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Subtypes of Intestinal Metaplasia and Helicobacter Pylorn Gut: First Published As 10.1136/Gut.33.5.597 on 1 May 1992

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Subtypes of Intestinal Metaplasia and Helicobacter Pylorn Gut: First Published As 10.1136/Gut.33.5.597 on 1 May 1992 Gut, 1992, 33, 597-600 597 Subtypes of intestinal metaplasia and Helicobacter pylorn Gut: first published as 10.1136/gut.33.5.597 on 1 May 1992. Downloaded from M E Craanen, P Blok, W Dekker, J Ferwerda, G N J Tytgat Abstract ing lesion, intestinal metaplasia are widely To determine whether there is a relationship recognised as being the most prevalent pre- between the presence of H pylon and the cursors of intestinal type gastric carcinoma.7 various subtypes ofintestinal metaplasia in the Subtypes of intestinal metaplasia have been gastric antrum, 2274 antral gastroscopic biop- identified based upon histological, ultra- sies from 533 patients were examined. Hpylon structural, enzyme, and mucin histochemical was found in 289 patients. Intestinal meta- characteristics. Some of the latter studies have plasia in general was found in 135 patients. suggested that a sulphomucin secreting, incom- Type I intestinal metaplasia was found in 133 plete intestinal metaplasia subtype is particularly patients (98.5%), type II in 106 patients (78.5%) closely linked to intestinal type gastric carcinoma and type III in 21 patients (15.6%). Ninety eight and may therefore be a marker of increased of these 135 patients (72.6%) were H pylori gastric cancer risk.8'~3 In another study evidence positive and 37 patients (27.4%) were H pylon was found for a strong association between the negative. No statistically significant difference presence of intestinal metaplasia in general and was found in the prevalence of type I and II H pylorn in the gastric antral mucosa.'4 We intestinal metaplasia between the intestinal undertook this study in order to investigate metaplasia positive and H pylon positive and further the relationship between the presence of intestinal metaplasia negative and H pylon H pylorn and the various subtypes of intestinal negative patients. Type III intestinal meta- metaplasia in the gastric antral mucosa. plasia was found less often in the intestinal metaplasia positive and H pylon positive patients (11.2%) as compared with intestinal Patients http://gut.bmj.com/ metaplasia positive and H pylon negative patients (27%) (p<0 05). In contrast with type I METHODS and II intestinal metaplasia type III intestinal All patients were referred to the St Elisabeth's of metaplasia was found more often in moderate/ Groote Gasthuis on clinical grounds for upper severe intestinal metaplasia than in mild gastrointestinal endoscopy between December intestinal metaplasia (p<0.02). Within the 1988 and June 1990. Endoscopy was carried group of patients with moderate/severe out after an overnight fast. The endoscopes on September 29, 2021 by guest. Protected copyright. intestinal metaplasia, type III was found less (Olympus GIF Q10,Q20) were cleaned with often in the H pylon positive patients detergent, disinfected with 70% ethanol and (p<0.05). We suggest that the gastric milieu rinsed with sterile water after each examination. for H pylon is less appropriate in type III Patients requiring emergency endoscopy or with intestinal metaplasia positive patients. As type previous gastric surgery were excluded. III intestinal be Department of Internal metaplasia might regarded as a Patients with antral abnormalities, varying Medicine, St Elisabeth's marker of possibly increased gastric cancer from mild erythema of the mucosa to full blown of Groote Gasthuis, risk, the lower prevalence of H pylon in these endoscopic gastritis, gastric ulcer and carcinoma Boerhaavelaan, Haarlem, type III intestinal metaplasia positive patients were included. The number of antral biopsies The Netherlands M E Craanen might be the result of severe changes in taken depended on the diagnosis made by the W Dekker mucosal architecture. endoscopists. Biopsies were taken at 3 cm from J Ferwerda the pylorus in mild erythema of the antral Department of mucosa and in cases where there was severe Pathology, Public Health There is overwhelming evidence that infection endoscopic erythematous/exudative gastritis Laboratory, Haarlem, with Helicobacter pylori causes chronic active with or without erosions. Where gastric ulcer The Netherlands P Blok gastritis, which invariably involves the gastric and carcinoma were present, biopsies were taken antrum. 