Gastritis and gastric atrophy Hala El-Zimaity a,b

Gastritis and gastric Hala El-Zimaity a,b a Department of Pathology, McMaster University, Hamilton, Ontario, Canada and b Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas, USA Correspondence to Hala El-Zimaity, MD, Hamilton Health Sciences, McMaster Division, 1200 Main Street West, Anatomical Pathology, RM 2N31, Hamilton, ON L8S 3Z5, Canada Tel: +1 905 521 2100 x76637; fax: +1 905 577 0198; e-mail: zimaity@mcmaster.ca Current Opinion in Gastroenterology 2008, 24:682 686 Purpose of review The majority of problems in interpreting gastritis remain Helicobacter related, but their nature has changed. The present review covers gastritis historically through cancer risk staging systems. Recent findings Key points to remember are: Helicobacter is associated with several forms of gastritis; in the present review, I am focusing on the two ends of the disease, Helicobacter pylori infection, that starts with antral predominant gastritis but can continue to oxyntic predominant disease with ; the role Helicobacter pylori plays in autoimmune gastritis with pernicious anemia remains unresolved; gastritis staging systems for cancer risk, namely Baylor and Operative Link on Gastritis Assessment, are currently available. Summary As most gastric carcinomas arise on a background of atrophic gastritis, and the risk increases with the extent of, an index of location and extent could be useful in predicting patients at greatest risk for carcinoma. It is now possible to stage patients for cancer risk. Nonetheless, in a field such as gastritis in which many issues remain unresolved, a classification or staging system that is more descriptive will likely prove more useful. Keywords, gastritis, staging Curr Opin Gastroenterol 24:682 686 ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins 0267-1379 Introduction As the development of gastric carcinoma is an unpredictable process, recognizing the presence and extent of gastritis with associated can help identify patients with different gastric cancer risk. The present review is an overview of our approach to gastritis, including the most recently described histology-based gastritis staging systems, the Baylor System [1] and Operative Link on Gastritis Assessment (OLGA) System [2,3 ]. Our past understanding of gastritis patterns Before the rediscovery of Helicobacter pylori, it was known that different patterns of gastritis were associated with different diseases [4,5]: (1) antral predominant gastritis with little or no gastric in duodenal ulcer disease with normal or increased acid secretion [6 9], (2) extensive gastritis with corpus (and invariably antral) in gastric ulcer disease, which tends to progress through intestinal metaplasia to intestinal type gastric cancer with hypochlorhydria or achlorhydria [6,10 13], and (3) corpus predominant gastritis in autoimmune gastritis. It was suggested that in the intestinal form of gastric carcinoma begins at the antrum corpus junction, specifically at the incisura angularis, with subsequent spread of foci up and down the lesser curvature and the anterior and posterior wall. Although Western countries concept of gastric was heavily influenced by Correa s proposal [14] of multifocal independent foci of (at the time equated with intestinal metaplasia) throughout the stomach [14,15], Eastern countries recognized the presence of an advancing atrophic border endoscopically in 1969 [16], a change they attributed to aging. Fueled by a need to group patients by cancer risk, Filipe et al. [17] suggested subtyping intestinal metaplasia using high iron diamine; intestinal metaplasia subtyped III (incomplete) was considered to be the most precancerous. Other forms of gastric such as pseudopyloric metaplasia have been observed particularly in gastric remnants following distal gastrectomy with gastroenteric anastomosis [18], but many considered it a sequel of autoimmune gastritis 0267-1379 ß 2008 Wolters Kluwer Health Lippincott Williams & Wilkins DOI:10.1097/MOG.0b013e328311d1cc

