Scandinavian Journal of Gastroenterology
ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: http://www.tandfonline.com/loi/igas20
The Story of Gastritis Max Siurala To cite this article: Max Siurala (1991) The Story of Gastritis, Scandinavian Journal of Gastroenterology, 26:sup186, 1-3, DOI: 10.3109/00365529109103978 To link to this article: http://dx.doi.org/10.3109/00365529109103978
Published online: 08 Jul 2009.
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The Story of Gastritis The story of gastritis began more than a century ago and several distinct phases can be distinguished in its history. The first phase can be termed surgical. The knowledge of gastritis was mostly based upon surgical specimens obtained by Billroth I and I1 procedures from patients operated upon because of peptic ulcer or gastric cancer. This research is represented by such well-known European gastroenterologists as Hurst, Konjetzy, Magnus, Puhl and Orator, and Scandinavian authors Faber, Meulengracht and Wallgren, who thoroughly described the morphological features of the gastric lesion in overt pernicious anaemia. Finnish authors like Salzman, Kalima and Tuomikoski made important contributions to our knowledge of the gastritis in ulcer- and cancer-bearing stomachs. At that time chronic gastritis was considered a common cause of abdominal complaints and a condition predisposing to peptic ulcer and gastric cancer. The following stage in gastritis research was related to the development of endoscopy of the stomach. Large-scale endoscopical studies overshadowed the earlier extensive morphological studies, many of which disappeared from our knowledge, to be once more reevaluated in connection with the development of blind and endoscopical direct vision biopsy. The development of endoscopy lead to the search for possibilities to get specimens for morphological evaluation. The first attempts were made by Thomenius and Benedict but their equipment was too clumsy and impractical for clinical and scientific purposes. Still, the ideas given by them contributed to the development of suction biopsy tubes which made it possible to obtain simultaneously several satisfactory biopsy specimens from the gastric mucosa. The first device was introduced by Wood and co-workers. The method was simple, rapid and reliable and could be performed without much inconvenience to the patient. However, the method suffered from two inherent drawbacks: antral mucosa remained outside the scope of the method and
massive bleeding occurred occasionally. The beginning of this "blind biopsy" era in gastritis research coincides with the establishment of the first gastroenterological unit in Finland in 1950. In 195 1 a "blind biopsy" equipment was developed in Finland by Setalii and co-workers, actually unaware of the device invented in Australia. The search for more effective endoscopy and biopsy equipment gained decisive progress by the development of the fiber gastroscope by Basil Hirschowitz, Subsequently the fiberscope was provided with a new effective biopsy equipment. These advances ensured a rapid progress of gastroenterology in the Nordic countries and was followed by the foundation of an inter-Scandinavian journal: The Scandinavian Journal of Gastroenterology. In view of the availability of specimens for morphological examination, gastritis again became a morphological concept after having been for a couple of decades an endoscopical disease. However, worldwide unanimity had not yet been obtained in the definition of the term gastritis. Thus, in some countries the term "gastritis" was used, and may be still in use, to describe a clinical condition characterized by abdominal complaints and "disturbances" in acid secretion. However, extensive studies performed with the "blind biopsy" and the direci vision biopsy equipments in dyspeptics and nondyspeptics, and between those with gastritic and a normal corpus mucosa disclosed a poor correlation between morphology and complaints. It has been known for a long time that gastritis is a common condition, its prevalence being in gastric carcinomas and proximally situated ulcers close to 100%. However, knowledge of its prevalence and distribution in the general population was not known and all evidence was based upon studies of outpatients or "healthy" volunteers. Data on randomly selected materials were not collected until in the late sixties, but at present there are several series available that have been collected and studied
