Extensive Intestinal Metaplasia Research Articles

Endoscopic Kyoto and Kimura-Takemoto Classifications Are Comparable in Predicting High-Risk Gastric Precancerous Lesions

Introduction: Severe and extensive gastric atrophy, extensive or incomplete gastric intestinal metaplasia, and gastric dysplasia are considered high-risk gastric precancerous lesions (HGPLs). Endoscopic findings based on the endoscopic Kyoto classification (EKC) and the Kimura-Takemoto classification (KTC) have been reported to be significantly associated with HGPLs. This study aimed to compare these two classifications in predicting active Helicobacter pylori (H. pylori) infection and HGPLs. Methods: This is a cross-sectional study conducted on naïve dyspeptic patients who underwent upper gastrointestinal endoscopy at a tertiary hospital. Endoscopic findings were scored according to the EKC and KTC. Mapping biopsies were taken, and H. pylori infection was determined using a locally validated rapid urease test and histology. The performance of EKC was compared with that of KTC using the area under the receiver operating characteristic curve (AUC) in predicting active H. pylori infection and HGPLs. Results: There were 292 patients with a median age of 46 and a male-to-female ratio of 1:1. The rates of active H. pylori infection and HGPLs were 61.3% and 14.0%, respectively. The EKC was better than the KTC in predicting active H. pylori infection (AUC: 0.771 vs. 0.658, respectively; p < 0.001). However, these two classifications had comparable performance in predicting HGPLs (AUC: 0.792 vs. 0.791, respectively; p = 0.956). Conclusion: Compared to EKC, KTC is inferior in predicting active H. pylori infection but has comparable performance in predicting HGPLs.

A Case of Multiple Gastrointestinal Ulcer: A Rare Presentation of Strongyloidiasis

Strongyloides stercolaris is a common intestinal nematode in tropical and subtropical countries like Bangladesh. The presentation of this infection is nonspecific. Mostly it remains asymptomatic with peripheral eosinophilia. Immunocompromised individuals are at high risk of hyper infection to disseminated disease. We present a case of Strongyloides in an immunocompetent patient with features of gastric outlet obstruction. Laboratory findings revealed hypereosinophilia with multiple gastrointestinal ulcers on endoscopy. Biopsy was taken from a gastric ulcer which revealed ulceration and dense infiltration of acute and chronic inflammatory cells along with extensive intestinal metaplasia. There were tiny helminthic bodies within the mucosal glands and on the surface consistent with Strongyloides stercoralis. Routine examination of stool also revealed larvae of Strongyloides stercolaris. J Dhaka Med Coll. 2022; 31(1) : 163-166

Impact of improved upper endoscopy quality on detection of gastric precancerous lesions.

Intestinal metaplasia (IM) is the point of no return in gastric carcinogenesis, and patients with extensive (antrum plus corpus) IM are at high risk of developing gastric cancer. We evaluated the impact of improved gastroscopy quality on the detection of gastric IM in an Italian area at high risk for gastric cancer. Data of consecutive patients with gastric biopsies according to the updated Sydney System observed in 2013, 2016 and 2019 resulting in IM diagnosis were retrieved. In the first period, endoscopy was performed with standard white light instruments. In the second period, preendoscopic gastric preparation was administered, and the examinations lasting at least 7 min with standard endoscopes were performed. In the third period, the latter procedure was followed, with virtual chromoendoscopy equipped instruments. The prevalence of IM in any gastric site and that of extensive IM were compared among the three periods. Data of 3485 patients were available. The detection of IM in at least one gastric site increased from 29.9 to 33.6% and 34.5% (95% CI, 32.1-36.8) in the first, second and third period, respectively. The difference was statistically significant between the first and last (P = 0.02; OR, 1.24; 95% CI, 1.04-1.48) period. When considering extensive IM, the detection increased from 4.28 to 6.1% and 5.44%, although the difference failed to reach statistical significance (P = 0.076). Our data showed that implementation of a quality protocol increased the probability to detect IM in the stomach, allowing us to select patients deserving stricter follow-up.

