Journal of Gastroenterology and Hepatology (1991) 6 , 207-208
ADONIS 081593199100037J
WORKING PARTY REPORT T O T H E WORLD CONGRESSES O F GASTROENTEROLOGY, SYDNEY 1990 The Sydney System: A new classification of gastritis. Introduction J. J.
MISIEWICZ*
Department of Gastroenterology and Nutrition, Central Middlesex Hospital, I,ondon, U K
INTRODUCTION Why a new classification of gastritis, when several systems for dealing with this very common condition are already in existence? Gastritis, defined as the inflammatory response of the gastric mucosa to injury, is a worldwide problem of enormous magnitude. The introduction and universal use of fibre-optic endoscopy and targeted biopsy has increasingly documented the widespread prevalence of gastritis. A continuing dilemma has been the size of the population suffering from gastritis coupled with the lack of a clearly identifiable pathogenic mechanism. The recent recognition that Helicobacter (previously Campylobacter) pylori is the major cause of chronic inflammation of the human gastric antral mucosa has in part solved this problem. This discovery has potentially very important implications for treatment and also perhaps for the prevention of peptic ulcer, and may be relevant to the initiation of gastric cancer. Many early classifications of gastritis were limited by the availability of material, which could be harvested only by blind gastric biopsy. Endoscopic targeted biopsy has enabled accurate anatomical siting and, consequently, the anatomical distribution of gastritis within the stomach to be recognized. T h e main concern has been with chronic, ‘non-specific’ gastritis rather than with acute gastritis or the rarer special patterns. Later, the classifications of gastritis were devised before the epidemiology of H . pyloriand its association with antral gastritis, with duodenal ulcer, and possibly with gastric carcinoma, were recognized. The multiplicity of classifications, each valid within its own terms, have produced some confusion and attendant difficulties in comparing data between centres. Because of this, and because of the pivotal role that infection with H . pylori is now known to play in the pathogenesis of gastritis, the time seemed right to reconsider the classification of gastritis and the responses of the gastric mucosa to injury. This was the remit of the Sydney Working Party on Gastritis, who were assisted by an ad hoc Advisory Group of European Pathologists.
It was decided to name the new classification T h e Sydney System for the classification of gastritis (Fig. I). This name differentiates it from previous classifications and conveys the concept behind the venture, viz. the creation of a flexible matrix of rules which will respond to the changing demands of the subject. In devising the Sydney System the Working Party aimed to produce a simple, easy to apply, comprehensive and comprehensible classification, which will be flexible and capable of correlation with pre-existing ideas. The Sydney System will be useful to generalists and specialists alike and sensitive to monitoring of the effects of treatment, which will be used increasingly to eradicate H . pylori infection. It is hoped that the Sydney System will provide a scheme that is structured, simple and logical and which has a wide appeal. It should prove suitable for routine work and for research. The System attempts to provide a flexible working formulation for the reporting of gastritis that overcomes some of the more rigid principles of other classifications, while incorporating their advantages. The previous categories of gastritis, such as Types A, 13. AB arid C, are no longer used. l’he Sydney System relies on adequately biopsied clinical material and on accurate description of histological features easily recognizable by histopathologists and agreed on after extensive consultations and discussions by leading members of the profession. Because most clinicians first encounter gastritis as viewed through the endoscope, a system for classifying endoscopic gastritis (the Endoscopic Division) has been developed in parallel with the histological system, while recognizing that the correlation between the two is as yet imperfect. The aim of producing an endoscopic system of classification is to encourage and facilitate the reporting of endoscopic appearances in a standard way. Prospective studies using the Sydney System of endoscopic gastritis will enable more accurate and extensive correlations between macroscopic and microscopic gastritis to be achieved in the future. T h e importance of microbial and immunological factors, natural history, epidemiology and prognosis of gastritis is underlined by separate discussion of these entities, although they do not directly enter into the main System.
*Workingparty Chairperson. Members: G. N . J. Tytgat, A. B. Price, C. S . Goodwin, R. G. Strickland and P. Sipponen. Corresponding Member: R. Cheli. Correspondence: Dr J. J. Misiewicz FRCP, Consultant Physician and Joint Director, Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London, NWlO 7NS, UK. Accepted for publication 14 December 1990.
J . J . Misiewicz
208
THE SYDNEY SYSTEM
MORPHOLOGY (suffix)
TOPOGRAPHY (core)
AETIOLOGY (prefix)
inflammation activity
GRADED
PATHOGENIC
-I
Gaslntrs Gaslntrs of antrum
Gastrills of corpus
Descriptive terms
intestinal
Rugal hyperplasia Rugal atrophy Visibility of vascular patlern Intramural bleedmg spots
Oedema Erythema Friability Exudate Flat erosion Raised erosion NOdularity
pangastritis
ASSOCIATIONS
II
MPOGRAPHY
I
ACUTE GASTRITIS CHRONIC GASTRITIS SPECIAL FORMS
Categories ofendoscopic gastritis
gastntis of antnun
Erythematous,exudalive flat erosive Haernorrhagic Raised erosive Renux Rugal hyperplastic Alrophic
gastntis of corpus
SEVERITY GRADING :
none
mild
moderate
-~~-
-~
severe -~~ -
Figure 1 Schematic representation of the Sydney System for the classification of gastritis.
ACKNOWLEDGEMENTS Members of the Working Party gratefully acknowledge the generous help and advice of the European Pathologists Advisory Group: V. Bogomoletz (France), M. Dixon
(UK), J. Haot (Belgium), K. Heillman (Germany), A. Price (UK), P. Sipponen (Finland), E. Solcia (Italy), M. Stolte (Germany) and J. Wyatt (UK). We also express our thanks to the many other colleagues, especially the Helicobacter pylori working party, who freely shared their expertise in numerous informal contacts and discussions.
