Is biopsy needed in every gastritis
found during endoscopy?

Muhammad Zubair¹, Muhammad Ali Channa²,
Masoom Raza Mirza³, Lubna Habib⁴

ABSTRACT

Objective: To find out concordance between endoscopic and histological diagnosis of gastritis in dyspeptic patients.

Methodology: All dyspeptic patients who underwent upper gastrointestinal endoscopy with endoscopic diagnosis of gastritis and available biopsy report from July 2006 to June 2008 in Hamdard Medical University Hospital and different private hospitals of Karachi were included in this study. The endoscopist formed a global impression on the presence or otherwise of gastritis according to the Sydney System. Patients with ulcer, growth and any other endoscopic diagnosis apart from gastritis were excluded. With standard biopsy forceps, minimum of two gastric biopsies from inflamed mucosa were taken for histological evidence of gastritis.

Results: Total 112 patients (44 males and 68 females) were included in the study with mean age of 41.95 years. Most common symptom experienced by patients was epigastric discomfort in 103 (92%) of patients. In all patients endoscopic diagnosis was gastritis. Biopsy reports showed chronic gastritis in 109 (97.3%) patients.

Conclusion: There is good concordance of endoscopic findings of gastritis with histological evidence of gastritis and thus biopsy is not required in every case of gastritis.

KEYWORDS: Endoscopic gastritis, Dyspepsia, Biopsy, Histology.

Pak J Med Sci    October - December 2009 (Part-I)    Vol. 25 No. 5    849-851

How to cite this article:

Zubair M, Channa MA, Mirza MR, Habib L. Is biopsy needed in every gastritis found during endoscopy? Pak J Med Sci 2009;25(5):849-851.

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1. Dr. Muhammad Zubair, FCPS, FRCS
Senior Registrar,
Surgical Unit IV,
Dow University of Health Sciences and
Civil Hospital, Karachi - Pakistan.
2. Dr. Muhammad. Ali Channa, FCPS
Senior Registrar,
3. Dr. Masoom Raza Mirza, FRCS
Associate Professor,
4. Dr. Lubna Habib, FCPS
Assistant Professor,
2-4: Hamdard College of Medicine & Dentistry,
Hamdard University Hospital,
Karachi - Pakistan.

Correspondence

Dr. Muhammad Zubair, FCPS, FRCS
Email: drmzubair@hotmail.com

* Received for Publication: April 6, 2009

* Revision Received: September 5, 2009

* Revisions Accepted: September 7, 2009

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INTRODUCTION

Dyspepsia is a common condition that is reported from 19% to 41% of the general population.1 About one out of every four subjects with dyspepsia consults his general practitioner and these accounts for 1-4% of all consultations in primary care.2,3 Dyspepsia is defined as an upper gastrointestinal symptom complex characterized by epigastric pain or discomfort and may include heartburn, acid regurgitation, excessive burping/belching, abdominal bloating, feeling of abnormal or slow digestion, early satiety or nausea.4 Management requires whether to arrange initial investigation by endoscopy or barium X-ray before starting therapy, to ‘test and eradicate’ Helicobacter pylori (H. pylori) infection or to start empirical symptomatic therapy. In practice, empirical anti-secretory treatment is commonly the first step unless the patient has new onset symptoms and is older or has alarm features (vomiting, gastrointestinal bleeding, abdominal mass, dysphagia, unexplained weight loss and anaemia), despite concerns that this approach may miss clinically significant upper gastrointestinal tract lesions.4,5 Most of the time patient is referred for upper GI endoscopy & it is a common practice for end-oscopists to make judgements on the presence or absence of gastritis on the basis of the endoscopic appearance of the gastric mucosa.6 The concept of "endoscopic gastritis" was given further acceptance by the acknowledgement of its existence by the working party that formulated the Sydney System of classifying gastritis.7 While doing endoscopy it is customary to take biopsy of inflammed mucosa in order to confirm the endoscopic findings & to test for H. pyl-ori infection. The practical role of gastric biopsy in the management of gastritis is controversial.