Downloaded by [University of California Santa Barbara] at 01:49 02 April 2016
2
M . Siuruku
in Estonia (Villako et al.) and Finland (Isokoski et al., Ihamaki et al.). They show that gastritis is a very common condition in the general population although the percentages vary from about 40% to nearly 100%.In these studies no correlation was found between subjective complaints and corpus gastritis. The availability of series collected at random and of suitable mathematical approaches has made it possible to look at gastritis as a dynamic process that seems to begin as a slight gastritis affecting simultaneously the antrum and the body and may progress to atrophy. In middle age there appears a dissociation of the antral and body process, with formation of more specific subtypes affecting mainly one part of the mucosa, either antrum or body. This process takes a long period of years, often almost the whole lifc span. The above presented views have been corroborated by endoscopic-bioptical follow-up studies performed in several countries, particularly in Finland and Estonia. However, the follow-up studies have also disclosed great variability in the course of gastritis. Indeed, in some cases the gastritis heals, in some progresses, but remains unchanged in most. The progression of the disease was assumed to be due to acute exacerbations, the absence of which would explain the retardation of the process. However, the basic factors responsible for the development of gastritis and its further progress have been unknown until recent years. There is general agreement that chronic gastritis is etiologically and pathogenetically a multifactorial disease determined by many genetic and environmental factors. Genetic studies (Varis 1971)have disclosed that a single major factor is operating in the pernicious anaemia type of gastritis and that it is obviously inherited in a dominant Mendelian way. The available data also suggest that genetic factors may be operating in other forms and also at more early stages of gastritis; the evidence, however, is still inconclusive. As concerns environmental factors, most authors have been well aware of their importance, particularly at the early stages of the disease, but their definition has not as yet been
possible. No dietary factors or abuse of tobacco or alcohol have been shown to be of any decisive significance. Likewise research lasting decades on the effects of duodenal regurgitation have been disappointing and at present the concept of duodenal regurgitation is rather in line with the opinions expressed by Boldyreff a century ago that duodenal regurgitation is, at least in its milder degrees, a more or less physiological phenomenon. The theory that nitroso-compounds are important factors in the pathogenesis of gastritis has faced a similar fate. Despite considerable experimental evidence it has not been possible to show that under the conditions prevailing in the human stomach they are present in amounts large enough to give rise to gastritis. Indeed, only the discovery of Helirobarter pylori and its association with the acute and chronic signs of inflammation explain the immuno-nature of the round cell infiltration that characterizes the early stages of gastritis. There is hardly any doubt that HP is in some way related to the development of these early stages. On the other hand, its significance seems to decrease with further progression of gastritis, specifically in progression of the final stages of atrophy, where other factors such as the effects of genetic variation may play a more important role. It should also be noted that atrophic changes are associated with a decrease of normal and the appearance of strange secretory functions and the development of intestinal metaplasia all of which might interfere with the survival of the bacteria. Moreover, Helicobacter pylori is probably not the only gastritis-related microorganism in the human stomach. Occasionally other micro-organisms, like Gastrospirillum honzinis have been found and described as causative agents in gastritis. Interestingly, Gastrospirillum hominis as well as some Helicobucter pylori-like bacteria, are commonly found in the stomach of dogs and rats; this may offer an explanation of source and route of infection in humans. On the basis of the above discussed recent data a new classification of gastritis, the socalled "Sydney system", was introduced at the last World Congress of Gastroenterology 1990.
