Gastric endoscopy in the 21st century: appropriate use of an invasive procedure in the era of non-invasive testing

Abstract

Background: The acceptance of the premise that Helicobacter pylori infection is aetiologically related to gastric cancer and peptic ulcer and that the risk of gastric cancer among Helicobacter pylori infected individuals is related to the extent, severity and duration of atrophic gastritis has led to major changes in medical and endoscopic practices. The development of non-invasive methods to detect Helicobacter pylori and to estimate the extent and severity of gastritis has reduced the need for diagnostic endoscopy in asymptomatic individuals.

Methods and results: Here we provide recommendations regarding deciding whether non-invasive and endoscopic assessment of the gastric mucosa is preferred. We also include specific recommendations and caveats regarding the preferred biopsy number and sites as well as the identification of specimens, to allow the pathologist to reliable stage the severity and extent of gastritis, and thus provide prognostic information needed for patient managements (e.g., whether endoscopic surveillance is recommended).

Conclusion: In summary, while there is clearly a role for gastric endoscopy and endoscopic biopsy in the Helicobacter pylori era, obtaining useful diagnostic and prognostic information is critically dependent upon attention to detail with regard to biopsy site and identification as to the location from where the specimen was taken.

Figure 1

Schematic representation of the stomach from a gastric resection. The yellow area represents antral mucosa and its extension into the corpus as pseudopyloric metaplasia (see Figure 4). The hatched blue areas represent areas of intestinal metaplasia as multifocal intestinal metaplasia (see figure 3). The red areas are the sites where the gastric cancer was found on this patient (adapted from reference 9).

Figure 2

A. The stomach opened along the lesser curvature showing the different regions. B. Schematic representation of the spread of atrophic gastritis from the antrum to the corpus. C = closed-type and O = open type. The most extensive would be scored as O-3. C. An example of the atrophic border seen in a retroflexed view of the lesser curvature (score = C-2).

Figure 2

A. The stomach opened along the lesser curvature showing the different regions. B. Schematic representation of the spread of atrophic gastritis from the antrum to the corpus. C = closed-type and O = open type. The most extensive would be scored as O-3. C. An example of the atrophic border seen in a retroflexed view of the lesser curvature (score = C-2).

Figure 2

A. The stomach opened along the lesser curvature showing the different regions. B. Schematic representation of the spread of atrophic gastritis from the antrum to the corpus. C = closed-type and O = open type. The most extensive would be scored as O-3. C. An example of the atrophic border seen in a retroflexed view of the lesser curvature (score = C-2).

Figure 3

Methylene blue staining of the gastric mucosa showing multifocal intestinal metaplasia as the blue-staining mucosa scattered over the antral and corpus mucosa.

Figure 4

Gastric mucosal biopsy taken from the mid-corpus on the greater curve (site C-4, Figure 6) A. H&E staining showing pseudopyloric metaplasia with absence of parietal cells and B. Immunostaining for pepsinogen I confirming that the sample was from the corpus. Immunostaining for gastrin was negative (courtesy of Hala El-Zimaity, M.D.)

Figure 5

A and B show two different endoscopic appearances of intestinal metaplasia. The red and white alternating pappter (A) is the most easily recognized. Biopsy of either the red or white areas shows intestinal metaplasia. Intestinal metaplasia as seen in (B) is commonly confused with erosions. (C) shows intestinal metaplasia presenting as depressive erythema. The insert shows the site at high magnification.

Figure 5

A and B show two different endoscopic appearances of intestinal metaplasia. The red and white alternating pappter (A) is the most easily recognized. Biopsy of either the red or white areas shows intestinal metaplasia. Intestinal metaplasia as seen in (B) is commonly confused with erosions. (C) shows intestinal metaplasia presenting as depressive erythema. The insert shows the site at high magnification.

Figure 5

A and B show two different endoscopic appearances of intestinal metaplasia. The red and white alternating pappter (A) is the most easily recognized. Biopsy of either the red or white areas shows intestinal metaplasia. Intestinal metaplasia as seen in (B) is commonly confused with erosions. (C) shows intestinal metaplasia presenting as depressive erythema. The insert shows the site at high magnification.

Figure 6

Schematic representation of the stomach showing the preferred biopsy sites: 4 antral and corpus.

Figure 7

Endoscopic photograph of the distal corpus with the lesser curve on the right and the greater curve on the left. The gastric angle is seen in the distance on the right. The patient has severe atrophic gastritis with a clear demarcation of the atrophic border that has not yet fully involved the greater curvature.

Figure 8

Endoscopic appearance of the lesser curve of the corpus just proximal to the angularis with a Japanese type 0-IIc,Ul- gastric cancer emphasizing the importance of biopsy of any suspicious area [26].