countries. There is neither 14 d nor bismuth-based regimen in the first-line and second-line treatment in Japan. Such differences among countries might be due to differences in the approvals granted by the governments and national health insurance system in each country. Further studies are required to achieve the best results in the diagnosis and treatment of H. pylori infection based on cost-effectiveness in East Asian countries.