Downloaded by [University of California Santa Barbara] at 01:49 02 April 2016
Historical Review
3
The clinical significance of the Helicohacter Basically the classification is similar to those earlier used and that employed already by pylori-related gastritis per se is not clear. Some Schindler. It includes Schindler's superficial follow-up results after successful treatment of gastritis ("Gastritis without atrophy") and bacterial infestation seem to suggest that part of atrophic gastritis ("Gastritis with atrophy"). the symptoms might be due to the helicobacterHowever, it gives a more comprehensive and related gastritis, but the evidence is still inconall-round description of the different aspects of clusive. Indeed, all our cross-sectional evidence has been negative. On the other hand, it should chronic gastritis. Gastritis is certainly related in some way to be considered that we are dealing with a chronic chronic gastroduodenal ulcer and to gastric imflammatory reaction of long duration and that cancer. The prevalence of gastritis is high in cross-sectional bacteriological and morphological gastric and duodenal ulcer and in gastric carci- studies represent only an one-shot picture of a noma, and recent mathematical calculations of decades long process. Accordingly, the available cross-sectional and follow-up studies suggest evidence does not exclude the possibility that at that the risk of getting ulcer is increased in an earlier and more acute stage of the inflammagastritis and that gastritis precedes the occur- tory reaction there might occur some transitory rence of ulcer. Similar studies carried out with symptoms related to the bacterial infestation. From the above it appears that a large number regard to gastric carcinoma suggest that the cancer-risk is increased in gastritis with atrophy of epidemiological studies, have been performed and that in a large proportion of cancer cases in Estonia, and as a matter of fact, in close atrophic gastritis precedes the development of collaboration with the corresponding team in Finland. This year, 1991, the collaboration the malignancy. The associations between gastritis and cancer between scientists of the University of Tartu and and ulcer on the one hand and between gastritis our Finnish team has reached an important and HP infestation on the other hand might milestone: 20 years of successful collaboration provide a possibility of prevention of ulcer or has passed since K. Villako in Estonia and I in cancer by effective antibiotic treatment. This Finland started the collaboration. The present hardly seems feasible with regard to cancer issue of the Scandinavian Journal of Gastroenbecause of the practical, economical and psy- terology consists mainly of the results achieved chological inconveniences that concern both during the past few years of this collaboration, patient and society when large populations are and the next paper written by Professor VeHo screened for the detection of a rare disease. The Salupere of Tartu University will more closely question of prevention is more real in regard to delineate the Estonian approaches and their peptic ulcer because it is a more common results. disease and because there is already some MAX SIURALA evidence that antibiotic treatment may interfere Espoo with the further course of the disease. Finland
ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: http://www.tandfonline.com/loi/igas20
The Story of Gastritis Max Siurala To cite this article: Max Siurala (1991) The Story of Gastritis, Scandinavian Journal of Gastroenterology, 26:sup186, 1-3, DOI: 10.3109/00365529109103978 To link to this article: http://dx.doi.org/10.3109/00365529109103978
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=igas20 Download by: [University of California Santa Barbara]
Date: 02 April 2016, At: 01:49
Downloaded by [University of California Santa Barbara] at 01:49 02 April 2016
The Story of Gastritis The story of gastritis began more than a century ago and several distinct phases can be distinguished in its history. The first phase can be termed surgical. The knowledge of gastritis was mostly based upon surgical specimens obtained by Billroth I and I1 procedures from patients operated upon because of peptic ulcer or gastric cancer. This research is represented by such well-known European gastroenterologists as Hurst, Konjetzy, Magnus, Puhl and Orator, and Scandinavian authors Faber, Meulengracht and Wallgren, who thoroughly described the morphological features of the gastric lesion in overt pernicious anaemia. Finnish authors like Salzman, Kalima and Tuomikoski made important contributions to our knowledge of the gastritis in ulcer- and cancer-bearing stomachs. At that time chronic gastritis was considered a common cause of abdominal complaints and a condition predisposing to peptic ulcer and gastric cancer. The following stage in gastritis research was related to the development of endoscopy of the stomach. Large-scale endoscopical studies overshadowed the earlier extensive morphological studies, many of which disappeared from our knowledge, to be once more reevaluated in connection with the development of blind and endoscopical direct vision biopsy. The development of endoscopy lead to the search for possibilities to get specimens for morphological evaluation. The first attempts were made by Thomenius and Benedict but their equipment was too clumsy and impractical for clinical and scientific purposes. Still, the ideas given by them contributed to the development of suction biopsy tubes which made it possible to obtain simultaneously several satisfactory biopsy specimens from the gastric mucosa. The first device was introduced by Wood and co-workers. The method was simple, rapid and reliable and could be performed without much inconvenience to the patient. However, the method suffered from two inherent drawbacks: antral mucosa remained outside the scope of the method and
