Gram-negative bacterium with helical rod shape.Prominent flagellae facilitating penetration of thick mucous layer in the stomach.
(OLGA) system may afford a reliable indication of the cancer risk of individual patients.
Inflammation of the gastric mucosa leads to an increase in both PGI and PGII serum levels, usually with a more marked increase of PGIIand thus a decrease in the PGI/II ratio. With the development of atrophy and loss of specialized cells, both PGI and PGII may decrease, but PGI usually shows a more marked decrease than PGII, thus there is a further decline in the PGI/II ratio (see review by Kuipers EJ: “In through the out door: serology for atrophic gastritis,” Eur J GastroenterolHepatol 2003: 877–879). Thus, a low PGI level, a lowPGI/II ratio, or both, are good indicators of atrophic changes in the gastric mucosa.Subjects with severe gastric atrophy, in whom H pylori has disappeared and who are therefore serologically negative for H pylori, are at a particularly high risk.
both the oxyntic and the antral mucosa have to be “explored”and also considering the incisuraangularis “highly informative” for purpose of establishing earliest onset of atrophic–metaplastic transformation.
Antral atrophy scoreCorpus atrophy score
Patients on PPI, H. pylori may be difficult (or even impossible) to identify histologically at antral or corpus level, in which case coexisting inflammatory lesions (polymorphs and lymphoid infiltrate) may suggest the bacterium’s presence and a comment on the suspectedbacterial etiology (“suspicious for H. pylori infection”) should be added (whatever the stage of atrophy recorded).
OLGA staging sytemSamir Haffar M.D.Assistant Professor of Gastroenterology
Histological classification of gastritis• Sydney system1 1990• Houston version of Sydney system2 1994• Operative Link for Gastritis Assessment3 2005OLGA1 Price AB. J Gastroenterol Hepatol 1991 ; 6 : 209 – 22.2 Dixon MF et al. Am J Surg Pathol 1996 ; 20 : 1161 – 81.3 Rugge M & Genta RM. Human Pathol 2005 ; 36 : 228 – 233.reporting gastritis according to gastric cancer riskfrom lowest (stage 0) to highest (stage IV)
Risk factor for gastric cancer• H. pylori Most consistent risk factorEradication reduces risk of cancer• Genetic factors Cytokines: IL-1β, IL-8, IL-10, TNF-αNo recommended marker at present• Environmental factors N-nitroso compoundsSalted foods, tobacco, alcoholSubordinate to effect of HP infectionProtective effect of NSAID & aspirinMalfertheiner P et al. Gut 2012 ; 61: 646 – 664.
Gastric cancer pathwaysEradication of H pylori reduces risk of gastric cancerBut not eliminate cancer due to predetermined genetic pathways:Hereditary diffuse gastric cancers & autoimmune gastritisTalley NJ. Lancet 2008 ; 372 : 350 – 352.
Carcinogenicity of H. pyloriAtrophic corpus gastritisH. pylori infectionHypochlorhydriaOvergrowth of non-HPorganismsReduce nitrates to nitrites& N-nitrosaminesReduced/absent concentrationsof ascorbic acidAscorbic acid scavengescarcinogenic N-nitrosaminesMalfertheiner P et al. Gut 2012 ; 61: 646 – 664.
Prevention of gastric cancerIdentification of subjects with high risk of gastric cancer• Non-invasive tests Validated serology for H. pyloriLow incidence + Markers of atrophy (pepsinogens)PGI: chief cellPGII: chief cell – pyloric glandsLow PGI or low PG1/PGII → atrophy• Invasive test Gastroscopy & biopsiesHigh incidence OLGA staging system** OLGA: Operative Link for Gastritis AssessmentDinis-Ribeiro M et al. Endoscopy 2012 ; 44 : 74 – 94.Malfertheiner P et al. Gut 2012 ; 61: 646 – 664.