S3657 Primary Gastric Adenocarcinoma With Clear Cell Differentiation Presenting With Melena: A Rare Cancer Treated With Hybrid Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Introduction: Primary gastric clear cell carcinoma (GCCC) is an exceedingly rare type of adenocarcinoma. It can often be misdiagnosed as metastatic clear cell cancer with primary lesions in other body organs. We hereby present an interesting case of primary GCCC, successfully removed with hybrid endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Case Description/Methods: A 91-year-old male had ongoing anemia and melena due to intermittent oozing from a gastric body nodule. Previous EGD showed an oozing, nodular lesion in the gastric body (Figure 1A). On EUS, it was a benign, mucosal-based, friable lesion. Pathology revealed gastric intestinal metaplasia. His past history included hyperlipidemia, hypertension, skin cancer, transient ischemic attack, prior colon polyps, and sigmoid resection for diverticulosis. Home medications included cardizem, iron and vitamin C supplements, allopurinol, aspirin, and PPI. He denied recent weight loss, nausea, vomiting, early satiety, chest pain, dyspnea, fever, or dysphagia. He then came to our hospital for endoscopic removal of the gastric lesion. EGD showed a 3-cm sessile polyp on the posterior wall of the gastric body, located along the lesser curvature (Figure 1B, C). The polyp was completely removed by the hybrid EMR and ESD technique. Pathology revealed invasive adenocarcinoma of the intestinal type with clear cell features, arising in a background of extensive intestinal metaplasia (Figure 1; D, E, F). He developed post-procedure urinary retention and underwent temporary Foley's catheter placement, which was removed shortly after. No fever or GI bleeding was noted. After diagnosis, his oncologist recommended concurrent chemoradiotherapy. His most recent PET scan was unremarkable. No melena was reported at the follow-up after 3 months. Discussion: We herein presented a rare and interesting case of primary GCCC. In these patients, it is imperative for endoscopists to differentiate between primary GCCC and metastatic lesions to deliberate upon best therapeutic choice. Pathology with immunohistochemistry is the cornerstone of accurate diagnosis for primary GCCC. Given the extremely rare occurrence, no standard treatment guidelines exist for GCCC. Therefore, the therapeutic approach varies on a case-by-case basis, which largely depends on its localization. For instance, the 3-cm lesion in our patient was located along the lesser curvature and was successfully removed by hybrid EMR and ESD. Therefore, it did not necessitate total gastrectomy.Figure 1.: A: Previous EGD showing an actively oozing, nodular lesion in the gastric body. B and C: EGD showing a 3-cm sessile polyp on the posterior wall of the gastric body, located along the lesser curvature. D, E, and F: Pathologic examination of the polypectomy specimen showing invasive adenocarcinoma of the intestinal type with clear cell features, arising in a background of extensive intestinal metaplasia.

Inverse Association Between Gluteofemoral Obesity and Risk of Non-Cardia Gastric Intestinal Metaplasia

It is unclear whether obesity confers increased risk of non-cardia gastric adenocarcinoma and its precursor, gastric intestinal metaplasia. Here, we examined whether various dimensions of adiposity independently predispose to the development of non-cardia gastric intestinal metaplasia. We compared data from 409 non-cardia gastric intestinal metaplasia cases and 1748 controls without any gastric intestinal metaplasia from a cross-sectional study at the VA Medical Center in Houston, Texas. Participants completed standardized questionnaires, underwent anthropometric measurements, and underwent a study endoscopy with gastric mapping biopsies. Non-cardia gastric intestinal metaplasia cases included participants with intestinal metaplasia on any non-cardia gastric biopsy. We calculated odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression models. Increasing body mass index (BMI) was not associated with risk of non-cardia gastric intestinal metaplasia (per unit BMI adjusted OR, 0.98; 95% CI, 0.96-1.00). Similarly, we found no associations with increase in waist circumference (per 10-cm increase adjusted OR, 0.94; 95% CI, 0.87-1.03) and waist-to-hip ratio (WHR) (per unit WHR adjusted OR, 2.34; 95% CI, 0.37-14.7). However, there was a significant inverse association with gastric intestinal metaplasia and increasing hip circumference, reflecting gluteofemoral obesity (per 10-cm increase adjusted OR, 0.89; 95% CI, 0.80-0.98). The inverse association was observed for both extensive and focal gastric intestinal metaplasia. The independent dimensions of adiposity (BMI, waist circumference) are not associated with increased risk of non-cardia gastric intestinal metaplasia. The inverse association between gluteofemoral obesity and risk of gastric intestinal metaplasia warrants additional study.

Is intestinal metaplasia the point of no return in the progression of gastric carcinogenesis?

