Regular arrangement of collecting venules: Does patient age affect its accuracy?

Predicting Helicobacter pylori infection from endoscopic features

BACKGROUND

Helicobacter pylori infection, prevalent in more than half of the global population, is associated with various gastrointestinal diseases, including peptic ulcers and gastric cancer. The effectiveness of early diagnosis and treatment in preventing gastric cancer highlights the need for improved diagnostic methods. This study aimed to develop a simple scoring system based on endoscopic findings to predict H. pylori infection.

METHODS

A retrospective analysis was conducted on 1,007 patients who underwent upper gastrointestinal endoscopy at Asan Medical Center from January 2019 to December 2021. Exclusion criteria included prior H. pylori treatment, gastric surgery, or gastric malignancies. Diagnostic techniques included rapid urease and 13C-urea breath tests, H. pylori culture, and assessment of endoscopic features following the Kyoto gastritis classification. A new scoring system based on endoscopic findings including regular arrangement of collecting venules (RAC), nodularity, and diffuse or spotty redness was developed for predicting H. pylori infection, utilizing logistic regression analysis in the development set.

RESULTS

The scoring system demonstrated high predictive accuracy for H. pylori infection in the validation set. Scores of 2 and 3 were associated with 96% and 99% infection risk, respectively. Additionally, there was a higher prevalence of diffuse redness and sticky mucus in cases where the initial H. pylori eradication treatment failed.

CONCLUSION

Our scoring system showed potential for improving diagnostic accuracy in H. pylori infection. H. pylori testing should be considered upon spotty redness, diffuse redness, nodularity, and RAC absence on endoscopic findings as determined by the predictive scoring system.

Regular arrangement of collecting venules (RAC) as an endoscopic marker for exclusion of Helicobacter pylori (H. pylori) infection: A systematic review and meta-analysis

BACKGROUND

Helicobacter pylori (H. pylori) is the most common cause of gastric cancer. Growing evidence suggests that the regular arrangement of collecting venules (RAC) can be used as an endoscopic marker to diagnose H. pylori infection. However, data on the diagnostic accuracy of RAC for H. pylori infection are conflicting. We performed a systematic review and meta-analysis of relevant studies to determine the diagnostic accuracy and clinical utility of RAC for the diagnosis of H. pylori infection.

METHODS

We systematically searched PubMed, Embase, Web of Science and the Cochrane Library between inception and Oct 29, 2020, for studies that assessed the diagnostic accuracy of RAC for H. pylori infection.

RESULTS

The literature search yielded 2921 non-duplicated screened titles, of which 58 underwent full-text review. Fifteen studies, representing a total of 6621 patients, met the inclusion criteria. The area under the summary receiver operating characteristic curve was 0.98 (95% CI 0.96-0.99). The pooled estimates for RAC were 0.98 (95% CI 0.95-0.99) for sensitivity and 0.75 (95% CI 0.54-0.88) for specificity. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 3.8 (95% CI 1.9-7.7) and 0.03 (95% CI 0.02-0.07), respectively.

CONCLUSIONS

RAC can be used as an endoscopic marker for exclusion of H. pylori infection. However, it cannot be recommended as a single indicator for the confirmation of H. pylori infection. The conclusion of this study should be treated with caution because significant heterogeneity exists between the evaluated studies.

Association between regular arrangement of collecting venules and Helicobacter pylori status in routine endoscopy

Background

The sensitivity of regular arrangement of collecting venules (RAC)-positive pattern for predicting Helicobacter pylori (H. pylori)-negative status greatly altered from 93.8 to 48.0% in recent two decades of various studies, while the reason behind it remained obscure. The aim of this study was to investigate the value of RAC as an endoscopic feature for judging H. pylori status in routine endoscopy and reviewed the underlying mechanism.