1-3 Although acute gastritis has been from the lesions and from the adjacent mucosa Department of described in volunteers after within 1 cm the lesions the lesser and Gastroenterology and ingestion of of along Hepatology Academic H pylon,45 this condition is rarely encountered greater curvature within 4 cm from the pylorus. Medical Centre, and biopsied in routine clinical practice. All biopsies were fixed in 10% formalin, em- Amsterdam, The Eradication of H pylon may lead to rapid bedded in and cut at 5 ,im. Routine Netherlands paraffin G N J Tytgat reversion of the histological abnormalities found staining with haematoxylin and eosin (H&E) was Correspondence to: in Hpylori related gastritis.36 Failure to eradicate performed for histopathologic diagnosis and M E Craanen, Department of H pylon totally, however, yields only temporary detection of H pylor. Where it was doubtful Gastroenterology and Hepatology, Academic improvement ofthe histological picture. This, in whether H pylori was present, additional Giemsa Medical Centre, Meibergdreef turn, may eventually lead to the progression of staining was carried out. H pylon was judged to 9, 1105 AZ, Amsterdam, The Netherlands. chronic active gastritis to chronic gastritis with a be absent where both staining methods were Accepted for publication variable degree of atrophy. negative for Hpylon. 12 August 1991 Chronic atrophic gastritis and its accompany- The extent of intestinal metaplasia as well as 598 Craanen, Blok, Dekker, Ferverda, Tytgat the prevalence of its subtypes was assessed 289 patients (54.2%) (Table I). In the group independently by two of the authors (MC/PB). of 135 intestinal metaplasia positive patients, The extent of distribution of intestinal meta- type I was found in 133 patients (98 5%), type plasia was graded as follows: (1) none (-); (2) II in 106 patients (78*5%) and type III in mild degree (+), consisting of a few tubules to 21 patients (15.6%). Ninety eight of these 135 Gut: first published as 10.1136/gut.33.5.597 on 1 May 1992. Downloaded from one third of the total area biopsied; (3) moderate patients (72 6%) were H pylon' positive and degree (+ +), consisting of one third to two 37 patients (27.4%) were H pylon negative. thirds ofthe total area biopsied; (4) severe degree Although the prevalence of type III intestinal (+ + +); consisting of two thirds or more of the metaplasia, in contrast with type I and II, total area biopsied. Biopsies showing intestinal increased with age, the difference in mean metaplasia were serially sectioned and stained age between patients with type I, type II, with: (1) alcian blue pH 2*5/periodic acid-Schiff and type III intestinal metaplasia (type I: 66 (AB pH 2*5/PAS); (2) high iron diamine/alcian (14-1) years; type II intestinal metaplasia: blue pH 2.5 (HID/AB pH 2.5) in order to 66.5 (13-1) years; type III intestinal metaplasia: identify subtypes of intestinal metaplasia.' 1`6 71 (12-9) years) did not reach statistical signific- Subtypes of intestinal metaplasia were classified ance (0.05 p<O 1). For age related prevalence of as described by Filipe. 7 intestinal metaplasia, intestinal metaplasia sub- Type I intestinal metaplasia is characterised types and H pylon, see Table II. by the presence of goblet cells secreting acid sialomucins and sometimes sulphomucins, Paneth cells and mature, non-mucous secreting, RELATIONSHIP BETWEEN H PYLORI AND SUBTYPES absorptive cells. Type II is characterised by the OF INTESTINAL METAPLASIA (N= 135) presence of goblet cells secreting sialomucins No significant difference in prevalence of type I and sometimes sulphomucins, almost complete and II intestinal metaplasia was found between absence of Paneth cells and replacement of the H pylon positive patients (n=98) and the absorptive cells by columnar mucous cells H pylon negative patients (n= 37) - namely, type secreting non-sulphated mucins, and type III I intestinal metaplasia: 99% (97/98) v 97.3% (36/ resembles type II intestinal metaplasia in most 37) and type II 76.5% (75/98) v 83.9% (31/37). In respects but the columnar mucous cells secrete contrast, the prevalence of type III was signific- predominantly sulphomucins. antly lower in the H pylon' positive patients than in the H pylon negative patients (11.2% (11/98) v 27% (10/37) - p<0 05). STATISTICAL ANALYSIS Mild intestinal metaplasia was found in 103 moderate/severe intestinal The X2 correct test and two tailed Student's t test patients (76.3%), http://gut.bmj.com/ were used in the statistical analysis of the data metaplasia was found in 32 patients (23 7%). collected when appropriate. Although moderate/severe intestinal metaplasia was found more often in the H pylori negative group (32.4%) than in the Hpylon positive group Results (20.4%), this difference was not statistically A total of 2274 biopsies was examined from 533 significant (0-2 <p.0.3). No significant differ- patients. Intestinal metaplasia was found in 135 ence was found in the prevalence of type I patients (25 3%) and H pylori was found in and II intestinal metaplasia between mild and on September 29, 2021 by guest. Protected copyright. moderate/severe intestinal metaplasia (type I: 98% v 100%, type II: 75.7% v 87.5%). Type III TABLE I Characteristics ofpatients according to histological diagnosis (n= 533) was found more often
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