Is intestinal metaplasia the point of no return in the progression of gastric carcinogenesis?

Prevalence of Extensive and Limited Gastric Intestinal Metaplasia and Progression to Dysplasia and Gastric Cancer.

Guidelines cite extensive gastric intestinal metaplasia (GIM) as a bigger risk factor for gastric cancer (GC) than limited GIM and an indication for endoscopic surveillance. Data on progression of extensive GIM to GC in the USA are limited. This study aimed to estimate the prevalence and progression rates of extensive GIM in a US cohort. This retrospective study assessed the prevalence of extensive GIM between 1/1/1990 and 8/1/2019 at a large academic medical center. Multivariable regression was used to identify predictors of extensive GIM. Incidence of GC on follow-up was calculated as number of new diagnoses divided by person-years of follow-up. Presence of GIM on subsequent follow-up endoscopy was assessed. Of 1256 individuals with GIM, 352 (28%) had extensive GIM and 904 (72%) had limited GIM. On multivariable analysis, older age (OR 1.01, 95% CI 1.00-1.02) and Hispanic ethnicity (OR 1.55, 95% CI 1.11-2.16) were predictive of extensive GIM. The annual incidence of GC for GIM overall was 0.09%. There was no difference in progression to GC between extensive or limited GIM (IRR 0, 95% CI 0-2.6), or to advanced lesions overall (IRR 0.37, 95% CI 0.04-1.62). 70% of individuals had persistent GIM on follow-up biopsy, and 22% with limited GIM had extensive GIM on follow-up biopsy. 28% of individuals with GIM have the extensive subtype, and are more likely to be older and of Hispanic ethnicity. There was no difference in progression to GC between extensive and limited GIM. Further research is needed to better assess risk of GIM in the US context.

Kyoto classification risk scoring system and endoscopic grading of gastric intestinal metaplasia for gastric cancer: Multicenter observation study in Japan.

The usefulness of endoscopic and histological risk assessment for gastric cancer (GC) has not been fully investigated in Japanese clinical practice. In this multicenter observation study, GC and non-GC patients were prospectively enrolled in 10 Japanese facilities. The Kyoto classification risk scoring system, the Kimura-Takemoto endoscopic atrophy classification, the endoscopic grading of gastric intestinal metaplasia (EGGIM), the operative link on gastritis assessment (OLGA) and the operative link on gastric intestinal metaplasia assessment (OLGIM) were applied to all patients. The strength of an association with GC risk was compared. In addition, important endoscopic findings in the Kyoto classification were identified. Overall, 115 GC and 265 non-GC patients were analyzed. Each risk stratification method had a significant association with GC risk in univariate analysis. In multivariate analysis, OLGIM stage III/IV (odds ratio [OR] 2.8 [95% CI 1.5-5.3]), high EGGIM score (OR 1.8 [1.0-3.1]) and opened-type Kimura-Takemoto (OR 2.5 [1.4-4.5]) had significant associations with GC risk. In the Kyoto classification, opened-type endoscopic atrophy, invisible regular arrangement of collecting venules (RAC), extensive (>30%) intestinal metaplasia in the corpus in image-enhanced endoscopy, and map-like redness in the corpus were independent high-risk endoscopic findings. The modified Kyoto classification risk scoring system using these four findings demonstrated a better area under the receiver operating characteristic curve value (0.750, P = 0.052) than that of the original Kyoto classification (0.706). The OLGIM stage III/IV, high EGGIM score and open-typed Kimura-Takemoto had strong association with GC risk in Japanese patients. The modified Kyoto classification risk scoring system may be useful for GC risk assessment, which warrants further validation. (UMIN000027023).

The Transition from Gastric Intestinal Metaplasia to Gastric Cancer Involves POPDC1 and POPDC3 Downregulation.

