Areae Gastricae Research Articles

Endoscopic Features of Autoimmune Gastritis: Focus on Typical Images and Early Images.

Autoimmune gastritis (AIG) is chronic atrophic gastritis caused by an autoimmune mechanism of unknown etiology and presents with various pathological conditions by causing an achlorhydria state through parietal cell damage. The most characteristic endoscopic finding in AIG is advanced corpus-dominant mucosal atrophy. A recent study that examined several cases in Japan revealed the presence of endoscopic features other than corpus-dominant advanced atrophy. Remnants of oxyntic mucosa and sticky adherent dense mucus were found in ≥30% of cases, and hyperplastic polyps were found in ≥20% of cases. In image-enhanced endoscopy (IEE), white globe appearance (WGA) was observed in 32% of AIG cases. Additionally, some reports have stated that the findings in AIG cases using IEE showed cast-off skin appearance (CSA) and foveola type mucosa; however, a consensus is yet to be achieved. These endoscopic results were found in cases of advanced-stage AIG. There have been few reports concerning early-stage AIG cases. In these few reports, all of the cases were pathologically diagnosed as early AIG. In all of the cases, the pathological findings almost always showed neither parietal cell destruction nor atrophy. Endoscopic findings such as “mosaic pattern with slight swelling of the areae gastricae”, “diffuse reddened and edematous gastric fundic gland mucosa”, and “pseudopolyp-like nodules” may be common characteristics of early images. In such early cases, high antibody titers, no atrophic changes, and few clinical abnormal findings were shown. Endoscopists are expected to update their knowledge regarding AIG diagnosis with the evolution of imaging equipment.

Investigation of mucosal pattern of gastric antrum using magnifying narrow-band imaging in patients with chronic atrophic fundic gastritis.

BackgroundMagnifying narrow-band imaging (M-NBI) can reportedly help predict the presence and distribution of atrophy and intestinal metaplasia in the gastric corpus. However, the micro-mucosal pattern of the antrum shown by M-NBI differs from that of the corpus. We studied the distribution and histology of the micro-mucosal pattern in the antrum based on magnifying endoscopy.MethodsEndoscopic images of the greater curvature of the antrum were evaluated in 50 patients with chronic atrophic fundic gastritis (CAFG). The extent of CAFG was evaluated by autofluorescence imaging. The micro-mucosal pattern was evaluated by M-NBI and classified into groove and white villiform types. The localization of white villiform type mucosa was classified into three types in relation to the areae gastricae: null, central, and segmental types. Biopsies were taken from regions showing different micro-mucosal patterns. Associations among the extent of CAFG, micro-mucosal pattern, and histology were examined.ResultsAs the extent of CAFG increased, the proportion of white villiform type mucosa increased, whereas that of groove type mucosa decreased (P=0.022). In patients with extensive CAFG, most of the areae gastricae was composed of the segmental or central type of white villiform type mucosa (P=0.044). The white villiform type mucosa had significantly higher grades of atrophy (P=0.002) and intestinal metaplasia (P<0.001) than did the groove type mucosa.ConclusionWhite villiform type mucosa is indicative of atrophy and intestinal metaplasia in the gastric antrum. It extends to the whole or central part of the areae gastricae as CAFG becomes more extensive.

Correlation between the ABC classification and radiological findings for assessing gastric cancer risk.

To investigate the correlation between ABC risk assessment and radiological findings of gastric mucosa and to propose an improved method for gastric cancer screening. We evaluated 318 participants with Helicobacter pylori (Hp) antibody titers, serum pepsinogen (PG) and upper GI radiography and then classified them into three groups: A, double-negative; B, Hp-positive, PG-negative; C, PG-positive. Group A was subclassified as: A-1, Hp antibody titer <3.0 U/ml; A-2, Hp antibody titer ≥3.0 U/ml. Results for group A and non-A (B or C) participants and radiological findings of gastric mucosa (fold and area gastricae) were analyzed retrospectively. Radiological findings differed significantly between the 207 A-1 and 98 non-A group. Odds ratios were 17.72 for fold distribution, 10.63 for fold thickness, 6.10 for fold characteristics, and 10.62 for area gastricae. Presence of ≥2 risk factors offered 90.3% sensitivity, 94.7% specificity, and 93.3% accuracy. Nine (69.2%) of the 13 A-2 group participants and 11 (5.3%) A-1 group participants had a risk for gastric cancer according to radiological findings. A good correlation exists between ABC classifications and radiological findings for gastric cancer risk, but some discrepant cases exist. We recommend both methods as screening for gastric cancer.

