Journal of Gastroenterology and Hepatology (1991)6 , 223-234
ADONIS 081593199100039B
The Sydney System: Endoscopic division. Endoscopic appearances in gastritis/duodenitis G. N. J . TYTGAT Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands As almost all biopsies of the stomach are at present taken under endoscopic control, it is appropriate that the role of endoscopy should be discussed. One of the most difficult areas in clinical gastroenterology today is a precise description of the inflammatory changes of the stomach and the duodenum, and the endoscopic appearances upon which a macroscopic endoscopic diagnosis of inflammatory changes in the gastric or duodenal mucosal lining may be based. T h e literature dealing with this subject is confusing, because of the lack of precise terminology and major discrepancies in interpretation of macroscopic changes. Legitimately, one may ask whether it is appropriate that the endoscopist uses the terms ‘gastritis’ and ‘duodenitis’ to indicate macroscopic changes of the mucosal lining, or whether the terms ‘gastritis’ and ‘duodenitis’ should be reserved only for histologically demonstrable inflanunatory changes. This view is based partly upon the sometimes poor correlation between macroscopic and microscopic changes. Such poor correlation is especially present when only equivocal changes such as minor diffuse discolouration are apparent endoscopically. A purist point of view would be to avoid the terms ‘gastritis’ and ‘duodenitis’ in the endoscopic description. However, a compilation of unequivocal macroscopic alterations should allow endoscopic diagnosis of gastric or duodenal abnormality, in the same way as macroscopic changes allow the diagnosis of skin disorders. Close correlation between visible macroscopic abnormalities and corresponding microscopic changes or, indeed symptoms, may be absent or difficult to detect. Just because such correlation is lacking is no reason to disallow the use of the term ‘endoscopic gastritis’ or ‘duodenitis’ to indicate gross visible changes of the gastric or duodenal mucosal lining. Similar problems occur in staging malignancy. For example, it is generally accepted that there is a cTNM, u T N M and pTNM-staging. In a similar vein, it seems reasonable to use the term ‘endoscopic gastritis’ or ‘endoscopic duodenitis’ if a classified and defined set of unequivocal alterations of the mucosal lining is visible.
NORMAL APPEARANCE OF THE GASTRIC MUCOSA There is a great deal of ignorance about the normal macroscopic appearance of the gastric mucosal lining. In all
probability many of the appearances which endoscopists interpret as ‘normal’ are presumably not norma1.1-8 Endoscopists are so used to seeing some alterations of the mucosa in middle-aged or elderly people (which do, however, differ from the ‘normal’ appearance in young healthy subjects), that the common slightly altered appearances in the adult and elderly population are considered to represent normality. The mucosal appearance in the stomach is called ‘normal’ when the colour is an even shade of pink, and there is uniform smoothness and lustre throughout the mucosa. The antrum usually appears flat, or shows only slightly elevated prepyloric folds with adequate but not excessive i n s d a t i o n of air. Less commonly, one or two roofing folds can be seen, forming arches over the pyloric channel, or a few more prominent antropyloric folds are present. The fold or rugal pattern in the corpus-fundus area is regular and even, not exceeding 5 mm in cross-diameter. The folds should be pliant and flatten readily on insufllation. In a normal stomach there is no adherent fibrinopurulent exudate.
NORMAL APPEARANCE OF THE DUODENAL BULB T h e normal duodenal bulb is pear-shaped and shows a uniform smooth lining of even colour and lustre. Upon close inspection, minute unevenness may be appreciated because of the presence of villi, which give the mucosa a velvety appearance. Not uncommonly, islands of heterotopic gastric mucosa may be present, seen as small raised foci with a more opalescent or frosted glass appearance.
ENDOSCOPIC CHARACTERISTICS OF INFLAMMATION Endoscopic inflammation is defined as the presence of visible alterations of the mucosal appearance, presumably caused by vascular or infiltrative changes. Endoscopic or macroscopic inflammation is diagnosed when at least one but often a combination of the following abnormalities are unequivocally visible, either focally or diffusely. When one or several of these macroscopic appearances appear to be
Correspondence: Prof. G. N. J. Tytgat, Department of Gastroenterology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam Zuid Oost, T h e Netherlands. Accepted for publication 14 December 1990.
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Table 1 Endoscopic gastritis: Endoscopic characteristics of inflammation ~
Oedema Erythema Punctate Confluent Friability Exudate Punctate Confluent Flat erosion Raised erosion Rugal hyperplasia (hyperrugosity) Rugal atrophy (hyporugosity) Visibility of the vascular pattern Inrramural bleeding spots Functaza or petcchid Confluent or ecchymotic
Nodularity Fine Coarse
dominant they are used to indicate the most appropriate subcategory within the endoscopic spectrum of inflammation. To bring the endoscopic classification in line with the histologic classification, the dominant abnormality or abnormalities should be scored as mild, moderate or severe (Table 1).
Oedema (syn: swelling) Oedema is only readily diagnosed when it is severe; it is rather difficult to detect reliably when it is mild or moderate. Oedema may occasionally give a somewhat paler or whiter and slightly more opalescent tinge to the mucosa. Mild oedema may also slightly accentuate the more or less hexagonal areae gastricae pattern. Oedema is rarely, if ever, the most conspicuous abnormality, except perhaps in rare allergic disorders.
Erythema (syn: redness or hyperaemia) Erythema is diagnosed when there are patchy areas of mucosa unequivocally discernible as redder in shade than the adjacent mucosa. Diffuse mild erythema of uniform intensity is of dubious significance and difficult to interpret. Erythema may be mild, representing minimal but obvious change, moderate, when there is conspicuous patchy discolouration, or severe, when the colour change is beefy-red in intensity. On close inspection, patches of erythema appear to be composed of innumerable (tiny 1-3mm in diameter), minimally raised red dots, sometimes called fine pink speckling. Separating these slightly raised dots of erythema are yellow-white lines, the lineae gastricae. Erythema may be present in the antrum or corpus or throughout the stomach. Occasionally, erythema may be in the form of reddish streaks, especially in the antrum.
Friability The mucosal lining is called friable when minimal trauma (passage of the endoscope, retching and vomiting) causes punctate haemorrhage or frank oozing. When present, friability is usually mild. Exceptionally, friability is severe, the markedly swollen and congested mucosa bleeding readily.
Exudate Grey-yellowish, or sometimes brownish or greenish material, adherent to the mucosal surface, is called exudate. It may be difficult to distinguish genuine exudate from stomach contents which have not been completely eliminated. Occasionally the mucosal adherence of exudate is tenacious and resists vigorous rinsing, even with a powerful water-jet. Exudate may be punctate or may appear in the form of patches, strands or plaques. Exudate is mild when only a few punctate spots are visible, moderate when focally patches or plaques are seen, and severe when extensive areas are covered. Not uncommonly, whitish punctate spots of exudate may be seen in the antrum and occasionally in the bulb in Helicobacter pylori-associated inflammation. These are only discovered upon close inspection. Such exudate spots need differentiation from spots of highlights, caused by light reflections, which are more brilliant and less sharply demarcated.