Methods

A prospective study with high-definition non-magnifying endoscopy was performed. RAC-positive and RAC-negative patients were classified according to the collecting venules morphology of the lesser curvature in gastric corpus. Gastric biopsy specimens were obtained from the lesser and greater curvature of corpus with normal RAC-positive or abnormal RAC-negative mucosal patterns. Helicobacter pylori status was established by hematoxylin and eosin staining and immunohistochemistry.

Results

41 RAC-positive and 124 RAC-negative patients were enrolled from June 2020 to September 2020. The prevalence of H. pylori infection in patients with RAC-positive pattern and RAC-negative pattern was 7.3% (3/41) and 71.0% (88/124), respectively. Among all 124 RAC-negative patients, 36 (29.0%) patients were H. pylori-negative status. Ten patients (32.3%) demonstrated RAC-positive pattern in 31 H. pylori-eradicated cases. The sensitivity, specificity, positive predictive value, and negative predictive value of RAC-positive pattern for predicting H. pylori-negative status were 51.4% (95% CI, 0.395–0.630), 96.7% (95% CI, 0.900–0.991), 92.7% (95% CI, 0.790–0.981), and 71.0% (95% CI, 0.620–0.786), respectively.

Conclusions

RAC presence can accurately rule out H. pylori infection of gastric corpus, and H. pylori-positive status cannot be predicted only by RAC absence in routine endoscopy.

Trial registration The present study is a non-interventional trial.

Assessment of Helicobacter pylori status by examination of gastric mucosal patterns: diagnostic accuracy of white-light endoscopy and narrow-band imaging

Objectives

Helicobacter pylori infection is a common cause of chronic gastritis worldwide and an established risk factor for developing gastric malignancy. The endoscopic appearances predicting H. pylori status are an ongoing area of research, as are their diagnostic accuracies. This study aimed to establish the diagnostic accuracy of several mucosal features predictive of H. pylori negative status and formulate a simple prediction model for use at the time of endoscopy.

Design

Patients undergoing high-definition upper gastrointestinal (GI) endoscopy without magnification were recruited prospectively. During the endoscopy, the presence or absence of specific endoscopic findings was noted. Sydney protocol biopsies were used as the diagnostic reference standard, and urease test if taken. The results informed a logistic regression model used to produce a simple diagnostic approach. This model was subsequently validated using a further cohort of 30 patients.

Results

153 patients were recruited and completed the study protocol. The prevalence of active H. pylori infection was 18.3% (28/153). The overall diagnostic accuracy of the simple prediction model was 80.0%, and 100% of patients with active H. pylori infection were correctly classified. The presence of regular arrangement of collecting venules (RAC) showed a positive predictive value for H. pylori naïve status of 90.7%, rising to 93.6% for patients under the age of 60.

Conclusion

A simple endoscopic model may be accurate for predicting H. pylori status of a patient, and the need for biopsy-based tests. The presence of RAC in the stomach is an accurate predictor of H. pylori negative status, particularly in patients under the age of 60.

Trial registration number

The study was registered with ClinicalTrials.gov, No. NCT02385045.

Diagnosis of Helicobacter pylori Infection by the Arrangement of Collecting Venules Using White Light Endoscopy: Evaluation of Interobserver Agreement

BACKGROUND

Regular arrangement of collecting venules (RAC) in gastric mucosa accurately identifies patients without Helicobacter pylori (H pylori) infection. The aim of our study was to evaluate the reproducibility of RAC using white light endoscopy without magnification, in a European country, and to assess the impact of proton pump inhibitors (PPIs).

METHODS

A multicenter prospective study with image capture of the distal lesser gastric curvature and gastric biopsies was performed. The presence of starfish-like minute points regularly distributed throughout lesser curvature was considered as RAC positive (RAC+). A set of 20 images was used for the training phase and inter and intra-observer agreements were calculated.