massive bleeding occurred occasionally. The beginning of this "blind biopsy" era in gastritis research coincides with the establishment of the first gastroenterological unit in Finland in 1950. In 195 1 a "blind biopsy" equipment was developed in Finland by Setalii and co-workers, actually unaware of the device invented in Australia. The search for more effective endoscopy and biopsy equipment gained decisive progress by the development of the fiber gastroscope by Basil Hirschowitz, Subsequently the fiberscope was provided with a new effective biopsy equipment. These advances ensured a rapid progress of gastroenterology in the Nordic countries and was followed by the foundation of an inter-Scandinavian journal: The Scandinavian Journal of Gastroenterology. In view of the availability of specimens for morphological examination, gastritis again became a morphological concept after having been for a couple of decades an endoscopical disease. However, worldwide unanimity had not yet been obtained in the definition of the term gastritis. Thus, in some countries the term "gastritis" was used, and may be still in use, to describe a clinical condition characterized by abdominal complaints and "disturbances" in acid secretion. However, extensive studies performed with the "blind biopsy" and the direci vision biopsy equipments in dyspeptics and nondyspeptics, and between those with gastritic and a normal corpus mucosa disclosed a poor correlation between morphology and complaints. It has been known for a long time that gastritis is a common condition, its prevalence being in gastric carcinomas and proximally situated ulcers close to 100%. However, knowledge of its prevalence and distribution in the general population was not known and all evidence was based upon studies of outpatients or "healthy" volunteers. Data on randomly selected materials were not collected until in the late sixties, but at present there are several series available that have been collected and studied
Downloaded by [University of California Santa Barbara] at 01:49 02 April 2016
2
M . Siuruku
in Estonia (Villako et al.) and Finland (Isokoski et al., Ihamaki et al.). They show that gastritis is a very common condition in the general population although the percentages vary from about 40% to nearly 100%.In these studies no correlation was found between subjective complaints and corpus gastritis. The availability of series collected at random and of suitable mathematical approaches has made it possible to look at gastritis as a dynamic process that seems to begin as a slight gastritis affecting simultaneously the antrum and the body and may progress to atrophy. In middle age there appears a dissociation of the antral and body process, with formation of more specific subtypes affecting mainly one part of the mucosa, either antrum or body. This process takes a long period of years, often almost the whole lifc span. The above presented views have been corroborated by endoscopic-bioptical follow-up studies performed in several countries, particularly in Finland and Estonia. However, the follow-up studies have also disclosed great variability in the course of gastritis. Indeed, in some cases the gastritis heals, in some progresses, but remains unchanged in most. The progression of the disease was assumed to be due to acute exacerbations, the absence of which would explain the retardation of the process. However, the basic factors responsible for the development of gastritis and its further progress have been unknown until recent years. There is general agreement that chronic gastritis is etiologically and pathogenetically a multifactorial disease determined by many genetic and environmental factors. Genetic studies (Varis 1971)have disclosed that a single major factor is operating in the pernicious anaemia type of gastritis and that it is obviously inherited in a dominant Mendelian way. The available data also suggest that genetic factors may be operating in other forms and also at more early stages of gastritis; the evidence, however, is still inconclusive. As concerns environmental factors, most authors have been well aware of their importance, particularly at the early stages of the disease, but their definition has not as yet been