Flat erosion An erosion is a break in the mucosa. A flat erosion is, essentially, present within the plane of the mucosa. Flat erosions correspond to foci of necrosis, which do not disrupt or destroy the muscularis mucosae at histological examination. Flat erosions appear as whitish-greyish patches with or without a surrounding red halo. Endoscopic detection is relatively easy, especially when the base of the erosive defect is covered with a layer of fibrinopurulent exudate. They vary in size from pinpoint to ‘approximately’ 1 cm in diameter. They may be solitary or few (mild), multiple (moderate) or innumerable (severe). The distinction between a large, slightly deeper erosion and a superficial ulcer is arbitrary. Application of the term ‘ulcer’ requires an appreciable depth, estimated at 2 1 mm. Erosions in the bulb are almost always flat. Flat bulbar erosions often alternate with foci of intense erythema, creating the picture previously described by the term ‘salt-and-pepper’ or ‘salami’ a~pearance.~
Raised erosion (syn: varioliform erosion) In raised erosions (varioliform erosions), discrete mounds of elevated mucosa, capped by a central defect are characteristic. Raised erosions may be present in the antnun but usually predominate in the corpus. Not uncommonly, they are superimposed on the gastric folds. They may be solitary or few in number (mild), multiple (moderate) or numerous (severe). When numerous, the overall appearance of the stomach may mimic gastric polyposis.
The Sydney System: Endoscopic division. Endoscopic appearances in gastritislduodenitis
Rugal hyperplasia or hyperrugosity (syn: fold enlargement) Folds may vary considerably in size and estimation of fold size may be difficult. Pathologically enlarged folds do not flatten, or flatten only partially during insufflation. Mild hyperrugosity is seen when non-flattening folds of approximately 5 mm in thickness are seen. Fold enlargement is considered moderate if folds have a thickness of approximately 5-1Omm; fold enlargement is considered severe if folds exceed 10 mm in thickness. Enlarged folds may show superimposed nodular irregularities. Conspicuously enlarged folds, not flattening upon insufflation, are the dominant abnormality in the ‘rugal hyperplastic gastropathies’.
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CLASSIFICATION OF ENDOSCOPIC APPEARANCES OF GASTRIC INFLAMMATION Through a compilation of the mentioned macroscopic abnormalities and highlighting of the most dominant abnormality, an endoscopic classification of the common forms of inflammatory abnormality in the stomach can be made. The endoscopist should estimate the severity through analysis of the degree of severity (miidlmoderatelsevere) of the dominant abnormality, leading to the diagnostic subcategory (Table 2).
Rugal atrophy or hyporugosity
Endoscopic erythematous/exudative gastritis
Hyporugosity or fold atrophy is characterized by thinning of mild or moderate degree, and ultimate disappearance of the gastric rugae is called a severe degree of fold atrophy. This abnormality is usually most obvious in the corpus area. Occasionally, tiny mucosal elevations may remain in areas where the folds have disappeared.
This is the most common endoscopic abnormality diagnosed in clinical practice. The most conspicuous abnormality is patchy erythema, often combined with fine granularity, loss of lustre and, occasionally, punctate exudate. There may be mild friability. Occasionally, reddish streaks may be seen in the antrum, running radially towards the pylorus. This form of gastritis may be mild, moderate or severe and usually involves the antrum, but occasionally the antrum and corpus area are involved (Fig. 1).
Visibility of the vascular pattern In a normal, not overly distended, stomach no vascular ramifications are endoscopically visibly. Thinning of the mucosa is accompanied by the endoscopic appearance or visibility of ramifying vessels of variable size in the wall in the stomach. These vascular structures are often somewhat delineated and irregular or crotchety in appearance. Visibility is mild when only minute vascular structures are faintly visible, moderate when vascular ramifications are readily discernible and severe when the vascular pattern is uniformly striking and sometimes slightly protuberant. To avoid confusion, excessive gastric distension with air should be avoided, as overstreching and thinning of the wall may render the latter more transparent and allow the normal vasculature to be more visible.
Endoscopic flat erosive gastritis This is diagnosed when the dominant abnormality is the presence of raised erosions. In the case of raised erosions, ized in the antrum or throughout the stomach. A layer of exudate may cover the erosive defect. Occasionally there is a linear alignment of the erosions along folds which converge towards the pylorus. Flat erosions are also common in the centre of a standing prepyloric fold. Flat erosive gastritis may be mild, moderate or severe (Fig. 2).
Intramural bleeding spots
Endoscopic raised erosive gastritis
Loss of vascular integrity leads to intramural or intraluminal extravasation of blood. Intramural bleeding may be seen as punctate red spots (petechiae) in an oedematous and often somewhat erythematous mucosa, or as somewhat larger red-brownish or dark blackish ecchymotic spots, streaks or flecks. Such lesions are often multiple and at different stages of development, causing inequalities in colour due to various stages of haem decomposition. Occasionally, extravasation into the lumen may be seen, originating from the intramural bleeding spots. Bleeding is mild when only a few petechial spots are discernible, moderate when more than 10 petechial or ecchymotic spots are visible and severe when extensive areas of the stomach wall show evidence of bleeding.
This is diagnosed when the dominant abnormality is the presence of raised erosions. In the case of raised erosions, there is usually a discrete nodular elevation along the fold with the erosion in its centre. Focal erythema is often seen in conjunction with the white-based erosions. The degree (mild/moderate/severe)is based mainly upon the number of raised erosions (Fig. 3).
Noduhrity The mucosa is called finely (mild) or coarsely nodular (severe) when the evenness of the lining has disappeared, and moderate when a mixture of fine and coarse nodularity coexist.
Table 2 Endoscopic gastritis: Classification of endoscopic appearances of gastric inflammation Endoscopic erythematous/exudativegastritis Endoscopic flat erosive gastritis Endoscopic raised erosive gastritis Endoscopic atrophic gastritis Endoscopic haemorrhagic gastritis Endoscopic rugal hyperplastic gastritis Endoscopic enterogastric reflux gastritis
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(a)
Figure 1 (a) Mild endoscopic erythematous/exudative gastritis of the antrum. (b) Moderate to severe endoscopic erythematous/exudativegastritis of the antrum and corpus.
Figure 2 (a) Mild endoscopic flat erosive gastritis of the antrum. (b) Moderate endoscopic flat erosive gastritis of the antrum.
Endoscopic atrophic gastritis This is diagnosed when the vascular pattern becomes visible in the non-overdistended stomach. In addition there often is some pearly whitish mucosal discolouration. Furthermore, fold atrophy of variable degree may also be
present. This form of gastritis is scored as mild, moderate or severe, mainly using the visibility of the vascular pattern as dominant variable. Occasionally, areas of intestinal metaplasia may be macroscopically visible as grey-white patches with a slight opalescent tinge and/or a villous appearance on close inspection (Fig. 4).
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(b)
Figure 3 (a) and (b) Endoscopic raised erosive gastritis.
Endoscopic haemorrhagic gastritis This is diagnosed when, in addition to the usual characteristics of inflammation, there are punctate or ecchymotic reddish or brown-blackish flecks of various size present in the gastric wall. In addition, there may be adherent, usually dark-stained material or frank intraluminal bleeding. The number of bleeding spots determines whether haemorrhagic gastritis is mild, moderate or severe (Fig. 5).
