Socio-economic factors and medical conditions affecting regular stomach cancer screening in Korea: a retrospective longitudinal study using national public health data for 11 years.

OBJECTIVE: This study aimed to explore socio-economic factors and medical conditions that affect regular stomach cancer (SC) screening among Korean adults. STUDY DESIGN: This was a retrospective observational study. METHODS: Study subjects were 5545 adults aged ≥40 years who participated in the 2007-2012 Korean National Health and Nutrition Examination Survey and were followed up to year 2017 based on data linking to the Korean National Health Insurance Service and Korean Health Insurance Review and Assessment. Socio-economic factors included sex, age, residential area, education, occupation, marital status, disability, public and private health insurance, service through local public health organizations, history of cancer except for SC, and family history of SC. Medical factors included six gastric lesions with the possibility of facilitating SC screening, including benign gastric neoplasm, chronic atrophic gastritis, gastric polyp, Helicobacter pylori infection, intestinal metaplasia, and peptic ulcers. The outcome was adherence to SC screening, which was divided into non-adherence, irregular adherence, and regular adherence. RESULTS: After adjusting for the effects of socio-economic factors, multivariate ordinal logistic regression revealed that participants with a history of four types of gastric lesions were more likely to regularly participate in SC screening: chronic atrophic gastritis (odds ratio [OR] 1.567; 95% confidence interval [CI] = 1.276-1.923), gastric polyps (OR 1.565; 95% CI = 1.223-2.003), H. pylori infection (OR 1.637; 95% CI = 1.338-2.003), and peptic ulcer (OR 2.226; 95% CI 1.750-2.831). CONCLUSIONS: To improve participation in SC screening, it is necessary to implement personalized strategies for individuals at risk for gastric cancer in addition to population-based strategies for vulnerable groups.

Assessment of tumor microenvironment in gastric adenocarcinoma.

Gastric cancer (GC), despite the current possibilities of early diagnosis and curative treatment, remains a major public health problem, being one of the main causes of cancer, due to its detection in advanced stages. Screening programs applied in Western countries led to low incidence rates in these countries. Helicobacter pylori bacterial infection is considered to be the highest risk factor for the onset of GC because it causes chronic inflammation of the gastric mucosa and damages hydrochloric acid secretory glands, eventually leading to atrophic gastritis, which has a potential to progress to GC. In our study, we aimed at assessing the tumor microenvironment in gastric adenocarcinomas as approximately 90% of GCs are adenocarcinomas. Our study showed that the tumor microenvironment has an extremely complex morphological structure, totally different from the microscopic structure of the gastric wall, consisting of stromal cells, lymphocytes, plasma cells, macrophages, blood vessels, collagen fibers, extracellular connective matrix, other cells. The tumor microenvironment presents phenotypic, cellular and molecular heterogeneity; therefore, the microscopic aspect differs from one tumor to another and even from one region to another in the same tumor. Poorly or moderately differentiated adenocarcinomas show a more intense desmoplastic reaction than well-differentiated ones. Alpha-smooth muscle actin (α-SMA)-positive stromal cells (tumor-associated fibroblasts) and tumor macrophages were the most numerous cells of the tumor microenvironment. The tumor microenvironment is the result of cooperation between tumor cells, cancer-associated fibroblasts, immune system cells and blood vessels. It allows tumor cells to multiply, grow and metastasize.

The application of new gastric cancer screening score system for gastric cancer screening and risk assessment of gastric precancerous lesions in China.

