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ORIGINAL RESEARCH

Novel Sonographic Clues for Diagnosis of Antral Gastritis and Helicobacter pylori Infection A Clinical Study Emin Cakmakci, MD, Berna Ucan, MD, Bayram Colak, MD, Hasibe Gokçe Cinar, MD

Article includes CME test

Objectives—The purpose of this study was to find out whether transabdominal sonography may have a predictive role for detection of antral gastritis and Helicobacter pylori infection in the antrum. Methods—A total of 108 patients and 54 control participants were allocated into 3 groups: group 1, controls without any symptoms or findings of antral gastritis and H pylori infection; group 2, patients with symptoms and endoscopic findings consistent with gastritis in the absence of documented H pylori infection; and group 3, patients with symptoms and endoscopic findings consistent with gastritis and documented H pylori infection. These groups were compared in terms of demographics, antral wall thickness, mucosal layer (together with muscularis mucosa) thickness, and mucosal layer-toantral wall thickness ratio. Results—The groups had no statistically significant differences with respect to age, sex, body mass index, and smoking habits. However, it turned out that both antral walls and muscularis mucosa layers were thicker and the mucosal layer-to-antral wall thickness ratio was higher in groups 2 and 3 compared to group 1 (P > .001). In addition, group 3 had statistically significantly thicker antral walls and muscularis mucosa layers and a significantly increased mucosal layer-to-antral wall thickness ratio than group 2 (P < .001). Conclusions—Our results suggest that antral gastritis caused by H pylori infection is associated with characteristic features such as thickening of antral walls and mucosal layers on sonography. These novel clues may be useful in the diagnosis of gastritis, and unnecessary interventions and measures can be avoided in some cases.

Received October 16, 2013, from the Departments of Radiology (E.C.) and General Surgery (B.C.), Kelkit Government Hospital, Gumushane, Turkey; and Department of Radiology, Dr Sami Ulus Children’s Hospital, Ankara, Turkey (B.U., H.G.C.). Revision requested November 18, 2013. Revised manuscript accepted for publication December 31, 2013. Address correspondence to Emin Cakmakci, MD, Department of Radiology, Sisli Etfal Training and Research Hospital, Etfal Street, Sisli, 34360 Istanbul, Turkey. E-mail: [email protected] Abbreviations

BMI, body mass index doi:10.7863/ultra.33.9.1605

Key Words—antrum; diagnosis; gastritis; gastrointestinal ultrasound; Helicobacter pylori; sonography

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elicobacter pylori has been implicated as a major cause of gastritis and peptic ulcer disease.1,2 The antrum is usually the most common site of inflammation, and the submucosal layer is frequently colonized by H pylori. Radiologically, gastric wall thickening is one of the most important signs of gastrointestinal diseases. Due to mucosal erosion caused by proliferation of H pylori, the mucosal layer becomes thicker. Similarly, the submucosal layer as well as the mucosal layer (together with the muscularis mucosa) may gain thickness in parallel to the extent and severity of inflammatory changes.1–3

©2014 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2014; 33:1605–1610 | 0278-4297 | www.aium.org

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Cakmakci et al—Sonographic Clues for Diagnosis of Antral Gastritis and H pylori Infection

Up to now, the clinical applications of transabdominal gastric sonography have been limited. It has been used to evaluate gastric wall lesions and changes in gastric volume during accommodation and emptying of the stomach. As a diagnostic tool, sonography is a noninvasive, safe, inexpensive, and practical option for imaging the stomach. A systematic and dynamic approach with awareness of common technical difficulties must be taken by the radiologist to determine the essential clues for the diagnosis.4,5 To our knowledge, scarce data exist in the radiologic literature about the role of sonography in the diagnosis of antral gastritis and its relationship with H pylori infection. The aim of this prospective study was to characterize the sonographic findings in antral gastritis based on gastric wall thickness and to determine whether there are differences in the appearances of patients with antral gastritis with and without H pylori infection. Data obtained from this study can serve as baseline information with which to compare gastric sonographic findings in patients with H pylori colonization and antral gastritis.

Materials and Methods Study Design This study was approved by the local Institutional Review Board. Written informed consent was obtained from all participants. A total of 108 patients and 54 control participants, referred to the Department of Radiology of our tertiary center between September 2012 and May 2013, constituted the study group. Exclusion criteria were a history of gastric surgery, a known or suspected diagnosis of abdominal malignancy, a known or suspected diagnosis of acute pancreatitis or inflammatory bowel disease, a history of abdominal surgery or abdominal radiotherapy, use of nonsteroidal anti-inflammatory drugs, previous treatment of H pylori infection, and simple obesity (body mass index [BMI] ≥25 kg/m2). Sonography was routinely performed before endoscopy in all cases by the same examiner, and institutional fasting guidelines (solid and fluid intake up to 8 hours before sonography) were applied. A complete medical history was taken at hospital admission. A single 20-mg dose of butylscopolamine (Buscopan; Zentiva, Istanbul, Turkey) was administered via an intramuscular route before the sonographic examination. A curvilinear array, low-frequency (2–5-MHz) transducer (MyLab 60; Esaote SpA, Genoa, Italy) was used in this study. Patients were examined in the supine position followed by the right lateral decubitus position. The transducer was applied on the epigastric region in a sagittal