Gastritis and gastric El-Zimaity 683 [14,19,20]. In practice, it likely is a sequel of longstanding chronic inflammation of any cause. Our present understanding of gastritis patterns It is now recognized that a person s acid secretory status affects both the distribution and severity of H. pylorirelated gastritis and, therefore, indirectly determines whether they develop duodenal or gastric ulcer disease and, thus, their risk for gastric cancer [21 23]. In the early stages in which H. pylori-associated gastritis is antral predominant, the acid secretion of the oxyntic mucosa shows an exaggerated gastrin response to H. pylori, an increase enough to cause duodenal ulcer disease in some patients [7]. With continued inflammation, the development of hypochlorhydria and achlorhydria facilitates the proximal migration of the bacteria that allows the development of corpus gastritis and, eventually, corpus [24 26]. The natural history of H. pylori-related gastritis is for the inflammation to progress from the antrum into the adjacent corpus resulting in an advancing atrophic front of corpus injury (metaplastic and nonmetaplastic [14,27]), which incrementally destroys parietal cells causing further reduction in acid secretion and, thus, further proximal advancement of inflammation with associated injury with the eventual development of extensive corpus [21,27,28]. This situation is accelerated in clinical scenarios associated with low acid secretion such as chronic therapy with proton pump inhibitors, which is widely used in gastroesophageal reflux disease [29 31]. Thus, antral predominant gastritis may, in some instances, represent an earlier stage of atrophic pangastritis such that these patterns actually represent two ends of the spectrum of H. pylori infection rather than mutually exclusive diseases [21,32,33]. Interestingly, several investigators implicated H. pylori in modulating the host s immune response through molecular mimicry or cross-reactivity between H. pylori and the human stomach [14,34 37]. Recognizing that chronic autoimmune gastritis is significantly more common in H. pylori-infected patients with anti H þ K þ -ATPase antibodies [37 39] challenged our previous perception of autoimmune gastritis and H. pylori-related gastritis as two separate diseases. As studies on autoimmune gastritis preceded the rediscovery of H. pylori, many believed that simultaneous infection with H. pylori masked the pathology seen in autoimmune gastritis. For example, extensive pseudopyloric metaplasia with focal intestinal metaplasia, previously thought to be more common in later stages of autoimmune gastritis [14,19,20], is increasingly recognized in H. pylori-associated gastritis [27,40 42]. Some suggested that pernicious anemia (autoimmune gastritis) could be a long-term consequence of H. pylori infection [43]. Yet, contrary to classical autoimmune gastritis, patients with H. pylori-associated chronic gastritis exhibit a gradual decrease in acid secretion but seldom develop enterochromaffin-like cell (ECL) hyperplasia or megaloblastic anemia [44]. In addition, countries with a high incidence of gastric carcinoma do not have a high incidence of pernicious anemia. H. pylori may be responsible for initiating the process; nonetheless, only patients with a genetic predisposition will develop early destruction of corpus glandular components precipitating relatively rapid and profound achlorhydria and secondary hypergastrinaemia with the eventual development of ECL hyperplasia and gastric carcinoids. Classifications systems of gastritis As the progression from chronic gastritis to severe gastric mucosal is not inevitable and disease progression varies considerably from person to person [28], the recognition of a person s gastritis pattern is paramount. Several classifications systems have been introduced with the goal of understanding the status of the gastric mucosa [14,45,46]; the present classification of chronic gastritis the updated Sydney System takes into account the topography and morphology of gastric mucosal changes in addition to the microbiological aspects of the disease [14] (Table 1). Corpus, the precursor for intestinal-type gastric carcinoma, is currently defined as the loss of normal glands with and without its replacement with fibrosis, intestinal metaplasia or pseudopyloric metaplasia, also called pyloric metaplasia or mucus metaplasia and ulcerassociated cell lineage (Nick Wright, personal communication), or all [14,27,42]. Although incomplete intestinal metaplasia has been linked to gastric carcinoma, subtyp- Table 1 Gastritis classification systems (time period, 1972 1996) Year Classification system Comments 1972 Whitehead Mucosa type Type and stage of activity Presence and type of metaplasia 1973 Strickland-Mackay A (autoimmune) and B (nonautoimmune) 1975 Glass and Pitchumoni modification of Strickland-Mackay A (autoimmune), B (antrum), and AB 1990 Sydney Nonatrophic Atrophic Autoimmune Multifocal Special forms 1996 Updated Sydney Same as above, biopsy location changed from anterior and posterior wall to greater and lesser curve