Prediction ofHelicobacter pyloriInfection Status via Close Observation of Gastric Mucosal Pattern by Standard Endoscopy

2 , Cheorwon, Korea Background/Aims: Common endoscopic findings in stomachs with Helicobacter pylori infections include antral nodularity, thick- ened gastric folds, and visible submucosal vessels. These findings are suggestive but not diagnostic of H. pylori infection. Magnifying endoscopy can reveal more precisely the abnormal mucosal patterns in an H. pylori-infected stomach; however, it requires more training, expertise, and time. We aimed to establish a new classification for predicting H. pylori-infected stomachs by non-magnify- ing standard endoscopy alone. Materials and Methods: A total of 617 participants who underwent gastroscopy were prospectively enrolled from August 2011 to January 2012. We performed a careful close examination of the corpus at the greater curvature maintaining a distance ≤10 mm be- tween the endoscope tip and the mucosal surface. We classified gastric mucosal patterns into four categories: normal regular ar- rangement of collecting venules (numerous minute red dots), mosaic-like appearance (type A; swollen areae gastricae or snakeskin appearance), diffuse homogenous redness (type B), and mixed pattern (type C; irregular redness with groove) to predict H. pylori infection status. Results: The frequencies of H. pylori infection in patients with a normal regular arrangement of collecting venules pattern and types A, B, and C patterns were 9.4%, 87.7%, 98.1%, and 90.9%, respectively. The sensitivity, specificity, and positive and negative pre- dictive values of all abnormal patterns for prediction of H. pylori infection were 93.3%, 89.1%, 92.3%, and 90.6%, respectively. The overall accuracy was 91.6%. Conclusions: Careful close observation of the gastric mucosal pattern with standard endoscopy can predict H. pylori infection status. (Korean J Helicobacter Up Gastrointest Res 2014;14:45-51)

Endoscopic diagnosis of gastric intestinal metaplasia: A prospective multicenter study

Intestinal metaplasia (IM) of the gastric mucosa has long attracted attention as a premalignant lesion involved in gastric carcinogenesis. However, endoscopic diagnosis of IM has remained unclear for a long time. In recent years, the methylene blue staining technique and narrow-band imaging (NBI) magnifying endoscopy have facilitated clinical diagnosis of IM, although these methods have some problems due to their complexity. Simple methods for diagnosis of IM using conventional endoscopy and the indigo carmine contrast (IC) method are necessary. This study was a multicenter, prospective, randomized, comparative study involving 10 facilities. The appearance of IM was examined using conventional and IC methods with an electronic endoscope. Subjects included 163 patients, of whom 87 and 76 underwent conventional and IC methods, respectively. Sensitivity, specificity, and receiver operating characteristic/area under thecurve (ROC/AUC) of conventional and IC methods for the detection of IM in the gastric antrum showed that diagnostic performance of the conventional method was higher, but not significantly, than that of the IC method. Sensitivity, specificity and ROC/AUC of conventional and IC methods for the detection of IM in the gastric body showed that the IC method yielded better (but not significantly better) results than the conventional method. The diagnostic performance of the conventional method did not significantly differ from that of the IC method. A villous appearance, whitish mucosa, and rough mucosal surface, as observed by both methods, and areae gastricae pattern, as observed by the IC method, were useful indicators for endoscopic diagnosis of IM.