Endoscopic rugal hyperplastic gastritis This is diagnosed when the predominant abnormality is enlargement of the folds, or hyperrugosity, especially in the corpus-fundus area, of mild, moderate or severe degree. These folds do not flatten during adequate insufflation. Pliancy, assessed by means of the mucosal tenting sign (lifting the mucosa with biopsy forceps) helps to rule out infiltrative disorders. Occasionally, the folds show superimposed polypoid irregularities. The area of fold enlargement may be sharply demarcated or may shade into normality. Some patients have flat erosions on top of the folds. In Mhetrier’s disease there is often abundant mucus covering the enlarged folds, the crests of which sometimes exhibit a confluent polypoid appearance. In gastrinoma there is conspicuous accentuation of the areae gastricae pattern of the corpus mucosa, with copious production of a clear fluid. In rugal hyperplastic hypersecretory gastritis, the thickened folds usually reveal marked irregular discolouration, loss of lustre and adherent flecks of exudate (Fig. 6).
Endoscopic enterogastric reflux gastritis This is in essence a further refinement of the endoscopic erythmatous/exudative variant, which is thought to justify
a separate category because of the well known clinical characteristics and pathogenic mechanisms involved. Mild, moderate or severe grade is diagnosed when there is conspicuous erythema and oedema of the gastric folds, often stained with refluxed bile. The intensely beefy-red discolouration is particularly striking. Especially near the stoma the folds may be markedly oedematous and can present a polypoid appearance. Not uncommonly in such post-gastrectomy situations, there may be evidence of atrophic changes in the more proximal part of the gastric remnant (Fig. 7).
Endoscopic congestive gastroenteropathy This is not a form of gastritis in the true sense, as there is no inflammation, but needs to be differentiated from the common forms of gastritis. This entity is diagnosed when patients with portal hypertension (mainly hepatic cirrhosis) present with conspicuous erythematous spots on top of the folds, usually mainly found in the corpus area. T h e erythematous spots are delineated by the network of the lineae gastricae (Fig. 8).
CLASSIFICATION OF ENDOSCOPIC APPEARANCES OF BULBAR INFLAMMATION Through highlighting of the most dominant abnormality, an endoscopic classification of the common forms of inflammatory abnormality in the bulb can be mad( (Table 3).1°
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Figure 4 (a) Endoscopic atrophic gastritis of the antrum. (b) Endoscopic atrophic gastritis of the corpus. (c) and (d) Endoscopically visible intestinal metaplasia.
Table 3 Classification of endoscopic appearances of duodenal inflammation
Endoscopic erythematous/exudative bulbitis/duodenitis
Endoscopic (mild/moderate/severe) erythematous/exudative duodenitis Endoscopic (mild/moderate/severe) erosive duodenitis Endoscopic (mild/moderate/severe) haemorrhagic duodenitis Endoscopic (mild/moderate/severe) nodular duodenitis
This is the most common endoscopic abnormality in the bulb. The most conspicuous abnormality is patchy erythema," often combined with loss of lustre and occasionally with a few punctate spots of exudate. There may be mild friability. Occasionally, oedema and standing mucosal folds are considered to represent the early phases or
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(b)
Figure 5 (a) Moderate endoscopic haemorrhagic gastritis. (b) Moderate to severe endoscopic haemorrhagic gastritis of the corpus.
(a 1
(b)
Figure 6
(a)
and (b) Endoscopic rugal hyperplastic gastritis of the corpus.
concomitant features of such inflammation.1z Signs of prior ulcer disease may be seen as linear or circular scars. This form of duodenitis may be mild, moderate or severe.
Endoscopic erosive duodenitis This is diagnosed when the dominant abnormality is the
presence of one, or more often multiple, erosions, often covered with whitish-yellow-greyish exudate. Erosions may be small or may appear to coalesce. Erosions may be present in crops or spread over large parts of the bulb. Concomitant erythema, friability and variable degrees of oedema are always present. There may be some luminal narrowing because of oedema. Erosive duodenitis should be diagnosed as mild, moderate or severe.
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(a)
Figure 7 (a) and (b) Endoscopic enterogastric reflux gastritis.
Figure 8 (a) and (b) Endoscopic congestive gastroenteropathy.
Endoscopic haemorrhagic duodenitis
Endoscopic nodular duodenitis
This is diagnosed when, in addition to the usual characteristics of inflammation, punctate or ecchymotic bleeding is visible, of mild, moderate or severe degree.
This may be considered as a separate entity, because it is virtually confined to patients with renal insufficiency or on chronic dialysis. T h e dominant abnormality is diffuse nod-
The Sydney System: Endoscopic division. Endoscopic appearances in gastritislduodenitis
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ularity of the bulb of mild, moderate or severe degree. The mucosa may be strikingly erythematous and covered with small erosions and punctate or confluent exudate.13
confluent erosions. Additional features are slight oedema of the mucosa, accentuation of the fold pattern and conspicuously enhanced duodenal motor activity. (Figs. 9,10)
ENDOSCOPIC ABNORMALITIES IN HEL ZCOBAC TER P Y L ORI GASTRITIS/DUODENITIS
CORRELATION WITH HISTOLOGY
The endoscopic appearances of the stomach and bulb in the acute infectious phase of H.pylori-induced inflammation are poorly known. An occasional patient has been described with a strikingly red, friable and slightly erosive gastric mucosa, covered with abundant fibrinopurulent exudate in the antrum." In many patients with chronic H . pylori infection, usually in the distal part of the stomach, none or hardly any readily identifiable changes in the endoscopic appearance of the stomach are detectable. If endoscopic abnormalities are seen, they usually consist of patches of erythema, alternating with paler areas, some loss of lustre and sometimes slight unevenness of the mucosal lining. Close inspection, especially of the antral area, may reveal tiny punctate whitish spots of exudate. These abnormalities correspond to mild erythematous/exudative gastritis. I n more severe infection small erosions may be present, often on a standing prepyloric fold, corresponding to endoscopic mild flat erosive gastritis. Exceptionally, endoscopic moderate flat erosive gastritis is visible in the distal part of the stomach. Quite characteristic is the combination of discrete endoscopic abnormalities in the antrum combined with endoscopic evidence of inflammation in the duodenal bulb. Endoscopic duodenal inflammation is usually seen as patches of punctate erythema and areas of punctate or
Correlation between endoscopic macroscopic appearances and histology is often poor. Physicians often become frustrated because of this poor correlation between macroscopic abnormalities and corresponding microscopic changes. Several studies suggest that endoscopic appearances do not reliably predict the presence, or absence, of histologic g a s t r i t i ~ ~ but * ~ *there ' ~ is a great deal of uncertainty with respect to the severity of the endoscopic abnormalities, the biopsy site, or the number of biopsies examined. Based upon the currently available literature some general deductions can be made, while remaining fully aware of the shortcomings of many studies and the difficulties of interpretation (Table 4). Perhaps up to 40% or more of patients with endoscopically normal mucosa have histological gastritis visible on biopsy. When erythema is the most conspicuous endoscopic abnormality, histologic chronic gastritis has been found in 751'0 or more of patient^.^" When the endoscopic changes are more pronounced and certainly in the presence of erosions or frank atrophic gastritis, there are almost always corresponding histologic inflammatory changes. In general, the more severe the endoscopic gastric abnormalities, the better the correlation with histology2.1s.16. There is also controversy over the correlation between the endoscopic and histologic characteristics of duodenitis,
Figure 9 (a) H. pylorz-induced endoscopic erosive duodenitis. (b) Concomitant endoscopic flat erosive gastritis of the antrum.