Intestinal metaplasia (IM) is an intermediate step in the progression from premalignant to malignant stages of gastric cancer (GC). The Popeye domain containing (POPDC) gene family encodes three transmembrane proteins, POPDC1, POPDC2, and POPDC3, initially described in muscles and later in epithelial and other cells, where they function in cell–cell interaction, and cell migration. POPDC1 and POPDC3 downregulation was described in several tumors, including colon and gastric cancers. We questioned whether IM-to-GC transition involves POPDC gene dysregulation. Gastric endoscopic biopsies of normal, IM, and GC patients were examined for expression levels of POPDC1-3 and several suggested IM biomarkers, using immunohistochemistry and qPCR. Immunostaining indicated lower POPDC1 and POPDC3 labeling in IM compared with normal tissues. Significantly lower POPDC1 and POPDC3 mRNA levels were measured in IM and GC biopsies and in GC-derived cell lines. The reduction in focal IM was smaller than in extensive IM that resembled GC tissues. POPDC1 and POPDC3 transcript levels were highly correlated with each other and inversely correlated with LGR5, OLFM4, CDX2, and several mucin transcripts. The association of POPDC1 and POPDC3 downregulation with IM-to-GC transition implicates a role in tumor suppression and highlights them as potential biomarkers for GC progression and prospective treatment targets.

Liquid nitrogen spray cryotherapy for intramucosal carcinoma and extensive gastric intestinal metaplasia with dysplasia.

Background and AimsGastric intestinal metaplasia with dysplasia (GIM-D) that is visible as a discrete limited lesion on endoscopy is readily treated using endoscopic mucosal resection or endoscopic submucosal dissection. However, there are few options for more extensive and invisible dysplasia. Ablating a wide swath of tissue with argon plasma coagulation or radiofrequency ablation can be challenging and carries risks, including postprocedure ulceration. Liquid nitrogen spray cryotherapy is an established treatment for dysplasia in Barrett’s esophagus, but its use for GIM-D has not been previously reported.MethodsThree patients with intramucosal adenocarcinoma and GIM-D underwent a total of 10 sessions of spray cryotherapy. In all cases, spray cryotherapy was performed after passing an orogastric decompression tube into the stomach for active suctioning. Ablations were performed in cycles of 20 to 40 seconds, with at least 45 seconds between cycles to allow for tissue thawing. Between 2 and 7 ablations were performed during each procedure. Before each procedure, Sydney protocol biopsy specimens were obtained. No patient reported any postprocedure adverse events.ResultsThe first patient underwent 3 sessions of spray cryotherapy; there was no evidence of GIM-D after 1 session, no evidence of gastric intestinal metaplasia after 3 sessions, and no recurrence after 29 months. The second patient underwent 5 sessions of spray cryotherapy; after 1 session there was no adenocarcinoma, and at 14 months there was only GIM-D. The third patient underwent 2 spray cryotherapy sessions, and after 1 session there was gastric intestinal metaplasia but no GIM-D.ConclusionsVery few treatment modalities exist for extensive GIM-D. We present 3 cases in which off-label spray cryotherapy was used to treat extensive high-grade dysplasia with good treatment effect and patient tolerance. This adds to the body of literature supporting spray cryotherapy as a safe, well-tolerated, and effective treatment for extensive GIM-D.

Appropriate Color Enhancement Settings for Blue Laser Imaging Facilitates the Diagnosis of Early Gastric Cancer with High Color Contrast.

PurposeScreening image-enhanced endoscopy for gastrointestinal malignant lesions has progressed. However, the influence of the color enhancement settings for the laser endoscopic system on the visibility of lesions with higher color contrast than their surrounding mucosa has not been established.Materials and MethodsForty early gastric cancers were retrospectively evaluated using color enhancement settings C1 and C2 for laser endoscopic systems with blue laser imaging (BLI), BLI-bright, and linked color imaging (LCI). The visibilities of the malignant lesions in the stomach with the C1 and C2 color enhancements were scored by expert and non-expert endoscopists and compared, and the color differences between the malignant lesions and the surrounding mucosa were assessed.ResultsEarly gastric cancers mainly appeared orange-red on LCI and brown on BLI-bright or BLI. The surrounding mucosae were purple on LCI regardless of the color enhancement but brown or pale green with C1 enhancement and dark green with C2 enhancement on BLI-bright or BLI. The mean visibility scores for BLI-bright, BLI, and LCI with C2 enhancement were significantly higher than those with C1 enhancement. The superiority of the C2 enhancement was not demonstrated in the assessments by non-experts, but it was significant for experts using all modes. The C2 color enhancement produced a significantly greater color difference between the malignant lesions and the surrounding mucosa, especially with the use of BLI-bright (P=0.033) and BLI (P<0.001). C2 enhancement tended to be superior regardless of the morphological type, Helicobacter pylori status, or the extension of intestinal metaplasia around the cancer.ConclusionsAppropriate color enhancement settings improve the visibility of malignant lesions in the stomach and color contrast between the malignant lesions and the surrounding mucosa.