Close observation of gastric mucosal pattern by standard endoscopy can predict Helicobacter pylori infection status

Common endoscopic findings in stomachs with Helicobacter pylori infections include antral nodularity, thickened gastric folds, and visible submucosal vessels. These findings are suggestive but not diagnostic of H. pylori infection. Magnifying endoscopy can reveal more precisely the abnormal mucosal patterns in an H. pylori-infected stomach; however, it requires more training, expertise, and time. We aimed to establish a new classification for predicting H. pylori-infected stomachs by non-magnifying standard endoscopy alone. A total of 617 participants who underwent gastroscopy were prospectively enrolled from August 2011 to January 2012. We performed a careful close-up examination of the corpus at the greater curvature maintaining a distance ≤ 10 mm between the endoscope tip and the mucosal surface. We classified gastric mucosal patterns into four categories: normal regular arrangement of collecting venules (numerous minute red dots), mosaic-like appearance (type A; swollen areae gastricae or snakeskin appearance), diffuse homogenous redness (type B), and untypical pattern (type C; irregular redness with groove) to predict H. pylori infection status. The frequencies of H. pylori infection in patients with a normal regular arrangement of collecting venules pattern and types A, B, and C patterns were 9.4%, 87.7%, 98.1%, and 90.9%, respectively. The sensitivity, specificity, and positive and negative predictive values of all abnormal patterns for prediction of H. pylori infection were 93.3%, 89.1%, 92.3%, and 90.6%, respectively. The overall accuracy was 91.6%. Careful close-up observation of the gastric mucosal pattern with standard endoscopy can predict H. pylori infection status.

Comprehensive Investigation of Areae Gastricae Pattern in Gastric Corpus using Magnifying Narrow Band Imaging Endoscopy in Patients with Chronic Atrophic Fundic Gastritis

Background:Barium radiographic studies have suggested the importance of evaluating areae gastricae pattern for the diagnosis of gastritis. Significance of endoscopic appearance of areae gastricae in the diagnosis of chronic atrophic fundic gastritis (CAFG) was investigated by image-enhanced endoscopy.Materials and Methods:Endoscopic images of the corpus lesser curvature were studied in 50 patients with CAFG. Extent of CAFG was evaluated with autofluorescence imaging endoscopy. The areae gastricae pattern was evaluated with 0.2% indigo carmine chromoendoscopy. Micro-mucosal structure was examined with magnifying chromoendoscopy and narrow band imaging.Results:In patients with small extent of CAFG, polygonal areae gastricae separated by a narrow intervening part of areae gastricae was observed, whereas in patients with wide extent of CAFG, the size of the areae gastricae decreased and the width of the intervening part of areae gastricae increased (p < 0.001). Most areae gastricae showed a foveola-type micro-mucosal structure (82.7%), while intervening part of areae gastricae had a groove-type structure (98.0%, p < 0.001). Groove-type mucosa had a higher grade of atrophy (p < 0.001) and intestinal metaplasia (p < 0.001) compared with foveola type.Conclusions:As extent of CAFG widened, multifocal groove-type mucosa that had high-grade atrophy and intestinal metaplasia developed among areae gastricae and increased along the intervening part of areae gastricae. Our observations facilitate our understanding of the development and progression of CAFG.

Primary gastrointestinal lymphomas: A radiological–pathological review. Part 1: Stomach, oesophagus and colon

Primary gastrointestinal lymphomas are most common in the stomach, followed by small intestine and then colon. The most frequently used pathology classification of lymphomas is the Revised European and American Lymphoma /World Health Organization classification. The correlation of radiological morphology with histology is relatively poor, although characteristic subtypes will be discussed. In the stomach, the majority of primary lymphomas are of B-cell origin of mucosa-associated lymphoid tissue (MALT) type. Low-grade MALT lymphomas are associated with Helicobacter pylori infection and often respond to eradication of this organism. Radiological features include thickened folds, nodularity, depressed lesions, ulcers, prominent areae gastricae. High-grade (large B-cell) tumour patterns include infiltrative, polypoid, nodular, ulcerated or a combination. Endoscopy, endoscopic ultrasound and CT are important in diagnosis and staging, although appearances on barium studies should be recognized. Primary colonic lymphomas are rare. Most are of B-cell origin. Focal and diffuse forms are seen, the former producing polypoid or nodular or cavitating masses and the latter producing ulcerative or nodular (polyposis) patterns on imaging. Even when circumferential, lymphoma rarely causes obstruction. Small bowel lymphomas will be discussed in the forthcoming part 2 of this review.