Objective: To evaluate the value of new gastric cancer screening score system for risk assessment of gastric precancerous lesions.Methods: A total of 520 patients were enrolled after the examination of endoscopy at Endoscopy Center, Department of Gastroenterology, from June 2018 to December 2021. The patients were divided into three groups according to age, gender, serum helicobacter pylori antibody test, pepsinogen I (PGI), pepsinogen II (PGII), pepsinogen I/II ratio (PGR) and gastrin-17 test results before endoscopy: Group A defined as low-risk group (0-11 points), Group B defined as middle-risk group (12-16 points), Group C defined as high-risk group (17-23 points). The detection rates of gastric cancer and atrophic gastritis in three groups were analyzed. According to the range and degree of atrophy/intestinal metaplasia, patients were divided into five groups on the basis of OLGA/OLGIM staging system. The levels of PG I, PG II and PGR were compared between different groups, and the correlation between new gastric cancer screening score system and OLGA/OLGIM staging system were evaluated. Statistical analysis was accomplished by ANOVA, chi-square test and Gamma coefficient analysis.Results: A total of 520 patients were enrolled. 268 patients were classified into group A,222 patients into group B and 30 patients into group C, respectively. According to the pathological results, 281 cases were non-atrophic gastritis, 230 cases atrophic gastritis and 9 cases gastric cancer. For OLGA staging system, 281 patients were divided into stage-0 group, 121 patients into stage-I group, 72 patients into stage-II group, 33 patients into stage-III group and 13 patients into stage-IV groups. The PGI and PGR level correlated inversely with the rising OLGA stages (F = 3.028, p = .016, F = 6.036, p < .001). For OLGIM staging system, 252 patients were divided into stage-0 group, 137 patients into stage-I group, 80 patients into stage-II group, 36 patients into stage-III group and 15 patients into stage-IV group. The PGR level correlated inversely with the rising OLGIM stages (F = 3.466, p＝.007). The detection rates of gastric cancer and atrophic gastritis in Group C were much higher than other groups. (X2 = 14.727, p < .001; X2 = 51.280, p < .001). Gamma coefficient analysis showed significant correlations between OLGA/OLGIM and the new gastric cancer screening score system (p < .001).Conclusions: The new gastric cancer screening score system is closely linked with histological OLGA/OLGIM staging system in the risk assessment of gastric precancerous lesions. The role of new gastric cancer screening score system in future gastric precancerous lesions screening and high risk population identifying was promising.

Real-time determination of gastric juice pH with EndoFaster® for atrophic gastritis assessment.

BACKGROUND: In patients with atrophic gastritis involving gastric body mucosa the pH value of gastric juice is distinctly increased, so that pH assessment would allow predict this precancerous lesion. We tested whether EndoFaster® - a device allowing real-time pH measure and H. pylori diagnosis - may optimize the need of taking gastric biopsies. METHODS: In this prospective, multicentre study, the accuracy of EndoFaster® for ruling out gastric atrophy involving corporal mucosa was assessed. Real-time pH and ammonium determination was performed by aspirating 3-6 ml gastric juice during endoscopy. Histology performed on 5 standard gastric biopsies was used as gold standard. RESULTS: A total of 1008 consecutive patients were observed in 12 centres. At histology, gastric body mucosa atrophy/metaplasia was detected in 65 (6.4%) cases, and a pH value >4.5 in the gastric juice was observed in 150 patients. The values of EndoFaster® performance in predicting the presence of atrophic gastritis were as follow: 51% sensitivity, 84% specificity, 18% PPV, 96% NPV, and 82% accuracy. The NPV value was not distinctly affected by neither ongoing proton pump inhibitor therapy nor H. pylori infection. By considering also data of ammonium concentrations, the values of EndoFaster® in detecting extensive atrophy on gastric mucosa were 74% sensitivity, 84% specificity, 24% PPV, 98% NPV, and 83% accuracy. CONCLUSION: The very high NPV of EndoFaster® might allow to safely rule out presence of atrophic gastritis, reducing the need of taking gastric biopsies in unselected patients managed in clinical practice.

[The value of OLGA staging system in risk assessment of gastric precancerous states and precancerous lesions].

Objective: To investigate the role of operative link on gastritis assessment (OLGA) staging system in risk assessment of gastric precancerous states and precancerous lesions. Methods: A total of 682 patients undergoing gastroscopy from January to July 2016 at the First Hospital of Jiaxing were enrolled. According to the results of gastroscopy and pathology, patients were divided into five groups by OLGA staging system, respectively. The differences of atrophic progression/reversion rate, detection rates of intraepithelial neoplasia and gastric cancer among different OLGA groups during 5-year follow-up were compared. Results: A total of 437 patients completed endoscopic follow-up, including 207 cases in Stage-0, 158 cases in Stage-Ⅰ, 47 cases in Stage-Ⅱ, 18 cases in Stage-Ⅲ and 7 cases in Stage-Ⅳ. There were 24 cases of atrophy progression, 78 cases of atrophy reversion, 5 cases of intraepithelial neoplasia and 2 cases of gastric cancer. The atrophy progression rate correlated with the rising OLGA stages(χ2=19.14, P<0.001);The rate of atrophy reversion in high-risk group was significantly lower than that in low-risk group(χ2=4.96, P=0.026); The detection rate of intraepithelial neoplasia and gastric cancer in high-risk group was significantly higher than that in low-risk group(χ2=29.63, 11.60, both P<0.05). Conclusions: Histological OLGA staging system is helpful to realize the risk stratification assessment of gastric precancerous states and precancerous lesions. It has practical significance to formulate individualized endoscopic/histological follow-up plan for OLGA high-risk group.