Gastric cancer screening in low incidence populations: Position statement of AEG, SEED and SEAP

This positioning document, sponsored by the Asociacion Espanola de Gastroenterologia, the Sociedad Espanola de Endoscopia Digestiva and the Sociedad Espanola de Anatomia Patologica, aims to establish recommendations for the screening of gastric cancer (GC) in low incidence populations, such as the Spanish. To establish the quality of the evidence and the levels of recommendation, we used the methodology based on the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). We obtained a consensus among experts using a Delphi method. The document evaluates screening in the general population, individuals with relatives with GC and subjects with GC precursor lesions (GCPL). The goal of the interventions should be to reduce GC related mortality. We recommend the use of the OLGIM classification and determine the intestinal metaplasia (IM) subtype in the evaluation of GCPL. We do not recommend to establish endoscopic mass screening for GC or Helicobacter pylori. However, the document strongly recommends to treat H.pylori if the infection is detected, and the investigation and treatment in individuals with a family history of GC or with GCPL. Instead, we recommend against the use of serological tests to detect GCPL. Endoscopic screening is suggested only in individuals that meet familial GC criteria. As for individuals with GCPL, endoscopic surveillance is only suggested in extensive IM associated with additional risk factors (incomplete IM and/or a family history of GC), after resection of dysplastic lesions or in patients with dysplasia without visible lesion after a high quality gastroscopy with chromoendoscopy.

Opportunistic upper endoscopy during colonoscopy as a screening strategy for countries with intermediate gastric cancer risk.

Background and AimScreening upper endoscopy can detect esophagogastric (OG) cancers early with improved outcomes. Recent cost‐utility studies suggest that opportunistic upper endoscopy at the same setting of colonoscopy might be a useful strategy for screening of OG cancers, and it may be more acceptable to the patients due to cost‐saving and convenience. We aim to study the diagnostic performance of this screening strategy in a country with intermediate gastric cancer risk.MethodsA retrospective cohort study using a prospective endoscopy database from 2015 to 2017 was performed. Patients included were individuals age > 40 who underwent opportunistic upper endoscopy at the same setting of colonoscopy without any OG symptoms. Neoplastic OG lesions are defined as cancer and high‐grade dysplasia. Pre‐neoplastic lesions include Barrett's esophagus (BE), intestinal metaplasia (IM), and atrophic gastritis (AG).ResultsThe study population involved 1414 patients. Neoplastic OG lesions were detected in five patients (0.35%). Pre‐neoplastic lesions were identified in 174 (12.3%) patients. IM was found in 146 (10.3%) patients with 21 (1.4%) having extensive IM. The number needed to scope to detect a neoplastic OG lesion is 282.8 with an estimated cost of USD$141 400 per lesion detected. On multivariate regression, age ≥ 60 (RR: 1.84, 95% CI: 1.29–2.63) and first‐degree relatives with gastric cancer (RR: 1.64, 95% CI: 1.06–2.55) were independent risk factors for neoplastic or pre‐neoplastic OG lesion.ConclusionFor countries with intermediate gastric cancer risk, opportunistic upper endoscopy may be an alternative screening strategy in a selected patient population. Prospective trials are warranted to validate its performance.

S2074 Liquid Nitrogen Spray Cryotherapy Is a Safe and Effective Treatment Modality for Extensive Gastric Intestinal Metaplasia With Dysplasia