WE‐C‐I‐609‐06: Computerized Texture Analysis of Abnormal Areae Gastricae On Double‐Contrast Barium Examinations

Purpose: Abnormal areae gastricae occur in the body due to gastritis. Very frequently, gastritis is caused by the Heliobactor Pylori bacteria, in which case it can be treated with antibiotics. The purpose of this study is to assess the ability of computerized radiographic texture analysis to recognize the presence of abnormal areae gastricae. Potentially, this could aid radiologists in classifying radiographic features of the areae gastricae in pathologic states. Method and Materials: Digitized double‐contrast radiographs for 23 cases were obtained. Each case was classified as normal or abnormal based on clinical symptoms and the results of endoscopic examination, H Pylori testing, and/or barium examination. Similar locations of the gastric area were selected on each image from the lower region of the stomach. These regions were then divided into 64 × 64 and 128 × 128 regions of interest (ROI) for texture analysis. Standard deviation, and Fourier and Fractal based features were calculated for all ROIs. ROC analysis was performed on the results to test the ability to distinguish between normal and gastritic cases, using round‐robin analysis. Results: The texture analysis showed that there is a separation between the normal and abnormal cases. For 64 × 64 ROIs, ROC analysis yielded Az values in a range of 0.54 to 0.80 for single features and a range of 0.70 to 0.806 for multiple features. For 128 × 128 ROIs, single feature ROC analysis yielded Az values in a range of 0.55 to 0.85 for single features and a range of 0.77 to 0.8694 for multiple features. Conclusion: The results indicate that radiographic texture analysis of digitized double‐contrast radiographs have the potential to distinguish between normal and abnormal cases of areae gastricae. Conflict of Interest: ML Giger is a shareholder in R2 Technology, Inc., Sunnyvale, CA.

Gastric lymphoid hyperplasia: radiological evidence of childhood Helicobacter pylori infection

Helicobacter pylori is a spiral-shaped bacterial pathogen that lives almost exclusively in human gastric mucosa. Infection with H. pylori occurs primarily in early childhood1–3 causing chronic gastritis. This is associated with the development of gastric and duodenal ulceration, gastric adenocarcinoma and non-Hodgkin's lymphoma.4 The potential benefits of identification in a symptomatic patient and subsequent eradication are therefore considerable. The presenting symptoms of H. pylori in paediatric patients can include nausea, vomiting and epigastric pain,5 a clinical setting in which an upper gastrointestinal contrast study is often carried out. Therefore any manifestation of H. pylori that can be identified on contrast studies would be important. The radiological appearances that have been shown to be significantly associated with H. pylori infection include gastric fold thickening, polypoid gastritis, enlarged areae gastricae and antral erosions.6 An endoscopic feature of H. pylori often seen in children is gastric lymphoid hyperplasia.7 This finding has, however, only been described once in childhood on an upper gastrointestinal double contrast study, in a single case report.8 We present a case series of six paediatric patients who were demonstrated to have radiological evidence of lymphoid hyperplasia and subsequently had H. pylori infection confirmed. Strong evidence is therefore provided that the radiological appearance of lymphoid hyperplasia in children is synonymous with H. pylori infection.

Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection.

The purpose of this study was to characterize the radiographic findings of antral gastritis and to determine whether there are differences in the appearance of antral gastritis in patients with and without Helicobacter pylori infection. A search of radiology, endoscopy and pathology files revealed 90 patients with antral gastritis on double contrast upper gastrointestinal tract studies who had endoscopy with testing for H. pylori. The barium studies were evaluated to further characterize the findings of antral gastritis without knowledge of the H. pylori status of the patients or of the endoscopy or pathology findings. The radiographic findings of antral gastritis included thickened folds in 67 patients (74%), polypoid antral gastritis (a subset of patients with thickened folds) in 6 (9%), antral erosions in 21 (23%), enlarged areae gastricae in 14 (16%), crenulation of the lesser curvature in 4 (4%), mucosal nodularity in 2 (2%), a hypertrophied antral-pyloric fold in 2 (2%) and antral striae in 1 (1%). 43 patients (48%) with antral gastritis were H. pylori positive and 47 patients (52%) were H. pylori negative. Thickened folds were detected in 39 H. pylori-positive patients (91%) with antral gastritis vs 28 H. pylori-negative patients (60%) (p<0.001); polypoid gastritis in 6 H. pylori-positive patients (14%) vs 0 H. pylori-negative patients (p<0.05); enlarged areae gastricae in 14 H. pylori-positive patients (33%) vs 0 H. pylori-negative patients (p<0.0001); and antral erosions in 2 H. pylori-positive patients (5%) vs 19 H. pylori-negative patients (40%) (p<0.0001). Our experience suggests that antral gastritis caused by H. pylori infection is associated with characteristic features on double contrast studies (including thickened folds, polypoid gastritis and enlarged areae gastricae) and that this condition is rarely associated with antral erosions. Thus, radiologists can often suggest whether the patient's gastritis is caused by H. pylori on the basis of radiographic findings.