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(a)
Figure 10 (a) H. pylori-induced endoscopic erosive duodenitis. (b) Concomitant mild endoscopic erosive gastritis of the antrum.
Table 4 Correlation between endoscopy and histology in gastritis Endoscopic diagnosis
Histological diagnosis
Normal endoscopy
Chronic gastritis in variable percentage ( 2 40Y0?) Chronic gastritis in variable percentage ( 2 7S0,?)
Erythematouslexudative gastritis Flatiraised erosive gastritis
Atrophic gastritis
Almost invariably chronic gastritis, sometimes with active component High percentage of chronic gastritis with severe glandular atrophy
Table 5 Correlation between endoscopy and histology in duodenitis Endoscopic diagnosis
Histological diagnosis
Erythematous/exudative duodenitis
Chronic duodenitis in high percentage ( 2 85°/o)
Erosive duodenitis
Almost invariably chronic duodenitis with active component Invariably chronic duodenitis with active component
Nodular duodenitis
except for the severe In general, the endoscopic findings correlate better with the histologic findings in the duodenal bulb than in the stomach (Table 5).21-23
ENDOSCOPIC BIOPSY TECHNIQUE For targeted pinch biopsies in the stomach, three sizes of biopsy forceps are available, varying from 5, 7 to 9 Fg in cup size. Some of the cups are open or fenestrated, others are closed. In addition there may be a bayonet-type spike enclosed within the cup (Fig. 11). In general, 7 Fg biopsy forceps should be considered as standard for routine clinical practice, although superior quality biopsies can be obtained with 10 Fg forceps. If at all possible, gentle but sufficient pressure should be applied when taking the biopsy, in order to diminish traumatic fragmentation of the biopsy while allowing sampling of muscularis mucosae. Usually no attempt is made to orient the relatively small tissue specimens. Pinch biopsies using standard 7 F g biopsy forceps provide adequate samples in approximately 80% of instances.* The number and the site of targeted biopsy differ according to the circumstances. Full characterization of the inflammatory status in the whole stomach needs multiple endoscopic biopsies of all anatomical regions of the stomach. For that purpose biopsies should include anterior and posterior wall of the antrum and corpus: antral biopsies should be taken 2-5 cm from the pylorus; corpus biopsies should be taken some 10 cm from the cardia, and always from the anterior and posterior wall (Fig. 12).
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(b)
Figure 11 (a) 5, 7, and 9 Fg biopsy forceps. (b) Corresponding gastric biopsy sizes.
Figure 12 Endoscopic gastritis: where to biopsy?
Certainly, if biopsies are to be taken to document atrophic changes, both the antrum and the corpus should be always biopsied. In both sites a minimum of 2 biopsies should be obtained. At least one of these biopsies should be taken from areas which appear grossly abnormal. In the presence of diffuse abnormalities limited to the antrum, again, 2 biopsies from both the anterior and posterior aspects of the mid-antrum suffice for proper histological interpretation. It is unclear whether it is more appropriate to sample the erythematous areas or the non-altered surrounding mucosa. In the presence of tiny spots of punctate exudate, or tiny erosive lesions, sampling the edges of these abnormalities is preferred. If large focal lesions are present, additional biopsies of the base and edges of these lesions are obviously indicated. The prepyloric antrum (3-5 cm from the pylorus) has been the preferred site of biopsy for the demonstration of H . pylori infection. A small number (5-10°{,?) of infected
patients will be missed if only the antrum is sampled. Sampling both antrum and corpus will effectively eliminate the small possibility of a false negative result due to the presence of intestinal metaplasia in the antrum, or patchiness of infection and inflammation. The improvement in diagnostic yield achieved with an increase in the umber of biopsies is small and not sufficient to warrant taking more than 2 biopsies in the routine clinical setting. However, research protocols may demand a larger number of specimens.
CONCLUDING REMARKS For precise documention of the role of endoscopy, in parallel with histology in the various forms of gastric inflammation, new studies have to be designed with careful
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and systematic prospective scoring of any endoscopic abnormality and adequate sampling of the gastric mucosa for histological analysis. Such endoscopic and biopsy studies should be done before and after treatment directed against gastric inflammation. Perhaps the standardized use of video endoscopy with the possibilities for more objective analysis of the macroscopic image (degree and distribution of erythema, number of spots of punctate exudate, of erosions, etc) will allow a more objective and accurate endoscopic interpretation of the gastric mucosal lining. It is not to be expected that the mild forms of chronic gastritis without alteration of the overall mucosal thickness, or of the quality of the mucus-secreting epithelium, will induce readily obvious endoscopic changes. I n contrast, the more severe forms of chronic gastritis, especially those accompanied by mucin depletion, focal necrosis and disruption of the epithelial layer, should be readily detectable by endoscopy. If, ultimately, endoscopic biopsies prove to be the key diagnostic modality, where should they be taken from? At present it is unknown whether random and targeted biopsies are equally informative in H.pylori gastritis. This will depend to a large extent on the uniform and diffuse character of the inflammation. If inflammation is of equal severity over a certain segment of the stomach, random biopsies should be satisfactory. If, on the other hand, inflammation is patchy, more precise targeting may be more appropriate. It may be sensible to sample in particular those areas where there is distortion or disruption of the epithelial lining or where punctate exudate is present.