INTRODUCTION: Gastric intestinal metaplasia with dysplasia (GIM-D) that is visible as a discrete limited lesion on endoscopy is readily treated using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). However, there are few options for more extensive and invisible dysplasia. Ablating a wide swath of tissue with argon plasma coagulation (APC) or radiofrequency ablation (RFA) can be challenging and carry risks, including post-procedure ulceration. Liquid Nitrogen Spray Cryotherapy (LSNC) is an established treatment for dysplasia in Barrett’s esophagus, but its use for GIM-D has not been previously reported. CASE DESCRIPTION/METHODS: Three patients with GIM-D underwent a total of ten sessions of LNSC. In all cases, LNSC was performed after passing an orogastric decompression tube in the stomach for active suctioning. Ablations were performed in cycles of 20-40 seconds, with at least 45 seconds in between cycles to allow for tissue thawing. Between two to seven ablations were performed during each procedure. Prior to each procedure, Sydney protocol biopsies were obtained. No patient reported any mild, moderate, or severe post-procedure complications. Patient 1: 73-year-old with a 15 mm intramucosal adenocarcinoma in the fundus, resected using band ligation EMR. Random biopsies in the fundus demonstrated low-grade GIM-D. The patient underwent 3 sessions of LNSC throughout the fundus. There was no evidence of GIM-D after 1 session, no evidence of GIM after 3 sessions, and no recurrence after 29 months of follow up (Table 1). Patient 2: 72-year-old with pre-pyloric intramucosal adenocarcinoma, with a positive margin after ESD, extensive surrounding high-grade dysplasia (HGD) in the antrum. He underwent 5 sessions of LSNC to this area and surrounding antrum (Figure 1). After 1 session, there was no adenocarcinoma. At 14 months, there is GIM but no GIM-D. Patient 3: 71-year-old with HGD of the gastric antrum and incisura, and persistent GIM-D despite EMR. He underwent 2 sessions of LSNC over 3 months. After 1 session, there was GIM but no GIM-D. DISCUSSION: Very few treatment modalities exist for extensive GIM-D. LNSC appears to be a safe, well tolerated, and effective treatment for extensive GIM-D. Our series provides a scientific rationale to pursue larger studies evaluating LNSC for GIM-D.Table 1.: Liquid nitrogen spray cryotherapy treatment detailsFigure 1.: A. Gastric intestinal metaplasia with high grade dysplasia throughout the antrum, and ulceration at the prior resection site (*) B. Liquid nitrogen spray cryotherapy, which allows for ablation of a wide swath of the antrum.

Helicobacter pylori-related precancerous lesions in Turkey: a retrospective endoscopic surveillance study

AimTo assess the relationship between Helicobacter pylori (H. pylori) infection and atrophic gastritis (AG) and intestinal metaplasia (IM) development and to assess the rate of dysplasia or gastric cancer development in patients with AG and/or IM.MethodsThis retrospective endoscopic follow-up study enrolled 2214 patients. The patients were followed for at least five years between 2007 and 2017 at the Department of Endoscopy at Antalya Ataturk Government Hospital. The results of third-year and five-year surveillance biopsy were assessed.ResultsThe mean follow-up time was 7.77 ± 2.78 years. H. pylori was histologically assessed in 1417 (64.6%) patients. Of 198 patients with severe H. pylori infection, 32 (16%) and 139 (70.3%) developed extensive AG and extensive IM, respectively. There was a significant relationship between H. pylori density and AG and IM degrees. High grade dysplasia, early gastric cancer, and advanced gastric cancer were diagnosed in 73 patients with median age 58.2 (28-80) years, and the incidence rate was 3.29% (73/2214). The annual incidence of gastric neoplastic lesions was 0.46% in total, 0.08% for early GC, and 0.02% for advanced gastric cancer.ConclusionsH. pylori infection has an important role in the development of AG and IM. H. pylori density is directly related to atrophy and metaplasia degree.

Increased Risk of Progression to Gastric Adenocarcinoma in Patients with Non-dysplastic Gastric Intestinal Metaplasia Versus a Control Population.

In previous studies, the 5-year progression rate of gastric intestinal metaplasia to gastric adenocarcinoma has varied substantially. We investigated the incidence rate of dysplasia and gastric adenocarcinoma and the rate of progression among a cohort of patients with non-dysplastic gastric intestinal metaplasia. This is a single-center, single-cohort retrospective study. Patients who had undergone an EGD with biopsies from 01/01/1993 to 12/31/2013 were included. The primary outcome of interest was the composite of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma. Time to progression and risk factor subgroup analyses were performed. A total of 1628 subjects were screened, of whom 358 met the inclusion criteria. A total of 21 first-time events were recorded. The annual incidence rate of low-grade dysplasia was 2.1 (95% CI 1.3-3.5) cases per 1000 person-years, 0.5 (95% 0.2-1.3) per 1000 person-years for high-grade dysplasia, and 0.8 (95% CI 0.3-1.6) cases per 1000 person-years for gastric adenocarcinoma. The historical control group had an annual adenocarcinoma incidence rate of 0.07 per 1000 person-years. The event rate in Asians was also noted to be significantly higher between years 0-8 as compared with patients of non-Asian race, and extensive intestinal metaplasia was an independent risk factor (HR = 4.06 (95% CI 1.45-11.34), p = 0.007). Patients with non-dysplastic gastric intestinal metaplasia may progress to dysplasia and gastric adenocarcinoma. The incidence rate of gastric adenocarcinoma is higher than that of the historical control population (0.07 per 1000 person-years). The presence of extensive intestinal metaplasia was a risk factor for progression of disease. Triennial EGD may be warranted in patients with non-dysplastic gastric intestinal metaplasia.