Serum pepsinogen levels and OLGA/OLGIM staging in the assessment of atrophic gastritis types.

BACKGROUND: We assessed the validity of using serum pepsinogen tests (sPGTs) to differentiate autoimmune atrophic gastritis (AAG) from environmental atrophic gastritis (EAG). We also investigated the correlation and prognostic value between disease stage, according to Operative Link for Gastritis Assessment (OLGA)/Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM), and sPGT results in patients with gastric atrophy. METHODS: We enroled 115 patients in this prospective study: 95 with atrophic gastritis (16 with AAG and 79 with EAG) and 20 non-atrophic gastritis. These patients, along with 32 control patients, underwent esophagogastroduodenoscopy. Atrophy and intestinal metaplasia of the gastric biopsy specimens were staged according to the OLGA/OLGIM staging systems. RESULTS: The median (IQR) age of the patients (83 females (56.5%)) was 58 (46-67) years. Patients in the AAG group represented histologically advanced stages. The AAG group had lower pepsinogen (PG) I and II levels, as well as a lower PGI/PGII ratio, compared with the EAG group (p<0.01, p<0.05 and p<0.01, respectively). The optimal PGI/PGII ratio for predicting AAG was ≤1.9 (100% sensitivity and 100% specificity), and that for predicting EAG was ≤9.2 (47.5% sensitivity and 90.6% specificity). The OLGA/OLGIM stage was negatively correlated with the PGI level and PGI/PGII ratio. In the AAG group, four of five patients with low-grade dysplasia had OLGA/OLGIM stage III-IV disease. CONCLUSIONS: sPGT may provide valuable information for differentiating advanced-stage AAG from EAG, and in patients with atrophic gastritis, use of sPGTs and OLGA/OLGIM staging together may predict gastric cancer risk.

Use of endoscopic assessment of gastric atrophy for gastric cancer risk stratification to reduce the need for gastric mapping.

Background/Aims: Stratification for gastric cancer risk typically involves histologic grading of gastric biopsies. This study aimed to compare endoscopic assessment of gastric atrophy and histologic gastric mapping for gastric cancer risk stratification in a region with relatively high risk of gastric cancer.Methods: Endoscopic and histologic gastric cancer risk stratification were compared in Vietnamese patients with functional dyspepsia. Endoscopic gastric atrophy was graded according to the Kimura-Takemoto classification. High-risk histologic lesions were defined as gastric dysplasia, Operative Link on Gastritis Assessment (OLGA) gastritis stage III/IV, intestinal metaplasia in both the antrum and the corpus or incomplete intestinal subtype at any site. Two experienced pathologists, blinded to endoscopic information, jointly examined all specimens and reached a consensus. The presence of high-risk histologic lesions was compared among patients with different endoscopic grades of gastric atrophy.Results: There were 280 subjects (mean age, 46.1 ± 10 years, and male, 50%). The numbers of patients with moderate/severe grade of endoscopic gastric atrophy and high-risk histologic lesions were 126 (45.0%) and 46 (16.4%), respectively. The sensitivity, specificity, positive and negative likelihood ratios of moderate/severe endoscopic atrophic grade for detecting high-risk histologic lesions were 93% (95% CI 86%-100%), 65% (95% CI 58%-71%), 2.64 (95% CI 2.18 - 3.18) and 0.10 (95% CI 0.03 - 0.30), respectively.Conclusions: Gastric cancer risk assessment using endoscopic or histologic methods provided similar results such that the absence or a mild grade of endoscopic gastric atrophy would preclude the need for histologic mapping.

A single vial is enough in the absence of endoscopic suspected intestinal metaplasia - less is more!