ADONIS 081593199100037J
WORKING PARTY REPORT T O T H E WORLD CONGRESSES O F GASTROENTEROLOGY, SYDNEY 1990 The Sydney System: A new classification of gastritis. Introduction J. J.
MISIEWICZ*
Department of Gastroenterology and Nutrition, Central Middlesex Hospital, I,ondon, U K
INTRODUCTION Why a new classification of gastritis, when several systems for dealing with this very common condition are already in existence? Gastritis, defined as the inflammatory response of the gastric mucosa to injury, is a worldwide problem of enormous magnitude. The introduction and universal use of fibre-optic endoscopy and targeted biopsy has increasingly documented the widespread prevalence of gastritis. A continuing dilemma has been the size of the population suffering from gastritis coupled with the lack of a clearly identifiable pathogenic mechanism. The recent recognition that Helicobacter (previously Campylobacter) pylori is the major cause of chronic inflammation of the human gastric antral mucosa has in part solved this problem. This discovery has potentially very important implications for treatment and also perhaps for the prevention of peptic ulcer, and may be relevant to the initiation of gastric cancer. Many early classifications of gastritis were limited by the availability of material, which could be harvested only by blind gastric biopsy. Endoscopic targeted biopsy has enabled accurate anatomical siting and, consequently, the anatomical distribution of gastritis within the stomach to be recognized. T h e main concern has been with chronic, ‘non-specific’ gastritis rather than with acute gastritis or the rarer special patterns. Later, the classifications of gastritis were devised before the epidemiology of H . pyloriand its association with antral gastritis, with duodenal ulcer, and possibly with gastric carcinoma, were recognized. The multiplicity of classifications, each valid within its own terms, have produced some confusion and attendant difficulties in comparing data between centres. Because of this, and because of the pivotal role that infection with H . pylori is now known to play in the pathogenesis of gastritis, the time seemed right to reconsider the classification of gastritis and the responses of the gastric mucosa to injury. This was the remit of the Sydney Working Party on Gastritis, who were assisted by an ad hoc Advisory Group of European Pathologists.
It was decided to name the new classification T h e Sydney System for the classification of gastritis (Fig. I). This name differentiates it from previous classifications and conveys the concept behind the venture, viz. the creation of a flexible matrix of rules which will respond to the changing demands of the subject. In devising the Sydney System the Working Party aimed to produce a simple, easy to apply, comprehensive and comprehensible classification, which will be flexible and capable of correlation with pre-existing ideas. The Sydney System will be useful to generalists and specialists alike and sensitive to monitoring of the effects of treatment, which will be used increasingly to eradicate H . pylori infection. It is hoped that the Sydney System will provide a scheme that is structured, simple and logical and which has a wide appeal. It should prove suitable for routine work and for research. The System attempts to provide a flexible working formulation for the reporting of gastritis that overcomes some of the more rigid principles of other classifications, while incorporating their advantages. The previous categories of gastritis, such as Types A, 13. AB arid C, are no longer used. l’he Sydney System relies on adequately biopsied clinical material and on accurate description of histological features easily recognizable by histopathologists and agreed on after extensive consultations and discussions by leading members of the profession. Because most clinicians first encounter gastritis as viewed through the endoscope, a system for classifying endoscopic gastritis (the Endoscopic Division) has been developed in parallel with the histological system, while recognizing that the correlation between the two is as yet imperfect. The aim of producing an endoscopic system of classification is to encourage and facilitate the reporting of endoscopic appearances in a standard way. Prospective studies using the Sydney System of endoscopic gastritis will enable more accurate and extensive correlations between macroscopic and microscopic gastritis to be achieved in the future. T h e importance of microbial and immunological factors, natural history, epidemiology and prognosis of gastritis is underlined by separate discussion of these entities, although they do not directly enter into the main System.
*Workingparty Chairperson. Members: G. N . J. Tytgat, A. B. Price, C. S . Goodwin, R. G. Strickland and P. Sipponen. Corresponding Member: R. Cheli. Correspondence: Dr J. J. Misiewicz FRCP, Consultant Physician and Joint Director, Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London, NWlO 7NS, UK. Accepted for publication 14 December 1990.
J . J . Misiewicz
208
THE SYDNEY SYSTEM
MORPHOLOGY (suffix)
TOPOGRAPHY (core)
AETIOLOGY (prefix)
inflammation activity
GRADED
PATHOGENIC
-I
Gaslntrs Gaslntrs of antrum
Gastrills of corpus
Descriptive terms
intestinal
Rugal hyperplasia Rugal atrophy Visibility of vascular patlern Intramural bleedmg spots
Oedema Erythema Friability Exudate Flat erosion Raised erosion NOdularity
pangastritis
ASSOCIATIONS
II
MPOGRAPHY
I
ACUTE GASTRITIS CHRONIC GASTRITIS SPECIAL FORMS
Categories ofendoscopic gastritis
gastntis of antnun
Erythematous,exudalive flat erosive Haernorrhagic Raised erosive Renux Rugal hyperplastic Alrophic
gastntis of corpus
SEVERITY GRADING :
none
mild
moderate
-~~-
-~
severe -~~ -
Figure 1 Schematic representation of the Sydney System for the classification of gastritis.
ACKNOWLEDGEMENTS Members of the Working Party gratefully acknowledge the generous help and advice of the European Pathologists Advisory Group: V. Bogomoletz (France), M. Dixon
(UK), J. Haot (Belgium), K. Heillman (Germany), A. Price (UK), P. Sipponen (Finland), E. Solcia (Italy), M. Stolte (Germany) and J. Wyatt (UK). We also express our thanks to the many other colleagues, especially the Helicobacter pylori working party, who freely shared their expertise in numerous informal contacts and discussions.