possible. No dietary factors or abuse of tobacco or alcohol have been shown to be of any decisive significance. Likewise research lasting decades on the effects of duodenal regurgitation have been disappointing and at present the concept of duodenal regurgitation is rather in line with the opinions expressed by Boldyreff a century ago that duodenal regurgitation is, at least in its milder degrees, a more or less physiological phenomenon. The theory that nitroso-compounds are important factors in the pathogenesis of gastritis has faced a similar fate. Despite considerable experimental evidence it has not been possible to show that under the conditions prevailing in the human stomach they are present in amounts large enough to give rise to gastritis. Indeed, only the discovery of Helirobarter pylori and its association with the acute and chronic signs of inflammation explain the immuno-nature of the round cell infiltration that characterizes the early stages of gastritis. There is hardly any doubt that HP is in some way related to the development of these early stages. On the other hand, its significance seems to decrease with further progression of gastritis, specifically in progression of the final stages of atrophy, where other factors such as the effects of genetic variation may play a more important role. It should also be noted that atrophic changes are associated with a decrease of normal and the appearance of strange secretory functions and the development of intestinal metaplasia all of which might interfere with the survival of the bacteria. Moreover, Helicobacter pylori is probably not the only gastritis-related microorganism in the human stomach. Occasionally other micro-organisms, like Gastrospirillum honzinis have been found and described as causative agents in gastritis. Interestingly, Gastrospirillum hominis as well as some Helicobucter pylori-like bacteria, are commonly found in the stomach of dogs and rats; this may offer an explanation of source and route of infection in humans. On the basis of the above discussed recent data a new classification of gastritis, the socalled "Sydney system", was introduced at the last World Congress of Gastroenterology 1990.
Downloaded by [University of California Santa Barbara] at 01:49 02 April 2016
Historical Review
3
The clinical significance of the Helicohacter Basically the classification is similar to those earlier used and that employed already by pylori-related gastritis per se is not clear. Some Schindler. It includes Schindler's superficial follow-up results after successful treatment of gastritis ("Gastritis without atrophy") and bacterial infestation seem to suggest that part of atrophic gastritis ("Gastritis with atrophy"). the symptoms might be due to the helicobacterHowever, it gives a more comprehensive and related gastritis, but the evidence is still inconall-round description of the different aspects of clusive. Indeed, all our cross-sectional evidence has been negative. On the other hand, it should chronic gastritis. Gastritis is certainly related in some way to be considered that we are dealing with a chronic chronic gastroduodenal ulcer and to gastric imflammatory reaction of long duration and that cancer. The prevalence of gastritis is high in cross-sectional bacteriological and morphological gastric and duodenal ulcer and in gastric carci- studies represent only an one-shot picture of a noma, and recent mathematical calculations of decades long process. Accordingly, the available cross-sectional and follow-up studies suggest evidence does not exclude the possibility that at that the risk of getting ulcer is increased in an earlier and more acute stage of the inflammagastritis and that gastritis precedes the occur- tory reaction there might occur some transitory rence of ulcer. Similar studies carried out with symptoms related to the bacterial infestation. From the above it appears that a large number regard to gastric carcinoma suggest that the cancer-risk is increased in gastritis with atrophy of epidemiological studies, have been performed and that in a large proportion of cancer cases in Estonia, and as a matter of fact, in close atrophic gastritis precedes the development of collaboration with the corresponding team in Finland. This year, 1991, the collaboration the malignancy. The associations between gastritis and cancer between scientists of the University of Tartu and and ulcer on the one hand and between gastritis our Finnish team has reached an important and HP infestation on the other hand might milestone: 20 years of successful collaboration provide a possibility of prevention of ulcer or has passed since K. Villako in Estonia and I in cancer by effective antibiotic treatment. This Finland started the collaboration. The present hardly seems feasible with regard to cancer issue of the Scandinavian Journal of Gastroenbecause of the practical, economical and psy- terology consists mainly of the results achieved chological inconveniences that concern both during the past few years of this collaboration, patient and society when large populations are and the next paper written by Professor VeHo screened for the detection of a rare disease. The Salupere of Tartu University will more closely question of prevention is more real in regard to delineate the Estonian approaches and their peptic ulcer because it is a more common results. disease and because there is already some MAX SIURALA evidence that antibiotic treatment may interfere Espoo with the further course of the disease. Finland
