Chronic atrophic gastritis: Natural history, diagnosis and therapeutic management. A position paper by the Italian Society of Hospital Gastroenterologists and Digestive Endoscopists [AIGO], the Italian Society of Digestive Endoscopy [SIED], the Italian Society of Gastroenterology [SIGE], and the Italian Society of Internal Medicine [SIMI].

Chronic atrophic gastritis (CAG) is an underdiagnosed condition characterised by translational features going beyond the strict field of gastroenterology as it may manifest itself by a variable spectrum of gastric and extra-gastric symptoms and signs. It is relatively common among older adults in different parts of the world, but large variations exist. Helicobacter pylori-related CAG [multifocal] and autoimmune CAG (corpus-restricted) are apparently two different diseases, but they display overlapping features. Patients with cobalamin and/or iron deficiency anaemia or autoimmune disorders, including autoimmune thyroiditis and type 1 diabetes mellitus, should be offered screening for CAG. Pepsinogens, gastrin-17, and anti-H. pylori antibodies serum assays seem to be reliable non-invasive screening tools for the presence of CAG, helpful to identify individuals to refer to gastroscopy with five standard gastric biopsies in order to obtain histological confirmation of diagnosis. Patients with CAG are at increased risk of developing gastric cancer, and they should be estimated with histological staging systems (OLGA or OLGIM). H. pylori eradication may be beneficial by modifying the natural history of atrophy, but not that of intestinal metaplasia. Patients with advanced stages of CAG (Stage III/IV OLGA or OLGIM) should undergo endoscopic surveillance every three years, those with autoimmune CAG every three-five years. In patients with CAG, a screening for autoimmune thyroid disease and micronutrient deficiencies, including iron and vitamin B12, should be performed. The optimal treatment for dyspeptic symptoms in patients with CAG remains to be defined. Proton pump inhibitors are not indicated in hypochlorhydric CAG patients.

Priority and appropriateness of upper endoscopy out-patient referrals: Two-period comparison in an open-access unit.

BACKGROUND: In the early 2000s we introduced a prioritization model for referrals based on involvement of primary care physicians (PCPs) and specialists. AIMS: Assess the application of that model of prioritisation, comparing gastroscopies performed 8 years apart, with respect to priority level, appropriateness and relevant endoscopic findings (REFs). METHODS: The studies included 247 and 354 out-patients, who had undergone gastroscopy in 2006 and in 2014, respectively. To reduce interspecialists variability, both studies were performed by the same specialist as investigator. RESULTS: In both years, most patients were assigned low-priority referral by PCPs (78.6% and 75.1% respectively). The agreement PCPs versus specialist on referral priority was moderate in 2006 (0.60, Landis-Koch scale 0.41-0.60) and high in 2014 (0.81, Landis-Koch scale 0.81-1.00). In both years we observed a similar rate of inappropriateness: 27.5% and 27.1%, respectively. Due to multiple logistic regression, the odds ratio (OR) for REF increased when: (i) very high-priority referral versus nopriority referral was indicated (8.813 OR, p = 0.0012), (ii) referral followed the guidelines (9.29 OR, p<0.0001), and (iii) agreement of priority occurred (1.911 OR, p = 0.0308). CONCLUSIONS: Our findings highlighted that the issues of low-priority referrals should be addressed in order to discontinue gastroscopy overusing and reduce related operational costs.

Gastritis staging in the endoscopic follow-up for the secondary prevention of gastric cancer: a 5-year prospective study of 1755 patients.