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8. WEINSTEIN W. M. The diagnosis and classification of gastritis and duodenitis. J. Clin. Gastroenterol. 1981; 3 (suppl.): 7-16. 9. JOFFE S. N., LEEF. D. & BLUMGART L. H. Duodenitis. Clin. Gastroenterol.1978; 7 : 635-50. 10. SIRCUSW. Duodenitis: a clinical, endoscopic and histopathologic study. Quat. J . Med. 1985; 56. 11. VENABLES C. W. Duodenitis. Scand. J. Gastroenterol. 1985; 20 (SUPPI.):91-7. 12. JOFFE S. N. Relevance of duodenitis to non-ulcer dyspepsia and peptic ulceration. Scand. J. Gastroenterol. 1982; 17 (suppl.): 80-97. G . R., MILLSB. A., KOEHLER R. E., SIEGEL A., 3. ZUKERMAN HARTERH. R. & DE SCHRIJVER-KECSKEMETI K. Nodular duodenitis, pathologic and clinical characteristic in patients with end-stage renal disease. Dig. Dis. Sci. 1983; 28: 1018-24. A. V., KAMALM. F., AUR S. S., ARNAOUTM. A. 4. TOUKAN & ABU-ROMIYEH S. Gastroduodenal inflammation in patients with non-ulcer dyspepsia. A controlled endoscopic and morphometric study. Dig. Dis Sci. 1985; 30: 313-20. 5. MYRENJ. & SERCK-HANSSEN A. T h e gastroscopic diagnosis of gastritis with particular reference to mucosal reddening and mucus covering. Scand. 3. Gastroenterol. 1974; 9: 457-62. J. L. & SIMPSONI. W. Correlation between 6. CRONSTEDT gastroscopic and direct vision biopsy findings. Gastrointest. Endosc. 1973; 19: 174-5. R. Morphologic aspects of duodenitis. Scand. J. 17. WHITEHEAD Gastroenterol. 1982; 17 (suppl.): 80-3. E. A., BIEDERMAN M. A. & GELFANDD. W. 18. GELZAYED Changing concepts of duodenitis. Scand. 3. Gastroentol. 1975; 64: 213-6. J. A. & GARABEDIAN M. Duodenitis. Amer. 3. Gastro19. GREGG enrol. 1974; 61: 177-84. R. W., SINGD. & WOLLMAN J. Endoscopic and 20. MCCALLUM histological correlations of the duodenal bulb. Arch. Pathol. Lab. Med. 1979; 103: 169-72. R., BODEMAR G. & BRODINV. 21. J ~ N S S O NK-A., GOTTHARD The clinical relevance of endoscopic and histologic inflammation of gastroduodenal mucosa in dyspepsia of unknown origin. Scand. 3. Gastroenterol. 1989; 24: 385-95. 22. MYRENJ. Gastric secretion in duodenitis. Scand. 3. Gastroenterol. 1982; 17: 98-101. A. B., TIGHE J . R. & BEALES J . S. M. 23. COTTONP. B., PRICE Preliminary evaluation of ‘duodenitis’ by endoscopy and biopsy. EM J 1973; 3 : 430-3. G. N. J. Campylobacterpylori. W. 24. RAUWSE. A. J. & TYTGAT C. den Ouden B. V., Amsterdam. 1989. M., CELENER D . , PISKORZ E., 25. FONTANA. N., RAPAPORT PERALTA C. G. & RUBIOH . H. Chronic non-specific duodenitis (bulbitis). Endoscopy 1978; 10: 94-8. H. D. & BEHLER E. M . A study of the 26. ELTAG. H., APPELMAN correlation between endoscopic and histologic diagnosis in gastroduodenitis. Amer. 3. Gastroenterol. 1987; 82 : 749-53.
ADONIS 081593199100039B
The Sydney System: Endoscopic division. Endoscopic appearances in gastritis/duodenitis G. N. J . TYTGAT Department of Gastroenterology, Academic Medical Centre, Amsterdam, The Netherlands As almost all biopsies of the stomach are at present taken under endoscopic control, it is appropriate that the role of endoscopy should be discussed. One of the most difficult areas in clinical gastroenterology today is a precise description of the inflammatory changes of the stomach and the duodenum, and the endoscopic appearances upon which a macroscopic endoscopic diagnosis of inflammatory changes in the gastric or duodenal mucosal lining may be based. T h e literature dealing with this subject is confusing, because of the lack of precise terminology and major discrepancies in interpretation of macroscopic changes. Legitimately, one may ask whether it is appropriate that the endoscopist uses the terms ‘gastritis’ and ‘duodenitis’ to indicate macroscopic changes of the mucosal lining, or whether the terms ‘gastritis’ and ‘duodenitis’ should be reserved only for histologically demonstrable inflanunatory changes. This view is based partly upon the sometimes poor correlation between macroscopic and microscopic changes. Such poor correlation is especially present when only equivocal changes such as minor diffuse discolouration are apparent endoscopically. A purist point of view would be to avoid the terms ‘gastritis’ and ‘duodenitis’ in the endoscopic description. However, a compilation of unequivocal macroscopic alterations should allow endoscopic diagnosis of gastric or duodenal abnormality, in the same way as macroscopic changes allow the diagnosis of skin disorders. Close correlation between visible macroscopic abnormalities and corresponding microscopic changes or, indeed symptoms, may be absent or difficult to detect. Just because such correlation is lacking is no reason to disallow the use of the term ‘endoscopic gastritis’ or ‘duodenitis’ to indicate gross visible changes of the gastric or duodenal mucosal lining. Similar problems occur in staging malignancy. For example, it is generally accepted that there is a cTNM, u T N M and pTNM-staging. In a similar vein, it seems reasonable to use the term ‘endoscopic gastritis’ or ‘endoscopic duodenitis’ if a classified and defined set of unequivocal alterations of the mucosal lining is visible.
NORMAL APPEARANCE OF THE GASTRIC MUCOSA There is a great deal of ignorance about the normal macroscopic appearance of the gastric mucosal lining. In all
probability many of the appearances which endoscopists interpret as ‘normal’ are presumably not norma1.1-8 Endoscopists are so used to seeing some alterations of the mucosa in middle-aged or elderly people (which do, however, differ from the ‘normal’ appearance in young healthy subjects), that the common slightly altered appearances in the adult and elderly population are considered to represent normality. The mucosal appearance in the stomach is called ‘normal’ when the colour is an even shade of pink, and there is uniform smoothness and lustre throughout the mucosa. The antrum usually appears flat, or shows only slightly elevated prepyloric folds with adequate but not excessive i n s d a t i o n of air. Less commonly, one or two roofing folds can be seen, forming arches over the pyloric channel, or a few more prominent antropyloric folds are present. The fold or rugal pattern in the corpus-fundus area is regular and even, not exceeding 5 mm in cross-diameter. The folds should be pliant and flatten readily on insufllation. In a normal stomach there is no adherent fibrinopurulent exudate.
NORMAL APPEARANCE OF THE DUODENAL BULB T h e normal duodenal bulb is pear-shaped and shows a uniform smooth lining of even colour and lustre. Upon close inspection, minute unevenness may be appreciated because of the presence of villi, which give the mucosa a velvety appearance. Not uncommonly, islands of heterotopic gastric mucosa may be present, seen as small raised foci with a more opalescent or frosted glass appearance.
ENDOSCOPIC CHARACTERISTICS OF INFLAMMATION Endoscopic inflammation is defined as the presence of visible alterations of the mucosal appearance, presumably caused by vascular or infiltrative changes. Endoscopic or macroscopic inflammation is diagnosed when at least one but often a combination of the following abnormalities are unequivocally visible, either focally or diffusely. When one or several of these macroscopic appearances appear to be
Correspondence: Prof. G. N. J. Tytgat, Department of Gastroenterology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam Zuid Oost, T h e Netherlands. Accepted for publication 14 December 1990.
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Table 1 Endoscopic gastritis: Endoscopic characteristics of inflammation ~
Oedema Erythema Punctate Confluent Friability Exudate Punctate Confluent Flat erosion Raised erosion Rugal hyperplasia (hyperrugosity) Rugal atrophy (hyporugosity) Visibility of the vascular pattern Inrramural bleeding spots Functaza or petcchid Confluent or ecchymotic
Nodularity Fine Coarse
dominant they are used to indicate the most appropriate subcategory within the endoscopic spectrum of inflammation. To bring the endoscopic classification in line with the histologic classification, the dominant abnormality or abnormalities should be scored as mild, moderate or severe (Table 1).
Oedema (syn: swelling) Oedema is only readily diagnosed when it is severe; it is rather difficult to detect reliably when it is mild or moderate. Oedema may occasionally give a somewhat paler or whiter and slightly more opalescent tinge to the mucosa. Mild oedema may also slightly accentuate the more or less hexagonal areae gastricae pattern. Oedema is rarely, if ever, the most conspicuous abnormality, except perhaps in rare allergic disorders.