Gastric mucosa-associated lymphoid tissue lymphoma: spectrum of findings at double-contrast gastrointestinal examination with pathologic correlation.

Mucosa-associated lymphoid tissue (MALT) is found in the surface epithelium of the stomach. MALT lymphoma is extranodal lymphoma originating from MALT. In the stomach, a strong association with Helicobacter pylori infection has been demonstrated. Low-grade gastric MALT lymphoma has been reported to have variable features at upper gastrointestinal (UGI) examination. Twenty-two patients with low-grade MALT lymphoma had ulcers (n = 11), fold thickening (n = 7), mucosal nodularity (n = 7), masses (n = 6), or prominent areae gastricae (n = 4) at UGI examination. Six patients with high-grade MALT lymphoma had masses (n = 4), fold thickening (n = 3), ulcers (n = 1), or mucosal nodularity (n = 1) at UGI examination. These findings were similar to those in gastric carcinoma or gastritis. Differentiation of low-grade MALT lymphoma from gastritis or gastric carcinoma was more difficult than differentiation of high-grade MALT lymphoma. Lesions of MALT lymphoma associated with H pylori gastritis were diffuse or multiple in 65% of cases; however, lesions of MALT lymphoma without proved H pylori gastritis were focal or solitary in 80% of cases. Therefore, multiplicity of lesions in MALT lymphoma was closely associated with H pylori infection.

Visualization of areae gastricae on double-contrast upper gastrointestinal radiography: relationship to age of patients.

The purpose of this study was to determine whether the frequency of visualization of areae gastricae on double-contrast upper gastrointestinal tract examinations is related to a patient's age. A total of 141 double-contrast upper gastrointestinal tract examinations with normal findings were reviewed for the presence or absence of areae gastricae on double-contrast images of the stomach. All images were evaluated by two radiologists who were blinded to the age of the patients. The data were then analyzed to determine if the frequency of visualization of areae gastricae on double-contrast studies was significantly related to the age of patients. The frequency of visualization of areae gastricae increased significantly with increasing age (p = 0.008). The youngest age group (20--29 years old) exhibited areae gastricae in only four (19%) of 21 cases, whereas the oldest age group (> or = 70 years old) exhibited areae gastricae in 19 (76%) of 25 cases. On average, the rate of visualization of areae gastricae on double-contrast studies increased by 9% per decade. Our data show that the frequency of visualization of areae gastricae on double-contrast upper gastrointestinal tract examinations increases significantly with increasing patient age. It is important for radiologists to be aware of the effect of aging on the delineation of areae gastricae on double-contrast studies.

Prominent area gastricae is associated with Helicobacter pylori gastritis in children

Prominent area gastricae is associated with Helicobacter pylori gastritis in children

Gastritis and gastropathy of childhood.

Gastritis and gastropathy of childhood.

Lymphoid hyperplasia of the stomach caused by Helicobacter pylori: upper gastrointestinal findings.

H elicobacter pylon has become recognized as a leading cause of gastritis and peptic ulcer disease in both adults and children [1]. A spectrum of endoscopic and radiographic manifestations of H. pylon infection has been reported, including gastric fold thickening, antral nodularity and narrowing, enlarged areae gastricae, and gastric and duodenal ulcers [2-5]. One feature seen at endoscopy predominantly in children with H. pylon infection is the presence of gastric lymphoid hyperplasia [6]. We present the upper gastrointestinal findings of gastric lymphoid hyperplasia in a child with biopsy-proven H. pylon gastritis. Recognition of this radiographic pattern of H. pylon infection is important for prompt diagnosis and treatment.

Low-grade gastric mucosa-associated lymphoid tissue lymphoma: correlation of radiographic and pathologic findings.