RESULTS

174 patients were included and 85 (48.9%) were taking PPIs. Kappa values for interobserver and intra-observer agreements were substantial (0.786) and excellent (0.906), respectively. H. pylori infection was diagnosed in 29 patients (16.7%): 10/85 with PPIs and 19/89 without PPIs (11.8% vs. 21.3%; p = 0.09). All RAC + patients were free of H. pylori infection, with a sensitivity and negative predictive value of 100%, regardless of PPI intake.

CONCLUSION

The endoscopic diagnosis of H. pylori by RAC is an easy-to-learn and highly reproducible technique, even with PPI intake. Our results warrant RAC as a real-time diagnostic method for H. pylori-negative infection in Western practice.

The endoscopic predictors of Helicobacter pylori status: a meta-analysis of diagnostic performance

Objective:

The endoscopic findings associated with Helicobacter pylori–naïve status, current infection or past infection are an area of ongoing interest. Previous studies have investigated parameters with a potential diagnostic value. The aim of this study was to perform meta-analysis of the available literature to validate the diagnostic accuracy of mucosal features proposed in the Kyoto classification.

Data sources:

The databases of MEDLINE and Embase, clinicalTrials.gov and the Cochrane Library were systematically searched for relevant studies from October 1999 to October 2019.

Methods:

A bivariate random effects model was used to produce pooled diagnostic accuracy calculations for each of the studied endoscopic findings. Diagnostic odds ratios and sensitivity and specificity characteristics were calculated to identify significant predictors of H pylori status.

Results:

Meta-analysis included 4380 patients in 15 studies. The most significant predictor of an H pylori-naïve status was a regular arrangement of collecting venules (diagnostic odds ratio 55.0, sensitivity 78.3%, specificity 93.8%). Predictors of active H pylori infection were mucosal oedema (18.1, 63.7%, 91.1%) and diffuse redness (14.4, 66.5%, 89.0%). Map-like redness had high specificity for previous H pylori eradication (99.0%), but poor specificity (13.0%).

Conclusion:

The regular arrangement of collecting venules, mucosal oedema, diffuse redness and map-like redness are important endoscopic findings for determining H pylori status. This meta-analysis provides a tentative basis for developing future endoscopic classification systems.

Regular arrangement of collecting venules under endoscopy for predicting a Helicobacter pylori-negative stomach: A systematic review and meta-analysis

BACKGROUND AND AIMS

The regular arrangement of collecting venules (RAC) refers to the appearance of multiple regular tiny veins in the body of the stomach and is considered to be very effective for identifying gastric mucosa with non-Helicobacter pylori infection. This meta-analysis was conducted to systematically evaluate the value of the sign in predicting a Helicobacter pylori-negative stomach and the relevant factors that may affect the performance of this prediction.

METHODS

Two biomedical databases (PubMed and EMBASE) were systematically searched through April 20, 2020. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the SROC curve (AUC) were calculated.

RESULTS

Fourteen articles with 4070 patients were included. The pooled sensitivity, specificity, PLR, NLR, DOR and AUC for the RAC in predicting non-Hp infection were 0.80 (0.67-0.89), 0.97 (0.93-0.98), 24.8 (12.2-50.8), 0.21 (0.12-0.36), 120 (47-301) and 0.97 (0.19-1.00), respectively.

CONCLUSIONS

The RAC is a valuable endoscopic feature for the prediction of patients without Hp 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.

A systematic review of the role of non-magnified endoscopy for the assessment of H. pylori infection

