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 extensiv...

Surveillance strategies for precancerous gastric conditions after Helicobacter pylori eradication: There is still need for a tailored approach

“…However, there is still unresolved debate regarding the best-individualized follow-up strategies, based on malignant risk stratification, due to uncertainty of current evidence and the role of H. pylori inflammatory changes in underestimating IM extension and dysplastic lesions at the index endoscopy (Table 1 )[ 2 - 12 ].…”

“…Notably, a recent prospective cohort study[ 12 ], including 85 Italian patients with H. pylori -related active gastritis, undergoing upper gastrointestinal endoscopy 6 mo following eradication therapy, demonstrated that high-resolution endoscopy with NBI doubled the rate of identifying histological low-grade dysplasia (LGD) missed at pre-treatment endoscopy, in a high-risk subgroup which had extensive atrophy and IM at baseline. In over 40% of patients, visible gastric lesions with LGD were found following H. pylori eradication was not identified at their first pre-treatment endoscopy, thus suggesting that inflammatory changes associated with active H. pylori infection hinder the correct detection of gastric LGD lesions[ 12 ].…”

“…Of interest, in cases of indefinite gastric dysplasia, or with “not visible” dysplasia diagnosed randomly throughout the stomach without endoscopic evidence of visible lesions, the prevailing guidelines recommend a necessary endoscopic reassessment using high-resolution endoscopy with NBI to rule out dysplasia on missed visible lesions[ 12 , 15 ].…”

“…Moreover, some authors consider high-resolution surveillance endoscopy with NBI as “sufficient for a diagnosis of extensive IM or premalignant stomach even without biopsy sampling ”[ 13 ]. There is an established association between the endoscopic grading of gastric intestinal-metaplasia (EGGIM) and operative link on gastritis/intestinal-metaplasia assessment (OLGIM) stages in the assessment of the presence/extent of IM[ 12 , 13 ], and EGGIM stages ≥ 5 with OLGIM III/IV predicts early GC risk[ 12 , 13 ], although its reproducibility needs to be further confirmed in larger prospective studies as also expressed in the U.S. guidelines[ 14 ].…”

“…Nevertheless, even if feasible as a surveillance program in specialized referral centers, this strategy may not be widely applicable in endoscopy units that do not have access to such technologies. A targeted bioptic mapping seems more adequate for identifying mucosal gastric areas at risk of malignant transformation[ 12 ], despite the existing risk of overestimating OLGIM in patients with mild/focal IM. Concomitant H. pylori -related gastritis may limit the accuracy of EGGIM classification at the time of the initial endoscopy.…”