To describe upper gastrointestinal (Gl) examination findings of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma and to correlate them with pathologic examination findings. A retrospective review of upper Gl examinations was performed in 25 patients with proved low-grade gastric MALT lymphomas. Upper Gl examinations were reviewed for common findings and most probable diagnosis, and these findings were correlated with pathologic findings in resected specimens in 15 patients. The common findings at upper Gl examination included mucosal nodularity (n = 13), ulcer (n = 12), rugal thickening (n = 6), mass (n = 4), and enlarged areae gastricae (n = 2). The most probable diagnoses were early gastric carcinoma (n = 7), advanced gastric carcinoma (n = 6), gastritis (n = 9), and lymphoma (n = 3). Of 17 lesions found on resected specimens, six ulcers and two masses were not depicted at barium study. Disorganized convergent rugae projecting to multiple points and vague ulcer margins were present in four and seven lesions, respectively. Multiple ulcers were seen in two patients. Although the common radiographic and pathologic findings observed in low-grade gastric MALT lymphomas were similar to those of gastric carcinomas or gastritis, disorganized convergent rugae, vague ulcer margins, and multiplicity of lesions may be helpful in differentiating them from gastric carcinomas or gastritis.

Interobserver agreement and predictive value of endoscopic findings for H. pylori and gastritis in normal volunteers

Background: Endoscopic findings such as erythema are frequently labeled as gastritis. We sought to determine interobserver agreement for specific endoscopic features and assess the diagnostic value of features with good agreement for Helicobacter pylori and histologic gastritis. Methods: Fifty-two healthy subjects without ulcers, erosions, or hemorrhages had a full endoscopy recorded on video tape. Biopsy specimens were examined for H. pylori and gastritis. Two endoscopists independently reviewed the tapes for predefined features (erythema, area gastricae, clefts, and nodularity) in the gastric body and antrum. Diagnostic value of endoscopic features with acceptable agreement (κ > 0.40) was then determined for H. pylori and gastritis. Results: κ was greater than 0.40 only for prominent body area gastricae (0.49), body nodularity (0.65), and antral nodularity (0.68). For antral nodularity, sensitivity was 32%, specificity was 96%, and positive predictive value was 90% for H. pylori . When both antral nodularity and body area gastricae were both present, sensitivity was only 18% but specificity and positive predictive value were 100%. Conclusion: Interobserver agreement is poor for some features such as erythema labeled as gastritis. Antral nodularity is a fairly reproducible finding and is very specific, though not sensitive, for H. pylori gastritis. (Gastrointest Endosc 1995;42:420-3.)

Compression filming with high-density barium suspensions.

A method is described for use of high-density barium suspension (250% wt/vol) during compression filming performed in conjunction with the double-contrast examination of the stomach. The technique employs control of the distribution of barium within the stomach by table tilting and use of the vertebral column to stabilize the posterior wall of the stomach. The technique allows routine demonstration of the area gastricae and gastric erosions on compression films, as well as detection of anterior wall lesions that may be undetected by double-contrast films.

Superficial flat-type early carcinoma of the stomach

A clinicopathologic study was done on 21 cases of superficial flat-type early gastric carcinoma (IIb type EGC). In one case there was the two IIb type EGC. Nine patients had no symptoms, whereas the other 12 had either epigastralgia, hematemesis, or anorexia. The preoperative diagnosis was accurate in 15 patients; eight were demonstrated by barium study, and 13 by endoscopy. The suspicious finding of IIb type EGC was either the disappearance or irregularity of the areae gastricae by barium study and a mucosal color change by endoscopy. Well-differentiated or moderately differentiated adenocarcinomas showed a slight redness of the affected mucosa whereas the poorly differentiated adenocarcinomas were pale in color. Histologically, many well-differentiated or moderately differentiated adenocarcinomas occupied the entire thickness of the mucosal layer whereas most of the poorly differentiated adenocarcinomas spread horizontally with preservation of non-cancerous glands and foveolae. The growth pattern was super type in ten lesions and small mucosal type in 12 and no pen-type growth was seen. Concerning the cell nuclear DNA ploidy pattern, 21 showed a low ploidy pattern and only one had a high ploidy pattern. The IIb type EGC seemed to have a less malignant potential from the viewpoint of growth pattern and DNA ploidy pattern. Care must be taken at the proximal line of excision of the tumor so as not to leave behind residual carcinoma cells.