Background: For the correct staging of chronic atrophic gastritis (AG) and gastric intestinal metaplasia (GIM) at least 4 biopsies are recommended: 2 from the antrum/incisura and 2 from the body sent in two different vials. As virtual chromoendoscopy with narrow-band-imaging (NBI) is valid both in the diagnosis and staging of GIM, it is reasonable to question the need to separate biopsy samples in all procedures. Aims: To evaluate if biopsy samples can be placed in the same vial without implications in the diagnosis and follow-up of the patient, if during gastroscopy no typical endoscopic pattern of GIM with NBI is observed. Methods: Multicentre prospective study of a consecutive sample of patients (n = 183) submitted to gastroscopy using NBI with no superficial neoplastic lesions and no suggestive areas of GIM. Biopsies of both antrum/incisure and body were performed in all patients and samples were placed in the same vial for histologic assessment [according to OLGA (operative link for gastritis assessment) and OLGIM (operative link for gastric intestinal metaplasia)], blinded to endoscopic features. Results: In all patients, OLGA and OLGIM calculation was possible as the pathologists could distinguish biopsy samples from antrum/incisure from those of gastric body. The negative predictive value was 100% for advanced stages of GIM or AG as 179 (98%) patients presented OLGIM 0 and only 4 (2%) presented OLGIM I. Regarding AG, 150 (82%) presented OLGA 0, 23 (13%) OLGA I and 10 (6%) OLGA II. Conclusion: In the absence of a typical endoscopic pattern of GIM using NBI, it is effective to place biopsies' specimens in the same vial (for Helicobacter pylori diagnosis) or even to abstain from biopsies as no single patient with significant changes seems to be missed. This change in clinical practice can have a significant impact on endoscopy costs.

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.

Optical biopsy strategy for the assessment of atrophic gastritis, intestinal metaplasia, and dysplasia.

BACKGROUND AND AIMS: The pathogenesis of gastric cancer involves premalignant changes of the gastric mucosa. An accurate estimation of the topography and severity of these lesions represents an important step in detecting premalignant lesions, thereby classifying patients into low or high risk of developing gastric cancer. We prospectively analyzed the diagnostic performance of narrow-band imaging with magnification endoscopy (NBI-ME) for assessing premalignant gastric lesions during real-time examination. PATIENTS, MATERIALS AND METHODS: A total number of 59 patients were examined by NBI-ME and target biopsies of the antrum, corporeal, and incisura angularis levels. Modified endoscopic patterns were classified into three groups: type A [tubulo-villous mucosal pattern with regular microvessels, or the light blue crest (LBC) sign], type B [disappearance of normal subepithelial capillary network (SECN) pattern], and type C [irregular mucosal pattern (IMP) and∕or irregular vascular pattern (IVP)]. The endoscopic diagnosis was compared to histological findings (the gold standard). The NBI-ME results were assessed for accuracy, sensitivity, specificity, and negative and positive predictive values in detecting intestinal metaplasia, atrophic gastritis and dysplasia. RESULTS: Analysis of endoscopic patterns showed a good correlation with premalignant lesions (p<0.05). Type A pattern showed 80.2% accuracy, 80.43% sensitivity and 80% specificity [area under receiver operating characteristic (AUROC) of 0.8] in detecting intestinal metaplasia. Diagnostic performance for assessment of atrophic gastritis was not ideal (69.5% accuracy, 83.72% sensitivity, 56.04% specificity, AUROC 0.69). Pattern C represents a reliable endoscopic marker for the diagnosis of dysplasia (91.1% accuracy, 83.3% sensitivity, 91.81% specificity, AUROC 0.87). The extension of precancerous lesions was estimated during endoscopic examination. CONCLUSIONS: NBI-ME represents a valuable tool in the assessment of premalignant gastric lesions, thereby categorizing patients into low and high risks of developing gastric cancer. The applicability of the method in routine practice is promising, as it helps shape the follow up protocol of patients with premalignant lesions of the stomach. It is worth mentioning that, this method requires standardization, additional training, and expertise.

Multiplex serology of Helicobacter pylori antigens in detection of current infection and atrophic gastritis - A simple and cost-efficient method.