OBJECTIVE: Operative link on gastritis assessment (OLGA) staging for gastritis ranks the risk for gastric cancer (GC) in progressive stages (0-IV). This prospective study aimed at quantifying the cancer risk associated with each gastritis stage. DESIGN: A cohort of 1755 consecutive patients with dyspepsia underwent initial (T-0) oesophagogastroduodenoscopy with mapped gastric biopsies, OLGA staging and assessment of Helicobacter pylori infection. Patients were followed for 55 months (median); patients with stages II III and IV underwent a second endoscopy/restaging (T-1), and those with stages 0 and I were followed clinically and through in-depth clinical and record checking. Endpoints were OLGA stage at T-1 and development of gastric epithelial neoplasia. RESULTS: At T-0, 77.6% of patients had stage 0, 14.4% stage I, 5.1% stage II, 2.1% stage III and 0.85% stage IV. H. pylori infection was detected in 603 patients at T-0 and successfully eradicated in 602 of them; 220 had a documented history of H. pylori eradication; and 932 were H. pylori naïve-negative. Incident neoplastic lesions (prevalence=0.4%; low-grade intraepithelial neoplasia (IEN)=4; high-grade IEN=1; GC=2) developed exclusively in patients with stages III-IV. The risk for epithelial neoplasia was null in patients at stages 0, I and II (95% CI 0 to 0.4), 36.5 per 1000 person-years in patients at stage III (95% CI 13.7 to 97.4) and 63.1 per 1000 person-years in patients at stage IV (95% CI 20.3 to 195.6). CONCLUSIONS: This prospective study confirms that OLGA staging reliably predicts the risk for development of gastric epithelial neoplasia. Although no neoplastic lesions arose in H. pylori-naïve patients, the H. pylori eradication in subjects with advanced stages (III-IV) did not abolish the risk for neoplastic progression.

Appropriateness and yield of surveillance colonoscopy in first-degree relatives of colorectal cancer patients: A 5-year follow-up population-based study.

BACKGROUND AND AIMS: There are few prospective data about the use of surveillance colonoscopy and the risk of recurrent neoplasia in first degree relatives (FDRs) of colorectal cancer (CRC) patients. We examined the use and yield of surveillance colonoscopy in a population-based screening program (Trentino, Italy) METHODS: 1252 FDRs have been included in this study. We calculated compliance (percentage of FDRs who underwent surveillance colonoscopy among those eligible), appropriateness of colonoscopy (appropriate if performed within 6 months of the guidelines recommended interval) and diagnostic yield for neoplasia. We compared these data with those of 765 individuals without a family history (FH) of CRC who underwent screening colonoscopy in the same period (controls). RESULTS: Compliance and appropriateness were higher in FDRs than in controls (93.0% vs. 48.0%; p < 0.001; 59.6% vs. 18.8%; p < 0.0001, respectively). Younger age, female sex, FH of CRC and both non-advanced adenomas (nAA) and advanced adenomas (AA) at screening colonoscopy were predictors of appropriate surveillance. The cumulative incidence of nAA and AA was similar in FDRs and controls (31.7% and 4.9% in FDRs, including three invasive cancers; 32.4% and 5.8% in controls, respectively). CONCLUSION: FH does not increase the risk of AA in a 5-year follow-up; appropriate surveillance practices in FDRs could be highly expected in an organized screening program.

A multicentre case control study on complicated coeliac disease: two different patterns of natural history, two different prognoses.

BACKGROUND: Coeliac disease is a common enteropathy characterized by an increased mortality mainly due to its complications. The natural history of complicated coeliac disease is characterised by two different types of course: patients with a new diagnosis of coeliac disease that do not improve despite a strict gluten-free diet (type A cases) and previously diagnosed coeliac patients that initially improved on a gluten-free diet but then relapsed despite a strict diet (type B cases). Our aim was to study the prognosis and survival of A and B cases. METHODS: Clinical and laboratory data from coeliac patients who later developed complications (A and B cases) and sex- and age-matched coeliac patients who normally responded to a gluten-free diet (controls) were collected among 11 Italian centres. RESULTS: 87 cases and 136 controls were enrolled. Complications tended to occur rapidly after the diagnosis of coeliac disease and cumulative survival dropped in the first months after diagnosis of complicated coeliac disease. Thirty-seven cases died (30/59 in group A, 7/28 in group B). Type B cases presented an increased survival rate compared to A cases. CONCLUSIONS: Complicated coeliac disease is an extremely serious condition with a high mortality and a short survival. Survival depends on the type of natural history.

Barrett's esophagus and adenocarcinoma risk: the experience of the North-Eastern Italian Registry (EBRA).