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plane. The gastric antrum and body were examined by shifting the transducer from right to left to achieve a qualitative impression of the gastric cavity. The antrum has a characteristic multilayered wall and is best visualized in a parasagittal plane just right of the midline using the left lobe as an acoustic window. It is surrounded by the left lobe and caudate lobe of the liver anteriorly and the head or neck of the pancreas posteriorly. The wall thickness is measured in a cross section with a longitudinal section of the superior mesenteric artery in the image. On transabdominal sonography, a hyperechoic mucosal layer can be observed in the form of linear stripes in an empty stomach and in a trabeculated form due to gastric piliforms when there is content in the stomach lumen. Right below this layer, the presence of H pylori at an 80% to 90% rate and the hyperechoic mucosal layer (together with the muscularis mucosa) that was measured in our study can be seen. Outside lies the hyperechoic submucosa and hypoechoic muscularis propria, and at the outermost section, a hyperechoic serositis/adventitia layer can be observed. In this study, the seemingly hypoechoic mucosal layer and full antral wall thicknesses were measured in the groups described below, and their ratios were compared within groups (Figures 1 and 2). Diagnoses of antral gastritis and H pylori infection were confirmed by evaluation of biopsy specimens obtained during endoscopic examination. The participants were allocated into 3 groups: group 1, controls without any symptoms of antral gastritis and H pylori infection, who underwent sonography without endoscopy; group 2, patients with symptoms and endoscopic findings consistent with gastritis in the absence of documented H pylori infection; and group 3, patients with symptoms and endoscopic findings consistent with gastritis and documented H pylori infection. Outcome Parameters Demographics such as age, sex, BMI, and smoking history were recorded. The antral wall thickness and mucosal layer thickness (MLT) were measured by sonography. Since these variables may be affected by personal variations, and the degree of H pylori infection may vary from one patient to another, the mucosal layer-to-antral wall thickness ratio was also taken into account. Statistical Analyses Data were analyzed with SPSS version 19.0 software for Windows (IBM Corporation, Armonk, NY). A normal distribution of the quantitative data was checked with Kolmogorov-Smirnov and Shapiro-Wilk tests. Parametric

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Cakmakci et al—Sonographic Clues for Diagnosis of Antral Gastritis and H pylori Infection

tests were applied to data with a normal distribution, and nonparametric tests were applied to data with a questionably normal distribution. An independent-samples t test and 1-way analysis of variance were used to compare independent groups. The Tamhane test was used for post hoc comparisons. To calculate correlation coefficients, a partial correlation test was used. An η test was used when comparing continuous and categorical variables. The distribution of categorical variables in both groups was compared by the Pearson χ2 test. The results for all items were expressed as mean ± standard deviation, assessed within 95% reliance and at a significance level of P < .05.

Figure 1. Transabdominal sonogram from a participant in group 1 without any stomach symptoms or endoscopic pathologic findings: parasagittal oblique middle line view. Air extends from the distal antrum and antropyloric zone (triangle) of the stomach to the stomach lumen. Arrow indicates the linearly extended echogenic mucosal layer together with the linearly extended hypoechoic muscularis mucosa right below it echogenic submucosa, hypoechoic muscularis propria, and serositis/ adventitia layer at the outermost. Brace indicates the full layer of the antral wall.

Results The 3 groups were compared in terms of demographics such as age, sex, BMI, and smoking habits, and the sonographic parameters antral wall thickness, mucosal layer thickness, and mucosal layer-to-antral wall thickness ratio. The groups had no significant differences with respect to age, sex, BMI, and smoking habits. It turned out that antral walls and muscularis mucosa layers were thicker in groups 2 and 3 compared to group 1 (P > .001). In addition, group 3 had statistically significantly thicker antral walls and muscularis mucosa layers than group 2 (P < .001). Comparative data for the groups are shown in Table 1. Scatterplots of the data are shown in Figure 3.

Figure 2. Transabdominal sonogram from a patient in group 3 with gastric symptoms and a diagnosis of H pylori infection after endoscopic biopsy: parasagittal oblique middle line view. The distal antrum of the stomach is shown. In contrast to Figure 1, the ratio of the hypoechoic mucosal layer thickness (circle) to the full-layer antral wall thickness (brace) was increased.

Table 1. Comparison of Demographics and Sonographic Features in the 3 Groups Parameter Age, y Female, n (%) Male, n (%) BMI, kg/m2 Smoking, packs/y AWT, mm MLT, mm MLT/AWT ratio

Group 1 49.48 ± 12.54 (18–65) 28 (51.9) 26 (48.1) 28.77 ± 3.91 (21.9–38.1) 14.40 ± 7.10 (0–29) 4.60 ± 0.70 (3.1–6.4) 2.18 ± 0.39 (1.3–3.2) 0.48 ± 0.03 (0.37–0.56)

Group 2 49.77 ± 11.29 (19–70) 27 (50.9) 26 (49.1) 27.10 ± 2.94 (23.2–35.1) 18.56 ± 8.30 (0–34) 7.68 ± 2.12 (3.2–8.7) 3.65 ± 0.74 (1.7–5.6) 0.56 ± 0.06 (0.45–0.67)

Group 3 49.62 ± 11.83 (19–69) 26 (47.3) 29 (52.7) 26.80 ± 2.18 (20.5–33.2) 15.11 ± 8.88 (0–43) 8.48 ± 1.23 (3.5–13.5) 5.03 ± 1.30 (2.2–8.9) 0.67 ± 0.06 (0.58–0.80)

P .276 .880 .062 .051

Novel sonographic clues for diagnosis of antral gastritis and Helicobacter pylori infection: a clinical study.

The purpose of this study was to find out whether transabdominal sonography may have a predictive role for detection of antral gastritis and Helicobac...
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