OLGA staging system for gastritisInternational group of gastroenterologists & pathologists• Applies histology reporting format for chronic hepatitis• Given number of portal tracts for staging of hepatitisWell-defined biopsy protocol Antrum (3) – Corpus (2)• Main lesion of cirrhosis risk FibrosisMain marker of gastric cancer Mucosal atrophy• Staging by combining degree of atrophy & topography• Assess risk of gastric cancer Stage 0 to stage 4OLGA: Operative Link for Gastritis AssessmentRugge M & Genta RM. Gastroenterology 2005 ; 129 : 1807 – 8 .
Gastric biopsy sampling protocolA1 – A2Greater & lesser curvatures of distal antrumA3Lesser curvature at incisura angularisC1 – C2Anterior & posterior walls of proximal corpusAt least five biopsiesRugge M et al. Dig Liver Dis 2008 ; 40 : 650 – 658.Minimum requirement for reliable staging of gastritis
Normal & atrophic glandular units in stomachNl mucosecreting gland Non-metaplastic atrophyNormal oxyntic gland Non-metaplastic atrophy Metaplastic atrophyPseudopyloric metaplasiaMetaplastic atrophyIntestinal metaplasiaRuggea M et al. Dig Liver Dis 2008 ; 40 : 650 – 658.AntrumCorpus
OLGA staging system for gastritisCombining degree of atrophy & location• Atrophy No atrophy (0%) Score 0Mild (1 – 30%) Score 1Moderate (31 – 60%) Score 2Severe (> 60%) Score 3• Location Antral atrophy score (Aas) Mean A1 + A2 + A3Corpus atrophy score (Cas) Mean C1 + C2• OLGA Overall Aas & Cas Stage 0, I, II: low riskStage III, IV: high riskRugge M et al. Dig Liver Dis 2008 ; 40 : 650 – 658.
OLGA staging system for gastritisRuggea M et al. Dig Liver Dis 2008 ; 40 : 650 – 658.AntrumNo atrophyScore 0Mild atrophyScore 1Moderate atrophyScore 2Severe atrophyScore 3Stage 0 Stage I Stage II Stage IIStage I Stage I Stage II Stage IIIStage II Stage II Stage III Stage IVStage III Stage III Stage IV Stage IVAtrophy scoreCorpusNo atrophyScore 0Mild atrophyScore 1Moderate atrophScore 2Severe atrophyScore 3
Stage 0 gastritisRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.Visual analog scales at each of biopsy level to stage a given patientH. pylori-status has to be reported
Stage I gastritisRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.Atrophy most frequently detected in angularis incisuraIn patients on PPI, HP may be difficult or impossible to identifyCoexisting polymorphs & lymphoid infiltrate suggest presence of HP
Stage II gastritisRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.Stages 0, I, and II are associated with DU more than GU
Stage III gastritisRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.GU encountered more frequently than in OLGA stages 0 – I – II
Stage III gastritisCorpus predominant atrophy should suggest an autoimmune etiologyRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.
Stage IV gastritisPan-atrophic gastritisEndoscopic surveillance in stage III–IV patientsRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.
Assessment of elementary lesions• H. pylori status Positive – NegativeAbsent in PPI user & atrophic gastritis• Inflammation Lympho-monocytic – PolymorphicMay suggest presence of HP• Metaplasia Intestinal – Pseudo-pyloric• Precancerous lesions IEN (formerly dysplasia)** IEN: Intra-Epithelial NeoplasiaRugge M et al. Dig Liver Dis 2011 ; 43S : S373 – S384.Information on likely etiology: H. pylori, autoimmune,..
Staining for H. pylori• Basic stain Hematoxylin & eosin• Special stain Modified Giemsa• Triple stain GentaEl-Zimaity• ImmunohistochemicalHP status assessed by special stain has to be reported
Eradicating epidemic gastric cancer has long been a dreamNow this dream can come trueRugge M et al. Nat Rev Gastroenterol Hepatol 2012 ; 9 : 128 – 129.