Overall, endoscopic examinations are 2-dimentional and performed in-situ whereas histological examination are pinpoint and performed on in-vitro specimens, which is the reason for discrepancies in diagnosis.8 Numerous studies have shown that there is low concordance between endoscopy and histology with regard to the diagnosis of gastritis9,10 while some other studies have suggested that the concordance is good.11,12

In Pakistan like many developing countries facilities for endoscopy are not so commonly available to our vast majority of patients. In those cases where endoscopy is performed and gastritis was diagnosed, doing routine biopsy is a costly procedure for most of our poor patients. Also there are chances of infecting patients with hepatitis with this invasive procedure, which causes a breach in mucosa as compared to simple visual endoscopy. The objective of this study was to find out the concordance between endoscopic and histological diagnosis of gastritis.

METHODOLOGY

All dyspeptic patients who underwent upper GI endoscopy with endoscopic diagnosis of gastritis and available biopsy report were included in this retrospective study from July 2006 to June 2008 in Hamdard University Hospital and different private hospitals of Karachi. Endoscopy was performed by the conventional method after six hours of fasting prior to the procedure under throat anaesthesia with 4% xylocaine spray. Intravenous sedation with midazolam was used selectively.

The endoscopist formed a global impression on the presence or absence of gastritis according to the Sydney System (oedema, erythema, friability, exudates, erosions, rugal hyperplasia and atrophy, visibility of vascular pattern, intramural bleeding spots and course nodularity) in the antrum and body of the stomach.7 Patients with ulcer, growth and any other endoscopic diagnosis apart from gastritis were excluded. With standard biopsy forceps, at least two gastric biopsies from the inflammed mucosa of the antrum were taken for histological evidence of gastritis.

RESULTS

Total 112 patients (44 males and 68 females) were included in the study. Mean age of the patients was 41.95 years (Range 15-68). Mean duration of symptoms was 2.1 years (Range: 0.3-20). The most common symptom experienced was epigastric discomfort in 103 (92%) of patients. In all patients the endoscopic diagnosis was chronic gastritis. Biopsy reports showed chronic gastritis in 109 (97.3%) patients Table-I.

DISCUSSION

Upper gastrointestinal diseases are leading causes of morbidity and mortality globally. Among diagnostic modalities, endoscopy holds an important role. It enables visualization, photography, ultrasonography, and biopsies of suspicious lesions and also facilitates the performance of therapeutic procedures such as sclerotherapy, polypectomy, and gastrostomy.12.13 Our results showed there is good concordance between endoscopic diagnosis of gastritis as compared with histological evidence of chronic gastritis. This may suggest that in every case of gastritis, biopsy should not be taken for confirmation, firstly because of additional cost of biopsy to most of our poor patients and secondly, chances of spread of hepatitis. Different studies have shown that endoscopic instruments can be a good source of hepatitis C virus.14 A study to detect HCV genome on endoscopes and biopsy-forceps used in patients with known chronic HCV infection showed that HCV genome is detected in 27% of cases in the biopsy-suction channel after an endoscopic procedure performed on chronic HCV infected patients. The biopsy-forceps are PCR positive in 6% of cases.15 The infected gastric juice may play a role in the contamination of the endoscopes. Another study reported 100% frequency of contamination of the endoscopes by hepatitis C virus in 19 patients with chronic replicative hepatitis C.14 The complete disinfection procedure seems effective to eliminate HCV but cannot guarantee complete disinfection all the time especially in our setup with overall poor quality control. Endoscope reprocessing is a multi-stepped process that renders a contaminated endoscope safe for reuse. Its steps include meticulous cleaning, complete immersion in a liquid chemical sterilant (LCS) or disinfectant to achieve high-level disinfection (or "liquid sterilization"), water rinsing, and proper handling and storage.16 We encounter large number of unscreened hepatitis patient in our practice and we can minimize the chances of infecting normal patient with this chronic disease by selective use of biopsy.