OBJECTIVE: To establish the incidence and risk factors for progression to high-grade intraepithelial neoplasia (HG-IEN) or Barrett's esophageal adenocarcinoma (BAc) in a prospective cohort of patients with esophageal intestinal metaplasia [(BE)]. BACKGROUND: BE is associated with an increased risk of BAc unless cases are detected early by surveillance. No consistent data are available on the prevalence of BE-related cancer, the ideal surveillance schedule, or the risk factors for cancer. METHODS: In 2003, a regional registry of BE patients was created in north-east Italy, establishing the related diagnostic criteria (endoscopic landmarks, biopsy protocol, histological classification) and timing of follow-up (tailored to histology) and recording patient outcomes. Thirteen centers were involved and audited yearly. The probability of progression to HG-IEN/BAc was calculated using the Kaplan-Meier method; the Cox regression model was used to calculate the risk of progression. RESULTS: HG-IEN (10 cases) and EAc (7 cases) detected at the index endoscopy or in the first year of follow-up were considered to be cases of preexisting disease and excluded; 841 patients with at least 2 endoscopies {median, 3 [interquartile range (IQR): 2-4); median follow-up = 44.6 [IQR: 24.7-60.5] months; total 3083 patient-years} formed the study group [male/female = 646/195; median age, 60 (IQR: 51-68) years]. Twenty-two patients progressed to HG-IEN or BAc (incidence: 0.72 per 100 patient-years) after a median of 40.2 (26.9-50.4) months. At multivariate analysis, endoscopic abnormalities, that is, ulceration or nodularity (P = 0.0002; relative risk [RR] = 7.6; 95% confidence interval, 2.63-21.9), LG-IEN (P = 0.02, RR = 3.7; 95% confidence interval, 1.22-11.43), and BE length (P = 0.01; RR = 1.16; 95% confidence interval, 1.03-1.30) were associated with BE progression. Among the LG-IEN patients, the incidence of HG-IEN/EAc was 3.17 patient-years, that is, 6 times higher than in BE patients without LG-IEN. CONCLUSIONS: These results suggest that in the absence of intraepithelial neoplastic changes, BE carries a low risk of progression to HG-IEN/BAc, and strict surveillance (or ablative therapy) is advisable in cases with endoscopic abnormalities, LG-IEN or long BE segments.

Errors and near misses in digestive endoscopy units.

BACKGROUND: Not much is known about errors and near misses in digestive endoscopy. AIMS: To verify whether an incident report, with certain facilitating features, gives useful information about unintended events, only excluding errors in medical diagnosis. METHOD: Nine endoscopy units took part in this cross sectional, prospective, multicentre study which lasted for two weeks. Members of the staff were required to report any unintended, potentially dangerous event observed during the daily work. A form was provided with a list of "reminders" and facilitators were appointed to help. The main outcome measurements were type of event, causes, corrective interventions, stage of occurrence in the workflow and qualification of the reporters. RESULTS: A total of 232 errors were reported (two were not related to endoscopy). The remaining 230 amount to 10.3% of 2239 procedures; 66 (29%) were considered errors with consequences, 164 (71%) "near misses". There were 150 pre-operative errors (65%), 22 operative (10%) and 58 post-operative (25%). Corrective interventions were provided for 60 cases of errors and 119 near misses. Most of the events were reported by the nurses (106 out of 232, 46%). CONCLUSIONS: Short-term incident reporting focusing on near misses, using forms with lists of "reminders", and the help of a facilitator, can give useful information on errors and near misses in digestive endoscopy.

Colonoscopic findings in first-degree relatives of patients with colorectal cancer: a population-based screening program.