INTRODUCTION: Helicobacter pylori express a large array of antigens, each of which is duly responsible for successful colonization and pathogenesis. Here, we have studied host serum antibody responses to four of its immunodominant antigens in association with the infection status and the resulting clinical outcomes. METHODS: For this purpose, four individual H. pylori proteins (UreB, CagA, Tip-α and HP0175) were produced in recombinant forms. Serum antibody responses of 246 (75 GC and 171 NUD) patients, against the above antigens, were evaluated by multiplex immunoblotting. The associations between the resulting data and the infection status, as well as clinical outcomes were evaluated using logistic regression models. RESULTS: Serum antibodies to all four recombinant antigens increased the chances of detecting screening ELISA-positive subjects, in an escalating dose-dependent manner, ranging from 2.6 (1.5-4.7) for HP0175 to 14.3 for UreB (4.3-50.7), exhibiting the lowest and highest odds ratios, respectively (PAdj ≤ 0.001), such that 98.2% of the subjects with antibodies to all four antigens, were also positive by the screening ELISA (P < 0.0001). Among the screening ELISA-positive subjects, the three antigens of CagA, Tip-α, and HP0175 were able to segregate current from past H. pylori infection (P < 0.05). Accordingly, subjects with antibodies to one or more antigen(s) were at 5.4 (95% CI: 1.8-16.4) folds increased chances of having current infection, as compared to triple negatives (PAdj = 0.003). In reference to the clinical outcomes, those with serum antibodies to CagA were more prevalent among gastric cancer, as compared to NUD patients (ORAdj: 5.4, 95% CI: 2.4-12.2, PAdj < 0.0001). When NUD patients were categorized according to their histopathologic status, multiple antigen analysis revealed that subjects with serum antibodies to one or more of the 3 current infection-positive antigens (CagA, Tip-α, and HP0175) were at 9.7 (95% CI: 2.1-44.9, P = 0.004) folds increased risk of atrophic gastritis, in reference to triple negatives. CONCLUSION: The non-invasive multiplex serology assay, presented here, was able to not only detect subjects with current H. pylori infection, it could also screen dyspeptic patients for the presence of gastric atrophy. This simple and cost-efficient method can supplement routine screening ELISAs, to increase the chances of detecting current infections as well as atrophic gastritis.

Narrow band imaging and serology in the assessment of premalignant gastric pathology.

BACKGROUND: Patient outcomes in gastric adenocarcinoma are poor due to late diagnosis. Detecting and treating at the premalignant stage has the potential to improve this. Helicobacter pylori is also a strong risk factor for this disease. AIMS: Primary aims were to assess the diagnostic accuracy of magnified narrow band imaging (NBI-Z) endoscopy and serology in detecting normal mucosa, H. pylori gastritis and gastric atrophy. Secondary aims were to compare the diagnostic accuracies of two classification systems using both NBI-Z and white light endoscopy with magnification (WLE-Z) and evaluate the inter-observer agreement. METHODS: Patients were prospectively recruited. Images of gastric mucosa were stored with histology and serum for IgG H. pylori and Pepsinogen (PG) I/II ELISAs. Blinded expert endoscopists agreed on mucosal pattern. Mucosal images and serological markers were compared with histology. Kappa statistics determined inter-observer variability for randomly allocated images among four experts and four non-experts. RESULTS: 116 patients were prospectively recruited. Diagnostic accuracy of NBI-Z for determining normal gastric mucosa was 0.87(95%CI 0.82-0.92), H. pylori gastritis 0.65(95%CI 0.55-0.75) and gastric atrophy 0.88(95%CI 0.81-0.94). NBI-Z was superior to serology at detecting gastric atrophy: NBI-Z gastric atrophy 0.88(95%CI 0.81-0.94) vs PGI/II ratio < 3 0.74(95%CI 0.62-0.85) p<.0001. Overall NBI-Z was superior to WLE-Z in detecting disease using two validated classifications. Inter-observer agreement was 0.63(95%CI 0.51-0.73). CONCLUSIONS: NBI-Z accurately detects changes in the GI mucosa which currently depend on histology. NBI-Z is useful in the detection of precancerous conditions, potentially improving patient outcomes with early intervention to prevent gastric cancer.

The potential value of serum pepsinogen for the diagnosis of atrophic gastritis among the health check-up populations in China: a diagnostic clinical research.