Limitations of the study: Only patient with endoscopic gastritis were included in the study. To find the sensitivity and specificity of endoscopic gastritis, biopsy should be required for patient with normal macroscopic changes. But in clinical practice we didn’t take any biopsy of normal looking mucosa.

CONCLUSION

There is good concordance of endoscopic findings of gastritis with histological evidence of gastritis. Biopsy is not required in every case of gastritis. More work is required about biopsy findings in dyspeptic patients with normal looking mucosa to generalize our findings.

REFERENCES

1. Arents NLA, Thijs JC, Kleibeuker JH. A rational approach to uninvestigated dyspepsia in primary care: review of the literature. Postgrad Med J 2002;78:707-16.

2. Penston JG, Pounder RE. A survey of dyspepsia in Great Britain. Aliment Pharmacol Ther 1996;10:83-9.

3. Heikkinen M, Pikkarainen P, Takala J. General practitioners’ approach to dyspepsia. Scand J Gastroenterol 1996;31:648-53.

4. Veldhuyzen van Zanten SJ, Flook N, Chiba N. An evidence- based approach to the management of patients with uninvestigated dyspepsia in the era of Helicobacter pylori. Can Med Assoc J 2000;162(12 Suppl.):S3–S20.

5. Chiba N, Bernard L, O’Brien BJ, Goeree R, Hunt RH. A Canadian physician survey of dyspepsia management. Can J Gastroenterol 1998;12:83-90.

6. Thomson AB, Barkun AN, Armstrong D, Chiba N, White RJ, Daniels S, et al. The prevalence of clinically significant endoscopic findings in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment - Prompt Endoscopy (CADET-PE) study. Aliment Pharmacol Ther 2003;17(12):1481-91.

7. Tytgat GNJ. The Sydney System: Endoscopic division. Endoscopic appearances in gastritis/duodenitis. J Gastroenterol Hepatol 1991;6:223-34.

8. Guindy AE, Ghoraba H. A study of the Concordance between endoscopic gastritis and histological gastritis in nonulcer dyspeptic patients with and without Helicobacter Pylori infection. Tanta Med Sci J 2007;2(2):67-82.

9. Kaur G, Raj SM. A study of the concordance between endoscopic gastritis and histological gastritis in an area with a low background prevalence of Helicobacter pylori infection. Singapore Med J 2002;43(2):090-2.

10. Atkins L, Benedict EB. Correlation of gross gastroscopic findings with gastroscopic biopsy in gastritis. N Eng J Med 1956;254:641-4.

11. Fung WP, Papadimitriou JM, Matz LR. Endoscopic, histological and ultrastructural correlations in chronic gastritis. Am J Gastroenterol 1979;71(3):269-79.

12. Tytgat GNJ. Role of endoscopy and biopsy in the work up of dyspepsia. Gut 2002;50(Suppl. 4):13-16.

13. Axon ATR, Bell GD, Jones RH, Quine MA, McCloy RF. Guidelines on appropriate indications for upper gastrointestinal endoscopy. BMJ 1995;310:853-6.

14. Deflandre J, Cajot O, Brixko C, Crine M, Labalue J, Senterre JM. Risk of contamination by hepatitis C of endoscopes utilized in gastroenterology hospital service. Rev Med Liege 2001;56(10):696-8.

15. Becheur H, Harzic M, Colardelle P, Deny P, Coste T, Dubeaux B, et al. Hepatitis C virus contamination of endoscopes and biopsy forceps. Gastroenterol Clin Biol 2000;24(10):906-10.

16. Muscarella LF. Inconsistencies in endoscope-reprocessing and infection-control guidelines: The importance of endoscope drying. Am J Gastroenterol 2006;101(9):2147-54.

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