Background and study aims  There is growing interest in the endoscopic recognition of Helicobacter pylori infection, and application to routine practice. We present a systematic review of the current literature regarding diagnosis of H. pylori during standard (non-magnified) endoscopy, including adjuncts such as image enhancement and computer-aided diagnosis. Method  The Medline and Cochrane databases were searched for studies investigating performance of non-magnified optical diagnosis for H. pylori , or those which characterized mucosal features associated with H. pylori infection. Studies were preferred with a validated reference test as the comparator, although they were included if at least one validated reference test was used. Results  Twenty suitable studies were identified and included for analysis. In total, 4,703 patients underwent investigation including white light endoscopy, narrow band imaging, i-scan, blue-laser imaging, and computer-aided diagnostic techniques. The endoscopic features of H. pylori infection observed using each modality are discussed and diagnostic accuracies reported. The regular arrangement of collecting venules (RAC) is an important predictor of the H. pylori -naïve stomach. "Mosaic" and "mottled" patterns have a positive association with H. pylori infection. The "cracked" pattern may be a predictor of an H. pylori- negative stomach following eradication. Conclusions  This review summarizes current progress made in endoscopic diagnosis of H. pylori infection. At present there is no single diagnostic approach that provides validated diagnostic accuracy. Further prospective studies are required, as is development of a validated classification system. Early studies in computer-aided diagnosis suggest potential for a high level of accuracy but real-time results are awaited.

Association between a regular arrangement of collecting venules and absence of Helicobacter pylori infection in a European population

BACKGROUND AND AIMS

Helicobacter pylori is the major cause of gastritis and gastritis-associated diseases. Detection of a regular arrangement of collecting venules (RAC) in the lesser gastric curvature correlates with negative H pylori status with a sensitivity and negative predictive value (NPV) higher than 90% in Asian countries. The aim of the study was to evaluate the value of RAC as a diagnostic method of H pylori infection in a European population.

METHODS

A prospective study with high-definition endoscopes without magnification was performed by 3 endoscopists. The presence of starfish-like minute points regularly distributed throughout the lesser curvature of the gastric body was considered RAC positive (RAC+). Gastric biopsies were performed during the procedure for H pylori diagnosis.

RESULTS

One hundred forty patients were included from February 2017 to May 2018. The prevalence of H pylori infection was 31% and 47 of 140 patients (34%) were RAC+; 13 of 23 patients in whom H pylori was eradicated were RAC+. The mean age of RAC+ patients was lower (44.4 vs 52.4 years, P = .004) and they had less- significant endoscopic findings (9; 19.1% vs 38; 80.9%; P = .017). Gender, use of nonsteroidal anti-inflammatory drugs, antithrombotic or anticoagulants treatments, and a history of H pylori eradication did not show differences in the RAC pattern. The absence of RAC was associated with H pylori infection in 47.3% (44/93) of cases. In contrast, all RAC+ patients were free of H pylori infection, with sensitivity and NPV of 100% for the exclusion of H pylori infection.

CONCLUSION

The presence of RAC+ in the lesser curvature evaluated with high-definition endoscopy can accurately identify patients without H pylori.

Irregular arrangement of collecting venules (IRAC) provides a critical endoscopic insight in Helicobacter pylori-induced gastritis: A secondary publication

The aim of this study was to evaluate the significance of an endoscopic atrophic border and irregular arrangement of collecting venules (IRAC) in the diagnosis of Helicobacter pylori (H. pylori)-induced gastritis. Upper gastrointestinal tract endoscopy was performed on 723 patients, who were screened them for H. pylori infection. Any patients who had undergone H. pylori eradication therapy were excluded from the study. The endoscopic atrophic border and IRAC in each patient were assessed. The H. pylori status was determined in the patients by combination of a serological test and/or histopathological examination. The H. pylori infection rates were 95.4% (455/477) in the group with an endoscopic atrophic border and 22.3% (55/246) in the group without an endoscopic atrophic border. In the diagnostic validity check, presence of an endoscopic atrophic border had a sensitivity of 89.2% and a specificity of 89.7%. Furthermore, the H. pylori infection rates were 95.5% (506/530) in the IRAC group and 2.1% (4/193) in the regular arrangement of collecting venules (RAC) group. In the diagnostic validity check, IRAC had a sensitivity of 99.2% and a specificity of 88.7%. In conclusion, the presence of an endoscopic atrophic border and IRAC are highly indicative of an H. pylori-infected gastric mucosa.