Demographic and Lifestyle Risk Factors for Gastric Intestinal Metaplasia Among US Veterans.

The risk of noncardia gastric cancer is increased in the presence of gastric intestinal metaplasia. We aimed to identify demographic and lifestyle factors independently associated with the risk of gastric intestinal metaplasia. We used data from a cross-sectional study of patients attending primary care and endoscopy clinics at the Michael E. DeBakey VA Medical Center in Houston, Texas, between February 2008 and August 2013. All patients completed standardized questionnaires and underwent endoscopy with gastric mapping biopsies. Gastric intestinal metaplasia cases included patients with intestinal metaplasia on any noncardia gastric biopsy; we defined extensive gastric intestinal metaplasia as antrum and corpus involvement. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate logistic regression models. We identified 423 cases with gastric intestinal metaplasia and 1,796 controls without gastric intestinal metaplasia. Older age (vs <60 years: 60-69 years AdjOR, 1.50; 95% CI, 1.17-1.93; ≥70 years AdjOR, 2.12; 95% CI, 1.48-3.04), male sex (AdjOR, 2.76; 95% CI, 1.50-5.10), nonwhite race/ethnicity (vs non-Hispanic white: Hispanic, AdjOR, 2.66; 95% CI, 1.89-3.76; black, AdjOR, 2.36; 95% CI, 1.85-3.02), and current smoking status (AdjOR, 1.78; 95% CI, 1.29-2.48) were independently associated with gastric intestinal metaplasia. These risk factors remained statistically significantly associated with gastric intestinal metaplasia after adjusting for Helicobacter pylori infection, and their effect sizes were larger for associations with extensive gastric intestinal metaplasia compared with focal gastric intestinal metaplasia. Older age, male sex, nonwhite race/ethnicity, and current smoking status were the nonendoscopic factors independently associated with gastric intestinal metaplasia in a predominantly nonimmigrant US population.

Reliability and accuracy of blue light imaging for staging of intestinal metaplasia in the stomach

Background and aims: An endoscopic grading system (EGGIM) using narrow-band-imaging (NBI) has shown to accurately identify patients with extensive gastric intestinal metaplasia (GIM). However, description with alternative systems such as blue-light-imaging (BLI) is limited. The aim of this study is to determine the reliability and accuracy of BLI-bright regarding diagnosis and staging of GIM.Methods: Reliability of WLE (white-light-endoscopy) and BLI among 6 observers was assessed using a standard classification based on endoscopic images. Afterward, 37 patients were submitted to gastroscopy using FujifilmEG-760Z and endoscopists had to determine EGGIM score using BLI-bright and to perform gastric biopsies for operative-link-of-gastric-intestinal-metaplasia (OLGIM) calculation. BLI-bright accuracy was determined by comparing results with prior EGGIM scores with NBI and current OLGIM.Results: Compared with WLE, the interobserver reliability between observers was substantially better with BLI (Weighted Kappa: 0.8 vs 0.41). There was an 84% agreement between BLI and NBI assessing EGGIM intervals (EGGIM 0-4vs5-10). The area under the ROC curve was 0.90 (95%CI: 0.79–1.0) using the cut-off of EGGIM > 4 to determine advanced GIM, with a sensitivity of 100% (95%CI: 88–100%).Discussion: BLI-bright is reliable for the diagnosis of gastric intestinal metaplasia and agrees significantly with NBI evaluation. Preliminary data suggests high sensitivity for identifying patients with increased risk of gastric cancer.