684 Stomach and duodenum Table 2 The current gastritis staging systems for gastric (Baylor [1] and Operative Link on Gastritis Assessment [3 ]) have different biopsy site(s) protocols and different staging system criteria Biopsy System OLGA Baylor Those recommended by updated Sydney System (Fig. 1) Additional biopsy sites were taken (Fig. 1) OLGA, Operative Link on Gastritis Assessment. Gastritis stage is obtained by combining antral with oxyntic scores (Fig. 2) An average reading is given for antrum. Corpus stage is independent of antral and independent of individual reading in each biopsy but dependent on location. Assuming that the atrophic border is circumferential, and the more proximal the extends, the greater the amount of present, at a distal location is graded mild and at a proximal location is graded severe ing intestinal metaplasia failed as a marker of disease severity, as areas of intestinal metaplasia (or a certain subtype) are generally small and can easily be missed in biopsy [27,47]; subtyping intestinal metaplasia is confined to research setting [14]. Nonetheless, recognizing the presence of does not equate with cancer, although, at least with the intestinal variant of carcinoma, the risk increases with the degree of and metaplasia. Aware of these impediments, two gastritis staging systems for (Baylor [1] and OLGA [3 ]) with different biopsy site(s) protocols and different staging system criteria have been introduced (Table 2, Figs 1 and 2). The two systems have had variable success. Whereas the Baylor gastritis staging system matched noninvasive testing of gastric with serum concentrations of pepsinogens and gastrin-17 levels used as indirect measure of gastric mucosal functional integrity [1], the OLGA system was successful in subgrouping patients by cancer risk [3 ]. On comparing both systems, the Baylor system was, not surprisingly, more sensitive in identifying, particular in early cases (unpublished data). Summary Our understanding of gastritis has seen many strides. In the early 1970s, gastritis was classified into autoimmune (type A) and nonautoimmune (type B: antral predominant). At that time, duodenal ulcer, gastric ulcer, and gastric cancer represented three primary diseases that affected the stomach. Today, H. pylori takes center stage, and we suspect that duodenal ulcer and gastric cancer are two ends of one disease, namely, H. pylori infection [21 23]. The prevalence of H. pylori is decreasing as a result of children not becoming infected in addition to treatment Figure 1 Recommended biopsy site(s) for the Sydney System include two from the antrum (A 1 and A 2 ), one from the incisura (1A) and two from the corpus (B 1 and B 2 ) The Baylor System uses the same biopsy sites as the Sydney System with additional distal biopsies from the corpus and antrum (Baylor).

Gastritis and gastric El-Zimaity 685 Figure 2 The Operative Link on Gastritis Assessment System Corpus Antrum Atrophy score No (score 0) Mild (score 1) Moderate (score 2) Severe (score 3) No (score 0) Mild (score 1) Stage 0 Stage I Stage II Stage II Stage I Stage I Stage II Stage III Moderate (score 2) Stage II Stage II Stage III Stage IV Severe (score 3) Stage III Stage III Stage IV Stage IV of H. pylori in both duodenal ulcer patients and asymptomatic patients [48,49]; gastric cancer secondary to H. pylori gastritis may not be tomorrow s challenge particularly in Western countries. As most gastric carcinomas arise on a background of atrophic gastritis, and the risk increases with the extent of, an index of location and extent could be useful in predicting patients at greatest risk for carcinoma. The OLGA system, although useful for categorizing patients by cancer risk [50], lacks an index of location in addition to requiring a degree of memorization (or constant referral to the chart) for criteria used for each stage. Further, it is not intuitive, as severe in the antrum and severe in the corpus both receive the same score. In the changing field of gastritis, a classification that is more descriptive will likely prove more useful. This extends to other gastritides such as those accompanying inflammatory bowel disease or autoimmune gastritis or both, in which disease presentation and progression are not yet well defined. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 751). 1 Graham DY, Nurgalieva ZZ, El-Zimaity HM, et al. 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