BACKGROUND: A screening colonoscopy is recommended in first-degree relatives (FDRs) of colorectal cancer patients; few prospective, controlled studies have evaluated colorectal findings in a population-based screening program. OBJECTIVE: To evaluate the prevalence of colorectal neoplasia (adenomas and adenocarcinomas) in this increased-risk population, to compare it with that of average-risk individuals, and to identify features that might allow risk stratification for neoplasia among FDRs. DESIGN: Cross-sectional study. SETTING: Population-based screening program in Trentino, Italy. PATIENTS: FDRs of colorectal cancer patients between 45 and 75 years of age with no history of hereditary colorectal cancer syndromes or inflammatory bowel disease. CONTROLS: Average-risk individuals undergoing screening colonoscopy. INTERVENTION: Screening colonoscopy. RESULTS: Neoplasia was found in 33.4% of 1252 FDRs and in 30.3% of 765 controls; advanced neoplasia was found in 11.3% of FDRs and in 6.3% of controls. Odds ratios (ORs) from the multivariate logistic regression analysis adjusted for age, sex, cecal intubation rates, and colon cleansing showed an increased risk of advanced neoplasia (OR 2.41; 95% CI, 1.69-3.43; P < .0001) in FDRs. Age older than 56 years (OR 1.83; 95% CI, 1.15-2.99; P = .013) and male sex (OR 2.17; 95% CI, 1.39-3.10; P < .001) are independent predictors of advanced neoplasia. LIMITATIONS: Italian subjects living in the same geographic area; of 4301 FDRs, 2521 were excluded. CONCLUSIONS: The increased risk of advanced neoplasia supports the current recommendation for colonoscopic screening in this group; age and sex may assist in risk stratification of these individuals.

Improving the appropriateness of referrals and waiting times for endoscopic procedures.

OBJECTIVE: There is a lack of standard methods for determining the clinical priority of patients referred by general practitioners (GPs) for specialist outpatient consultations. We introduced a system of progressive involvement by general practitioners and specialists with 80 diagnostic procedures. The aim of this study was to evaluate this new method of prioritization of patients suffering from significant gastroenterological disorders needing rapid access to diagnostic procedures. METHODS: The study included 438 outpatients who were referred for and underwent a gastroscopy or colonoscopy. GPs used a ranking of waiting times for different levels of clinical priority, called 'homogeneous waiting groups'. Specialists also assigned a priority level for each patient as well as evaluating the appropriateness of the referral and the presence of significant endoscopic disorders. Agreement between GPs' and specialists' priority assessments was evaluated by the kappa statistic. RESULTS: Most referrals (74.4%) were deemed low priority by GPs, with no maximum waiting time assigned. The level of agreement between GPs and specialists as regards patients' priorities was poor or moderate: for gastroscopy the kappa was 0.31 (weighted kappa 0.47) and for colonoscopy 0.44 (weighted kappa 0.46). There was an association between the proportion of significant disorders identified with endoscopy and the priority assigned to the referral (chi2 = 18.9, 1 df, p < 0.001). The overall proportion of referrals deemed inappropriate by specialists was 22.1%. CONCLUSIONS: There is value in liaison between GPs and specialists for achieving timely referrals and avoiding delayed diagnosis though higher levels of agreement need to be achieved.

Gastritis staging in clinical practice: the OLGA staging system.

BACKGROUND: The available classifications of gastritis are inconsistently used, possibly because none provides immediate prognostic/therapeutic information to clinicians. As histology reporting of hepatitis in terms of stage is clinically useful and widely accepted, an international group (Operative Link on Gastritis Assessment (OLGA)) proposed an equivalent staging system for reporting gastric histology. Gastritis staging integrates the atrophy score (obtained by biopsy) and the atrophy topography (achieved through directed biopsy mapping). AIM: To test in a prospective cross-sectional study whether OLGA staging consistently stratified patients according to their cancer risk and provided clear prognostic/therapeutic information. METHODS: OLGA staging for gastric cancer risk (0-IV) and gastritis grading (overall score of the inflammatory infiltrate, grade 1-4) were applied in 439 prospectively enrolled, consecutive, dyspeptic outpatients who underwent endoscopy with standardised biopsy sampling. Incidental neoplastic lesions and coexisting peptic ulcers were recorded. Results were presented as stage (including antral (A) and corpus (C) atrophy scores) and H pylori status (eg, A = 3; C = 2: stage IV; Hp+ve). RESULTS: Benign conditions (including duodenal ulcers; p<0.001) consistently clustered in stages 0-II, whereas all neoplastic (invasive and non-invasive) lesions clustered in stages III-IV (p<0.001). CONCLUSIONS: Gastritis staging, combined with H pylori status, provided clinically relevant information on the overall status of the gastric mucosa with implications for prognosis, therapy and management.