Erythema (syn: redness or hyperaemia) Erythema is diagnosed when there are patchy areas of mucosa unequivocally discernible as redder in shade than the adjacent mucosa. Diffuse mild erythema of uniform intensity is of dubious significance and difficult to interpret. Erythema may be mild, representing minimal but obvious change, moderate, when there is conspicuous patchy discolouration, or severe, when the colour change is beefy-red in intensity. On close inspection, patches of erythema appear to be composed of innumerable (tiny 1-3mm in diameter), minimally raised red dots, sometimes called fine pink speckling. Separating these slightly raised dots of erythema are yellow-white lines, the lineae gastricae. Erythema may be present in the antrum or corpus or throughout the stomach. Occasionally, erythema may be in the form of reddish streaks, especially in the antrum.
Friability The mucosal lining is called friable when minimal trauma (passage of the endoscope, retching and vomiting) causes punctate haemorrhage or frank oozing. When present, friability is usually mild. Exceptionally, friability is severe, the markedly swollen and congested mucosa bleeding readily.
Exudate Grey-yellowish, or sometimes brownish or greenish material, adherent to the mucosal surface, is called exudate. It may be difficult to distinguish genuine exudate from stomach contents which have not been completely eliminated. Occasionally the mucosal adherence of exudate is tenacious and resists vigorous rinsing, even with a powerful water-jet. Exudate may be punctate or may appear in the form of patches, strands or plaques. Exudate is mild when only a few punctate spots are visible, moderate when focally patches or plaques are seen, and severe when extensive areas are covered. Not uncommonly, whitish punctate spots of exudate may be seen in the antrum and occasionally in the bulb in Helicobacter pylori-associated inflammation. These are only discovered upon close inspection. Such exudate spots need differentiation from spots of highlights, caused by light reflections, which are more brilliant and less sharply demarcated.
Flat erosion An erosion is a break in the mucosa. A flat erosion is, essentially, present within the plane of the mucosa. Flat erosions correspond to foci of necrosis, which do not disrupt or destroy the muscularis mucosae at histological examination. Flat erosions appear as whitish-greyish patches with or without a surrounding red halo. Endoscopic detection is relatively easy, especially when the base of the erosive defect is covered with a layer of fibrinopurulent exudate. They vary in size from pinpoint to ‘approximately’ 1 cm in diameter. They may be solitary or few (mild), multiple (moderate) or innumerable (severe). The distinction between a large, slightly deeper erosion and a superficial ulcer is arbitrary. Application of the term ‘ulcer’ requires an appreciable depth, estimated at 2 1 mm. Erosions in the bulb are almost always flat. Flat bulbar erosions often alternate with foci of intense erythema, creating the picture previously described by the term ‘salt-and-pepper’ or ‘salami’ a~pearance.~
Raised erosion (syn: varioliform erosion) In raised erosions (varioliform erosions), discrete mounds of elevated mucosa, capped by a central defect are characteristic. Raised erosions may be present in the antnun but usually predominate in the corpus. Not uncommonly, they are superimposed on the gastric folds. They may be solitary or few in number (mild), multiple (moderate) or numerous (severe). When numerous, the overall appearance of the stomach may mimic gastric polyposis.
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Rugal hyperplasia or hyperrugosity (syn: fold enlargement) Folds may vary considerably in size and estimation of fold size may be difficult. Pathologically enlarged folds do not flatten, or flatten only partially during insufflation. Mild hyperrugosity is seen when non-flattening folds of approximately 5 mm in thickness are seen. Fold enlargement is considered moderate if folds have a thickness of approximately 5-1Omm; fold enlargement is considered severe if folds exceed 10 mm in thickness. Enlarged folds may show superimposed nodular irregularities. Conspicuously enlarged folds, not flattening upon insufflation, are the dominant abnormality in the ‘rugal hyperplastic gastropathies’.
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CLASSIFICATION OF ENDOSCOPIC APPEARANCES OF GASTRIC INFLAMMATION Through a compilation of the mentioned macroscopic abnormalities and highlighting of the most dominant abnormality, an endoscopic classification of the common forms of inflammatory abnormality in the stomach can be made. The endoscopist should estimate the severity through analysis of the degree of severity (miidlmoderatelsevere) of the dominant abnormality, leading to the diagnostic subcategory (Table 2).
Rugal atrophy or hyporugosity
Endoscopic erythematous/exudative gastritis
Hyporugosity or fold atrophy is characterized by thinning of mild or moderate degree, and ultimate disappearance of the gastric rugae is called a severe degree of fold atrophy. This abnormality is usually most obvious in the corpus area. Occasionally, tiny mucosal elevations may remain in areas where the folds have disappeared.
This is the most common endoscopic abnormality diagnosed in clinical practice. The most conspicuous abnormality is patchy erythema, often combined with fine granularity, loss of lustre and, occasionally, punctate exudate. There may be mild friability. Occasionally, reddish streaks may be seen in the antrum, running radially towards the pylorus. This form of gastritis may be mild, moderate or severe and usually involves the antrum, but occasionally the antrum and corpus area are involved (Fig. 1).
Visibility of the vascular pattern In a normal, not overly distended, stomach no vascular ramifications are endoscopically visibly. Thinning of the mucosa is accompanied by the endoscopic appearance or visibility of ramifying vessels of variable size in the wall in the stomach. These vascular structures are often somewhat delineated and irregular or crotchety in appearance. Visibility is mild when only minute vascular structures are faintly visible, moderate when vascular ramifications are readily discernible and severe when the vascular pattern is uniformly striking and sometimes slightly protuberant. To avoid confusion, excessive gastric distension with air should be avoided, as overstreching and thinning of the wall may render the latter more transparent and allow the normal vasculature to be more visible.
Endoscopic flat erosive gastritis This is diagnosed when the dominant abnormality is the presence of raised erosions. In the case of raised erosions, ized in the antrum or throughout the stomach. A layer of exudate may cover the erosive defect. Occasionally there is a linear alignment of the erosions along folds which converge towards the pylorus. Flat erosions are also common in the centre of a standing prepyloric fold. Flat erosive gastritis may be mild, moderate or severe (Fig. 2).
Intramural bleeding spots
Endoscopic raised erosive gastritis
Loss of vascular integrity leads to intramural or intraluminal extravasation of blood. Intramural bleeding may be seen as punctate red spots (petechiae) in an oedematous and often somewhat erythematous mucosa, or as somewhat larger red-brownish or dark blackish ecchymotic spots, streaks or flecks. Such lesions are often multiple and at different stages of development, causing inequalities in colour due to various stages of haem decomposition. Occasionally, extravasation into the lumen may be seen, originating from the intramural bleeding spots. Bleeding is mild when only a few petechial spots are discernible, moderate when more than 10 petechial or ecchymotic spots are visible and severe when extensive areas of the stomach wall show evidence of bleeding.
This is diagnosed when the dominant abnormality is the presence of raised erosions. In the case of raised erosions, there is usually a discrete nodular elevation along the fold with the erosion in its centre. Focal erythema is often seen in conjunction with the white-based erosions. The degree (mild/moderate/severe)is based mainly upon the number of raised erosions (Fig. 3).
Noduhrity The mucosa is called finely (mild) or coarsely nodular (severe) when the evenness of the lining has disappeared, and moderate when a mixture of fine and coarse nodularity coexist.