BACKGROUND: The aim of this study is to assess the validity of the measurement of pepsinogen as a screening test for chronic atrophic gastritis (AG) in health check-up populations in China. METHODS: Patients from consecutive regular health check-up were enrolled from January 2014 to June 2015. Endoscopy, combined with monitoring the Helicobacter pylori (Hp) infections, and measuring the serum pepsinogen (PG) were used to determine the diagnostic accuracy of PG for the screening of atrophic gastritis. Histopathology was assessed by the Operative Link on Gastritis Assessment (OLGA) system. Statistical analysis was performed using SPSS statistical software. RESULTS: The total Hp infection rate was 40%. Based on pathology, the 996 participants were divided into three groups: non-atrophic (NAG), mild-moderate atrophic (MAG): stage I and II of the OLGA classification, and severe atrophic (SAG): stage III and IV of the OLGA classification. Compared with NAG and MAG groups, PGR decreased significantly in SAG group (p < 0.05). PGI and PGII levels were significantly elevated in Hp-positive group, while the PGR was markedly decreased (p < 0.01). When MAG and SAG groups were combined and compared with NAG group, the best cutoff value for atrophy diagnosis was PGI ≤50.3 ng/ml; the cutoff value in Hp-negative group was absolutely higher than in Hp-positive group. When NAG and MAG groups were combined and compared with the SAG group, the best cutoff value for diagnosis of severe atrophy was at PGR ≤4.28. The cutoff values in Hp-negative and Hp-positive groups were calculated at PGR ≤6.28 and ≤4.28, respectively. CONCLUSIONS: Pepsinogens play an important role in the identification of patients with atrophic gastritis and severe AG. Use of different cutoff values of PG for Hp-negative and Hp-positive groups may offer greater efficacy in the diagnosis of AG.

The correlation between histological gastritis staging- 'OLGA/OLGIM' and serum pepsinogen test in assessment of gastric atrophy/intestinal metaplasia in China.

BACKGROUND: Serum pepsinogen (PG) test, as an indicator of gastric mucosal atrophy, reflects the functional and morphologic status of gastric mucosal and it is suggested to serve as a useful predictive marker for patients with gastric cancer (GC). The available classifications of gastritis, known as the Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastritis Intestinal Metaplasia (OLGIM), integrating the severity and topography of atrophy/intestinal metaplasia (IM), have been gradually accepted and used in screening for GC in recent years. GOALS: To assess whether serum pepsinogen test, including PGI, PGII, PGI/PGII and gastrin-17 (G-17) could reflect the extent and topography of gastric mucosal atrophy/IM. Furthermore, to discuss the relationship between OLGA/OLGIM staging system and serum pepsinogen test in assessment of gastric atrophy/IM. METHODS: The OLGA/OLGIM ranks the gastric staging according to both the topography and the severity of gastric atrophy/IM. A retrospective study was conducted with 331 patients who underwent endoscopy with consecutive biopsy sampling and reassessed according to OLGA/OLGIM staging system. Serum pepsinogen test, including PGI, PGII, PGI/PGII and G-17, as well as serological Helicobacter pylori (Hp) antibody were also measured. Results were presented as gastritis stage, serum pepsinogen level and Hp status. Baseline characteristics were compared using analysis of variance (ANOVA) test for continuous data and Pearson's χ2 test for categorical data. A logistic regression model was used for the correlation analysis between OLGA/OLGIM and serological pepsinogen test. RESULTS: A total of 177 non-atrophic gastritis and 154 atrophic gastritis were analyzed, among which 40 were antrum atrophy, 32 were corpus atrophy and 82 were pan-atrophy. All patients were assessed applying the OLGA/OLGIM criteria with a mean age of 54.7 ± 10.8 years. Patients among OLGA/OLGIM Stage III-IV were presented with a lower level of serum PGI and PGI/PGII (p < .05), especially for Stage IV (p = .01). For both Hp-positive patients and Hp-negative patients according to OLGA system, PGI/PGII level correlated inversely with the rising stage (p = .022; p = .028). As for OLGIM system, similar difference can be seen in PGI/PGII level in either Hp-positive patients, or Hp-negative patients (p = .036; p = .013). In addition, the percentage of G-17 <1 pmol/L combined with PG-negative in antrum atrophy group was much higher than that of non-atrophy group and corpus atrophy group (25 versus 15.8 versus 6.3%) (p = .029). The proportion of G-17 > 15 pmol/L combined with PG-positive was apparently higher in corpus atrophy group, compared with other two groups (25 versus 11.3 versus 8.1%) (p = .023). Logistic regression modeling showed there exist significant connections between OLGA/OLGIM stages and serum pepsinogen test in patient stratification for gastric mucosal atrophy assessment (p < .001, p < .001). CONCLUSIONS: Serum pepsinogen test has a strong correlation with OLGA/OLGIM gastritis stage and could provide important information in assessment of atrophy/intestinal metaplasia.