1686 Laparoscopic-Assisted Endoscopic Submucosal Dissection of Early Gastric Adenocarcinoma

INTRODUCTION: A 69-year-old man underwent esophagogastroduodenoscopy (EGD) a year ago which showed intestinal metaplasia without dysplasia in the gastric antrum and incisura. A repeat EGD showed a single plague in the distal esophagus and erosive gastritis. Biopsies revealed high grade dysplasia (HGD) in the gastric cardia and extensive intestinal metaplasia in the rest of the stomach. A subsequent endoscopic ultrasound and CT imaging of chest, abdomen and pelvis revealed no evidence of extraluminal extension or distant metastasis. Given the tumor location surgical resection would require a total gastrectomy. After consultation with surgical oncology, a decision was made to attempt endoscopic submucosal dissection (ESD) with laparoscopic assistance. CASE DESCRIPTION/METHODS: In this video report, an initial EGD was performed which confirmed a superficial gastric ulcer in the cardia. A laparoscopic gastrotomy with placement of the 15mm laparoscopic port was performed. The endoscope with a cap was introduced through the port directly into the stomach. The lesion in the gastric cardia was visualized in a retrograde direction. ESD was performed using a Dual-J Knife. A 15mm area was resected. The ESD site was examined for any perforation, bleeding or defects and none were noted. Following the endoscopic portion of the procedure, the abdomen was re-insufflated and inspected for signs of perforation and none were found. The gastrotomy was then closed. On gross pathologic examination the gastric cardia specimen measured 1.9 × 1.7 × 0.3 cm. Microscopic examination revealed well differentiated (G1) focal intramucosal adenocarcinoma arising in a background of intestinal metaplasia with HGD. Tumor invaded lamina propria but no invasion of muscularis mucosa was identified. All margins were uninvolved by carcinoma and dysplasia. The final pathologic stage of the resected specimen was pT1a. Given the findings, lymph node disease was determined to be extremely low and less invasive ESD was expected to be curative 1, 2. A follow up EGD 2-months post-procedure showed no evidence of recurrence. DISCUSSION: In conclusion, tumors of the gastric cardia are among the most technically difficult lesions to be removed by ESD with curative rates around 66% 3. This decreases further with tumors located in the anterior hemisphere or have deep submucosal invasion. Laparoscopic assistance provides a head on view for a full thickness ESD. Our case demonstrates this technique is safe and effective. Watch the video: http://bit.ly/2LuEe7N.

1781 Esophageal Squamous Cell Carcinoma Masquerading as Neuropathic Pain

INTRODUCTION: The most common symptoms for esophageal carcinoma are dysphagia and odynophagia, though most are asymptomatic. We describe a case of upper esophageal squamous cell carcinoma masquerading as subphrenic neuropathic pain, not previously described in the literature. CASE DESCRIPTION/METHODS: A 67 year-old male with a past medical history of cholecystitis status post cholecystectomy, hepatic steatosis, acid reflux, hyperlipidemia, and 5-pack year tobacco history presented with 2 years of neuropathic subphrenic pain that radiated below the subcostal margins. The ingestion of solids and liquids triggered the pain, lasting for 1-2 seconds. The pain did not respond to viscous lidocaine or proton pump inhibitors. EGD two years prior revealed a nodular area of mucosa suspicious for esophageal squamous papilloma. His BMI was 29.6 and physical examination was otherwise unremarkable. He had normal peristalsis on esophageal manometry. EGD revealed a nodular mucosal patch in the upper third of the esophagus. Biopsies reproduced the patient’s sharp neuropathic pain. Pathology revealed ulcerated high-grade squamous dysplasia with a focus suspicious for stromal invasion. The stomach demonstrated segmental moderate mucosal changes characterized by atrophy, discoloration, and altered texture along the greater curvature of the gastric body with chronic inactive gastritis with extensive intestinal metaplasia on biopsy. H. pylori testing was negative.Endoscopic ultrasound demonstrated a confirmed a 4cm superficial lesion involving 1/3rd of the lumen. Endoscopic submucosal dissection was performed and pathology demonstrated a T1a squamous cell carcinoma with infiltration into the lamina propria and a focal tongue of tumor in the superficial muscularis mucosa. His pain resolved following resection. DISCUSSION: Esophageal squamous cell carcinoma masquerading as neuropathic pain is highly unusual. The mechanism behind this presentation remains unclear. The squamous papilloma visualized on prior EGD was a risk factor for the development of carcinoma. This case illustrates that squamous cell carcinoma can present with neuropathic pain, a symptom with swallowing that warrants further investigation.