Helicobacter pylori-induced inflammation masks the underlying presence of low-grade dysplasia on gastric lesions

Abstract

Background: Helicobacter pylori (H. pylori) infection has been associated with a long-term risk of precancerous gastric conditions (PGC) even after H. pylori eradication.

Aim: To investigate the efficacy of High-Resolution White-Light Endoscopy with Narrow-Band Imaging in detecting PGC, before/after H. pylori eradication.

Methods: We studied 85 consecutive patients with H. pylori-related gastritis with/without PGC before and 6 mo after proven H. pylori eradication. Kimura-Takemoto modified and endoscopic grading of gastric intestinal metaplasia classifications, were applied to assess the endoscopic extension of atrophy and intestinal metaplasia. The histological result was considered to be the gold standard. The Sydney System, the Operative-Link on Gastritis-Assessment, and the Operative-Link on Gastric-Intestinal Metaplasia were used for defining histological gastritis, atrophy and intestinal metaplasia, whereas dysplasia was graded according to World Health Organization classification. Serum anti-parietal cell antibody and anti-intrinsic factor were measured when autoimmune atrophic gastritis was suspected.

Results: After H. pylori eradication histological signs of mononuclear/polymorphonuclear cell infiltration and Mucosal Associated Lymphoid Tissue-hyperplasia, disappeared or decreased in 100% and 96.5% of patients respectively, whereas the Operative-Link on Gastritis-Assessment and Operative-Link on Gastric-Intestinal Metaplasia stages did not change. Low-Grade Dysplasia prevalence was similar on random biopsies before and after H. pylori eradication (17.6% vs 10.6%, P = 0.19), but increased in patients with visible lesions (0% vs 22.4%, P < 0.0001). At a multivariate analysis, the probability for detecting dysplasia after resolution of H. pylori-related active inflammation was higher in patients with regression or reduction of Mucosal Associated Lymphoid Tissue hyperplasia, greater alcohol consumption, and anti-parietal cell antibody and/or anti-intrinsic factor positivity [odds ratio (OR) = 3.88, 95% confidence interval (CI): 1.31-11.49, P = 0.01; OR = 3.10, 95%CI: 1.05-9.12, P = 0.04 and OR = 5.47, 95%CI: 1.33-22.39, P < 0.04, respectively].

Conclusion: High-Resolution White-Light Endoscopy with Narrow-Band Imaging allows an accurate diagnosis of Low-Grade Dysplasia on visible lesions after regression of H. pylori-induced chronic gastritis. Patients with an overlap between autoimmune/H. pylori-induced gastritis may require more extensive gastric mapping.

Keywords: Autoimmune gastritis; Diagnosis; Dysplasia; Gastric cancer; Malignancy; Signs; Symptoms.

Figure 1

Flow diagram of patient’s selection. H. pylori: Helicobacter pylori; NSAIDs: Non-steroidal anti-inflammatory drugs; PPI: Proton pump inhibitor; HR-WLE: High resolution-white light endoscopy; NBI: Narrow band imaging; PGC: Precancerous gastric conditions.

Figure 2

Prevalence of Operative Link on Gastritis Assessment, endoscopic grading of gastric intestinal metaplasia, and Operative Link on Gastric Intestinal Metaplasia scores, respectively in the 85 patients before and after Helicobacter pylori eradication. OLGA: Operative Link on Gastritis Assessment; EGGIM: Endoscopic grading of gastric intestinal metaplasia; OLGIM: Operative Link on Gastric Intestinal Metaplasia.

Figure 3

Gastric white-light endoscopy, narrow band imaging and histological evaluation before Helicobacter pylori eradication. A, B: Gastritis during white-light endoscopy and narrow band imaging assessment of corpus before Helicobacter pylori eradication; and C: Histological evaluation: moderately atrophic chronically active gastritis with lymphoplasmacellular infiltration of the lamina propria and foveolar epithelium hyperplasia (fundus before Helicobacter pylori eradication. Sections of 3 microns colored with Hematoxylin Eosin and Giemsa respectively. Magnifications: × 10).

Figure 4

Gastric narrow band imaging and histological evaluation after Helicobacter pylori eradication. A: Low-grade dysplasia on flat lesion during narrow band imaging assessment of corpus after Helicobacter pylori eradication; B: Histological appearance: inactive chronically mild atrophic gastritis with intestinal metaplasia and low-grade dysplasia on intestinal metaplastic epithelium (fundus after Helicobacter pylori eradication); C: Low-grade dysplasia aspect of antrum on visible lesion during narrow band imaging assessment after Helicobacter pylori eradication; and D: Histological appearance: inactive chronically moderate atrophic gastritis with intestinal metaplasia and low-grade dysplasia on intestinal metaplastic epithelium (antrum after Helicobacter pylori eradication). Hematoxylin Eosin. Sections of 3 microns. Magnification: × 10.