Cost of detecting gastric neoplasia by surveillance endoscopy in atrophic gastritis in Italy: A low risk country.

BACKGROUND: Atrophic gastritis (AG) is at increased risk of gastric neoplasia, thus surveillance gastroscopy has been proposed. AIMS: To assess cost of detecting gastric neoplasias by surveillance endoscopy according to identified risk factors in Italy. METHODS: Post-hoc analysis of a cohort study including 200 AG-patients from Italy followed up for a mean of 7.5 (4-23.4) years was done. Considered risk factors were: age >50years, extensive atrophy, pernicious anaemia, OLGA-OLGIM scores 3-4 at diagnosis. The number of 4-year-surveillance endoscopies needed to be performed to detect one gastric neoplasia (NNS) was calculated. RESULTS: In 19 patients neoplasias (4 gastric cancers, 8 type 1 gastric carcinoids, 7 dysplasias) were detected at the 361 surveillance gastroscopies, corresponding to NNS of 19 and a cost per gastric neoplastic lesion of €2945. By restricting surveillance to pernicious anaemia patients, reduction of NNS and cost per neoplasia to 13.8 and €2139 may be obtained still detecting 74% of neoplasias. By limiting the surveillance to pernicious anaemia patients and OLGA 3-4, 5 (26.3%) neoplasias would have been detected with a corresponding NNS of 5.4 and a cost per lesion of €837. CONCLUSION: Risk factors may allow an efficient allocation of financial and medical resources for endoscopic surveillance in AG in a low risk country.

Operative link on gastritis assessment stage is an appropriate predictor of early gastric cancer.

AIM: To assess the predictive value of Operative Link on Gastritis Assessment (OLGA) and Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM) stages in gastric cancer. METHODS: A prospective study was conducted with 71 patients with early gastric cancer (EGC) and 156 patients with non-EGC. All patients underwent endoscopic examination and systematic biopsy. Outcome measures were assessed and compared, including the Japanese endoscopic gastric atrophy (EGA) classification method and the modified OLGA method as well as the modified OLGIM method. Helicobacter pylori (H. pylori) status was determined for all study participants. Stepwise logistic regression modeling was performed to analyze correlations between EGC and the EGA, OLGA and OLGIM methods. RESULTS: For patients with EGC and patients with non-EGC, the proportions of moderate-to-severe EGA cases were 64.8% and 44.9%, respectively (P = 0.005), the proportions of OLGA stages III-IV cases were 52.1% and 22.4%, respectively (P < 0.001), and the proportions of OLGIM stages III-IV cases were 42.3% and 19.9%, respectively (P < 0.001). OLGA stage and OLGIM stage were significantly related to EGA classification; specifically, logistic regression modeling showed significant correlations between EGC and moderate-to-severe EGA (OR = 1.95, 95% CI: 1.06-3.58, P = 0.031) and OLGA stages III-IV (OR = 3.14, 95%CI: 1.71-5.81, P < 0.001), but no significant correlation between EGC and OLGIM stages III-IV (P = 0.781). H. pylori infection rate was significantly higher in patients with moderate-to-severe EGA (75.0% vs 54.1%, P = 0.001) or OLGA/OLGIM stages III-IV (OLGA: 83.6% vs 55.8%, P < 0.001; OLGIM: 83.6% vs 57.8%, P < 0.001). CONCLUSION: OLGA classification is optimal for EGC screening. A surveillance program including OLGA stage and H. pylori infection status may facilitate early detection of gastric cancer.

Impact of the angulus biopsy for the detection of gastric preneoplastic conditions and gastric cancer risk assessment.