Table 2 Endoscopic gastritis: Classification of endoscopic appearances of gastric inflammation Endoscopic erythematous/exudativegastritis Endoscopic flat erosive gastritis Endoscopic raised erosive gastritis Endoscopic atrophic gastritis Endoscopic haemorrhagic gastritis Endoscopic rugal hyperplastic gastritis Endoscopic enterogastric reflux gastritis
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(a)
Figure 1 (a) Mild endoscopic erythematous/exudative gastritis of the antrum. (b) Moderate to severe endoscopic erythematous/exudativegastritis of the antrum and corpus.
Figure 2 (a) Mild endoscopic flat erosive gastritis of the antrum. (b) Moderate endoscopic flat erosive gastritis of the antrum.
Endoscopic atrophic gastritis This is diagnosed when the vascular pattern becomes visible in the non-overdistended stomach. In addition there often is some pearly whitish mucosal discolouration. Furthermore, fold atrophy of variable degree may also be
present. This form of gastritis is scored as mild, moderate or severe, mainly using the visibility of the vascular pattern as dominant variable. Occasionally, areas of intestinal metaplasia may be macroscopically visible as grey-white patches with a slight opalescent tinge and/or a villous appearance on close inspection (Fig. 4).
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(b)
Figure 3 (a) and (b) Endoscopic raised erosive gastritis.
Endoscopic haemorrhagic gastritis This is diagnosed when, in addition to the usual characteristics of inflammation, there are punctate or ecchymotic reddish or brown-blackish flecks of various size present in the gastric wall. In addition, there may be adherent, usually dark-stained material or frank intraluminal bleeding. The number of bleeding spots determines whether haemorrhagic gastritis is mild, moderate or severe (Fig. 5).
Endoscopic rugal hyperplastic gastritis This is diagnosed when the predominant abnormality is enlargement of the folds, or hyperrugosity, especially in the corpus-fundus area, of mild, moderate or severe degree. These folds do not flatten during adequate insufflation. Pliancy, assessed by means of the mucosal tenting sign (lifting the mucosa with biopsy forceps) helps to rule out infiltrative disorders. Occasionally, the folds show superimposed polypoid irregularities. The area of fold enlargement may be sharply demarcated or may shade into normality. Some patients have flat erosions on top of the folds. In Mhetrier’s disease there is often abundant mucus covering the enlarged folds, the crests of which sometimes exhibit a confluent polypoid appearance. In gastrinoma there is conspicuous accentuation of the areae gastricae pattern of the corpus mucosa, with copious production of a clear fluid. In rugal hyperplastic hypersecretory gastritis, the thickened folds usually reveal marked irregular discolouration, loss of lustre and adherent flecks of exudate (Fig. 6).
Endoscopic enterogastric reflux gastritis This is in essence a further refinement of the endoscopic erythmatous/exudative variant, which is thought to justify
a separate category because of the well known clinical characteristics and pathogenic mechanisms involved. Mild, moderate or severe grade is diagnosed when there is conspicuous erythema and oedema of the gastric folds, often stained with refluxed bile. The intensely beefy-red discolouration is particularly striking. Especially near the stoma the folds may be markedly oedematous and can present a polypoid appearance. Not uncommonly in such post-gastrectomy situations, there may be evidence of atrophic changes in the more proximal part of the gastric remnant (Fig. 7).
Endoscopic congestive gastroenteropathy This is not a form of gastritis in the true sense, as there is no inflammation, but needs to be differentiated from the common forms of gastritis. This entity is diagnosed when patients with portal hypertension (mainly hepatic cirrhosis) present with conspicuous erythematous spots on top of the folds, usually mainly found in the corpus area. T h e erythematous spots are delineated by the network of the lineae gastricae (Fig. 8).
CLASSIFICATION OF ENDOSCOPIC APPEARANCES OF BULBAR INFLAMMATION Through highlighting of the most dominant abnormality, an endoscopic classification of the common forms of inflammatory abnormality in the bulb can be mad( (Table 3).1°
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Figure 4 (a) Endoscopic atrophic gastritis of the antrum. (b) Endoscopic atrophic gastritis of the corpus. (c) and (d) Endoscopically visible intestinal metaplasia.
Table 3 Classification of endoscopic appearances of duodenal inflammation
Endoscopic erythematous/exudative bulbitis/duodenitis
Endoscopic (mild/moderate/severe) erythematous/exudative duodenitis Endoscopic (mild/moderate/severe) erosive duodenitis Endoscopic (mild/moderate/severe) haemorrhagic duodenitis Endoscopic (mild/moderate/severe) nodular duodenitis
This is the most common endoscopic abnormality in the bulb. The most conspicuous abnormality is patchy erythema," often combined with loss of lustre and occasionally with a few punctate spots of exudate. There may be mild friability. Occasionally, oedema and standing mucosal folds are considered to represent the early phases or
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(b)
Figure 5 (a) Moderate endoscopic haemorrhagic gastritis. (b) Moderate to severe endoscopic haemorrhagic gastritis of the corpus.
(a 1
(b)
Figure 6
(a)
and (b) Endoscopic rugal hyperplastic gastritis of the corpus.
concomitant features of such inflammation.1z Signs of prior ulcer disease may be seen as linear or circular scars. This form of duodenitis may be mild, moderate or severe.
Endoscopic erosive duodenitis This is diagnosed when the dominant abnormality is the
presence of one, or more often multiple, erosions, often covered with whitish-yellow-greyish exudate. Erosions may be small or may appear to coalesce. Erosions may be present in crops or spread over large parts of the bulb. Concomitant erythema, friability and variable degrees of oedema are always present. There may be some luminal narrowing because of oedema. Erosive duodenitis should be diagnosed as mild, moderate or severe.
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(a)
Figure 7 (a) and (b) Endoscopic enterogastric reflux gastritis.
Figure 8 (a) and (b) Endoscopic congestive gastroenteropathy.
Endoscopic haemorrhagic duodenitis
Endoscopic nodular duodenitis
This is diagnosed when, in addition to the usual characteristics of inflammation, punctate or ecchymotic bleeding is visible, of mild, moderate or severe degree.
This may be considered as a separate entity, because it is virtually confined to patients with renal insufficiency or on chronic dialysis. T h e dominant abnormality is diffuse nod-
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ularity of the bulb of mild, moderate or severe degree. The mucosa may be strikingly erythematous and covered with small erosions and punctate or confluent exudate.13
confluent erosions. Additional features are slight oedema of the mucosa, accentuation of the fold pattern and conspicuously enhanced duodenal motor activity. (Figs. 9,10)
ENDOSCOPIC ABNORMALITIES IN HEL ZCOBAC TER P Y L ORI GASTRITIS/DUODENITIS
CORRELATION WITH HISTOLOGY
The endoscopic appearances of the stomach and bulb in the acute infectious phase of H.pylori-induced inflammation are poorly known. An occasional patient has been described with a strikingly red, friable and slightly erosive gastric mucosa, covered with abundant fibrinopurulent exudate in the antrum." In many patients with chronic H . pylori infection, usually in the distal part of the stomach, none or hardly any readily identifiable changes in the endoscopic appearance of the stomach are detectable. If endoscopic abnormalities are seen, they usually consist of patches of erythema, alternating with paler areas, some loss of lustre and sometimes slight unevenness of the mucosal lining. Close inspection, especially of the antral area, may reveal tiny punctate whitish spots of exudate. These abnormalities correspond to mild erythematous/exudative gastritis. I n more severe infection small erosions may be present, often on a standing prepyloric fold, corresponding to endoscopic mild flat erosive gastritis. Exceptionally, endoscopic moderate flat erosive gastritis is visible in the distal part of the stomach. Quite characteristic is the combination of discrete endoscopic abnormalities in the antrum combined with endoscopic evidence of inflammation in the duodenal bulb. Endoscopic duodenal inflammation is usually seen as patches of punctate erythema and areas of punctate or
Correlation between endoscopic macroscopic appearances and histology is often poor. Physicians often become frustrated because of this poor correlation between macroscopic abnormalities and corresponding microscopic changes. Several studies suggest that endoscopic appearances do not reliably predict the presence, or absence, of histologic g a s t r i t i ~ ~ but * ~ *there ' ~ is a great deal of uncertainty with respect to the severity of the endoscopic abnormalities, the biopsy site, or the number of biopsies examined. Based upon the currently available literature some general deductions can be made, while remaining fully aware of the shortcomings of many studies and the difficulties of interpretation (Table 4). Perhaps up to 40% or more of patients with endoscopically normal mucosa have histological gastritis visible on biopsy. When erythema is the most conspicuous endoscopic abnormality, histologic chronic gastritis has been found in 751'0 or more of patient^.^" When the endoscopic changes are more pronounced and certainly in the presence of erosions or frank atrophic gastritis, there are almost always corresponding histologic inflammatory changes. In general, the more severe the endoscopic gastric abnormalities, the better the correlation with histology2.1s.16. There is also controversy over the correlation between the endoscopic and histologic characteristics of duodenitis,
Figure 9 (a) H. pylorz-induced endoscopic erosive duodenitis. (b) Concomitant endoscopic flat erosive gastritis of the antrum.
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(a)
Figure 10 (a) H. pylori-induced endoscopic erosive duodenitis. (b) Concomitant mild endoscopic erosive gastritis of the antrum.
Table 4 Correlation between endoscopy and histology in gastritis Endoscopic diagnosis
Histological diagnosis
Normal endoscopy
Chronic gastritis in variable percentage ( 2 40Y0?) Chronic gastritis in variable percentage ( 2 7S0,?)
Erythematouslexudative gastritis Flatiraised erosive gastritis
Atrophic gastritis
Almost invariably chronic gastritis, sometimes with active component High percentage of chronic gastritis with severe glandular atrophy
Table 5 Correlation between endoscopy and histology in duodenitis Endoscopic diagnosis
Histological diagnosis
Erythematous/exudative duodenitis
Chronic duodenitis in high percentage ( 2 85°/o)
Erosive duodenitis
Almost invariably chronic duodenitis with active component Invariably chronic duodenitis with active component
Nodular duodenitis
except for the severe In general, the endoscopic findings correlate better with the histologic findings in the duodenal bulb than in the stomach (Table 5).21-23
ENDOSCOPIC BIOPSY TECHNIQUE For targeted pinch biopsies in the stomach, three sizes of biopsy forceps are available, varying from 5, 7 to 9 Fg in cup size. Some of the cups are open or fenestrated, others are closed. In addition there may be a bayonet-type spike enclosed within the cup (Fig. 11). In general, 7 Fg biopsy forceps should be considered as standard for routine clinical practice, although superior quality biopsies can be obtained with 10 Fg forceps. If at all possible, gentle but sufficient pressure should be applied when taking the biopsy, in order to diminish traumatic fragmentation of the biopsy while allowing sampling of muscularis mucosae. Usually no attempt is made to orient the relatively small tissue specimens. Pinch biopsies using standard 7 F g biopsy forceps provide adequate samples in approximately 80% of instances.* The number and the site of targeted biopsy differ according to the circumstances. Full characterization of the inflammatory status in the whole stomach needs multiple endoscopic biopsies of all anatomical regions of the stomach. For that purpose biopsies should include anterior and posterior wall of the antrum and corpus: antral biopsies should be taken 2-5 cm from the pylorus; corpus biopsies should be taken some 10 cm from the cardia, and always from the anterior and posterior wall (Fig. 12).
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(b)
Figure 11 (a) 5, 7, and 9 Fg biopsy forceps. (b) Corresponding gastric biopsy sizes.
Figure 12 Endoscopic gastritis: where to biopsy?
Certainly, if biopsies are to be taken to document atrophic changes, both the antrum and the corpus should be always biopsied. In both sites a minimum of 2 biopsies should be obtained. At least one of these biopsies should be taken from areas which appear grossly abnormal. In the presence of diffuse abnormalities limited to the antrum, again, 2 biopsies from both the anterior and posterior aspects of the mid-antrum suffice for proper histological interpretation. It is unclear whether it is more appropriate to sample the erythematous areas or the non-altered surrounding mucosa. In the presence of tiny spots of punctate exudate, or tiny erosive lesions, sampling the edges of these abnormalities is preferred. If large focal lesions are present, additional biopsies of the base and edges of these lesions are obviously indicated. The prepyloric antrum (3-5 cm from the pylorus) has been the preferred site of biopsy for the demonstration of H . pylori infection. A small number (5-10°{,?) of infected
patients will be missed if only the antrum is sampled. Sampling both antrum and corpus will effectively eliminate the small possibility of a false negative result due to the presence of intestinal metaplasia in the antrum, or patchiness of infection and inflammation. The improvement in diagnostic yield achieved with an increase in the umber of biopsies is small and not sufficient to warrant taking more than 2 biopsies in the routine clinical setting. However, research protocols may demand a larger number of specimens.
CONCLUDING REMARKS For precise documention of the role of endoscopy, in parallel with histology in the various forms of gastric inflammation, new studies have to be designed with careful
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and systematic prospective scoring of any endoscopic abnormality and adequate sampling of the gastric mucosa for histological analysis. Such endoscopic and biopsy studies should be done before and after treatment directed against gastric inflammation. Perhaps the standardized use of video endoscopy with the possibilities for more objective analysis of the macroscopic image (degree and distribution of erythema, number of spots of punctate exudate, of erosions, etc) will allow a more objective and accurate endoscopic interpretation of the gastric mucosal lining. It is not to be expected that the mild forms of chronic gastritis without alteration of the overall mucosal thickness, or of the quality of the mucus-secreting epithelium, will induce readily obvious endoscopic changes. I n contrast, the more severe forms of chronic gastritis, especially those accompanied by mucin depletion, focal necrosis and disruption of the epithelial layer, should be readily detectable by endoscopy. If, ultimately, endoscopic biopsies prove to be the key diagnostic modality, where should they be taken from? At present it is unknown whether random and targeted biopsies are equally informative in H.pylori gastritis. This will depend to a large extent on the uniform and diffuse character of the inflammation. If inflammation is of equal severity over a certain segment of the stomach, random biopsies should be satisfactory. If, on the other hand, inflammation is patchy, more precise targeting may be more appropriate. It may be sensible to sample in particular those areas where there is distortion or disruption of the epithelial lining or where punctate exudate is present.
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