BACKGROUND: Gastric atrophy and intestinal metaplasia (IM) are preneoplastic conditions in the development of gastric cancer. Histopathological assessment is based on the updated Sydney system and superordinate staging systems, operative link on gastritis assessment (OLGA) and operative link on gastritis assessment using IM (OLGIM), all requiring a biopsy from the incisura angularis (angulus). AIM: To determine the value of the angulus biopsy for the detection of preneoplastic conditions and cancer risk evaluation using OLGA and OLGIM prospectively. METHODS: Biopsies from antrum (2), angulus (1) and corpus (2) were obtained from 213 patients (age 19-94 years, median 54 years, female to male ratio 138:75) undergoing upper endoscopy. Histological assessment according to the updated Sydney system, OLGA and OLGIM staging was performed by gastrointestinal pathologists. Statistical analysis used exact confidence limits for dichotomous variables and repeated measurement analysis of variance. RESULTS: 8% of the cases with atrophic gastritis and 3% with IM (17 vs 6/213) would have been missed without the angulus biopsy. More patients were diagnosed with a preneoplastic condition when the angulus biopsy was considered (13.1%, CI 8.9% to 18.4%), but the grade of atrophy, if present at both sides, did not vary significantly in angulus and antrum. OLGA and OLGIM scores dropped significantly when recalculated without the angulus (difference in means±SD 0.131±0.402 and 0.075±0.313, respectively). The impact on the identification of high-risk stages is limited. CONCLUSIONS: The angulus biopsy adds to the detection of mild gastric atrophy in particular. It allows identifying a small additional number of patients with high-risk gastritis.

[Digestive insufficiency of the stomach in children from the positions of clinical morphology and its role in the assessment of the indications for nutritional support ].

The structure of gastric mucosa (GM) of the stomach fundus (SF) was studied in children with various gastrointestinal diseases. In children, the main structural parameters of the SF (GM thickness, depth of glands and thickness of the mucosal epithelium area) varied widely (3.5-5.3 times). The following ranges were allocated: hypotrophy ("atrophy"), eutrophy (area of mean values) and hypertrophy of SF GM thickness, depth of the glands and thickness of the mucosal epithelium area. Hypotrophy ("atrophy") of the SF glands was found in approximately one third of the children of different age which could lead to decrease in the digestive function of the stomach and cause specific clinical symptoms of dyspepsia. Atrophic changes of SF GM were observed in children of all age groups. Most often (49%), fundic glands hypotrophy was observed in children of early age. With age, the incidence of atrophic changes of SF GM decreased. Atrophic changes in the GM can be detected during microanatomical or histopathological (using morphometry) examination of the SF.

Surveillance strategy of atrophic gastritis and intestinal metaplasia in a country with a high prevalence of gastric cancer.

BACKGROUND: It is not clear which screening examinations are best suited for gastric cancer prevention, especially in patients with atrophic gastritis and intestinal metaplasia. Therefore, we investigated the gastric cancer screening methods and intervals that are performed in clinical practice in an area with a high prevalence of gastric cancer. METHODS: Eighty-seven physicians voted by keypad and discussed the consistency of endoscopic diagnosis of atrophic gastritis and intestinal metaplasia at the Annual Symposium of the Korean College of Helicobacter and Upper Gastrointestinal Research. Additionally, 100 core members of this academic society were asked via e-mail to complete the questionnaires related to screening strategies for gastric cancer. RESULTS: The most common recommendation for the subjects with intestinal metaplasia was an annual endoscopic follow-up (95.5% vs. 80.4% in the expert and non-expert groups, respectively; P = 0.118). Annual endoscopic follow-up was also the most predominant recommendation for atrophic gastritis (95.5% vs. 76.5%; P = 0.092), regardless of the physicians' endoscopic experience, position, and degree of the hospital. However, the correct answer rate for the diagnosis of normal endoscopic findings was only 16.7 and 14.1% in the expert and non-expert groups, respectively (P = 0.883). CONCLUSIONS: The most common practical screening strategy for patients with atrophic gastritis and intestinal metaplasia in Korea was annual endoscopic examination. However, a new program estimating individualized gastric cancer risk might be needed because of the low inter-observer agreement in the endoscopic diagnosis of atrophic gastritis and intestinal metaplasia.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.