Gut: first published as 10.1136/gut.30.7.922 on 1 July 1989. Downloaded from Gut, 1989, 30, 922-929 Chronic gastritis and gastroduodenal ulcer: a case control study on risk of coexisting duodenal or gastric ulcer in patients with gastritis P SIPPONEN, K SEPPALA, M AARYNEN, T HELSKE, AND P KETTUNEN From the Department ofPathology and Internal Medicine, Jorvi Hospital, Espoo, District Hospital of Kuusankoski, Kuusankoski, and Second Department of Medicine, University ofHelsinki, Helsinki, Finland SUMMARY Chronic (atrophic) gastritis (AG) is common in active duodenal (DU) and gastric ulcer (GU) disease. In this case control study in consecutive prospective outpatients (571 cases and 1074 controls) who had undergone diagnostic upper gastrointestinal endoscopy and routine biopsies from both antral and body mucosa, we calculated the risk of coexisting active DU and/or GU in different gastritis ofthe antrum or body and according to grade (superficial gastritis, mild, moderate or severe atrophic gastritis). The risk of coexisting active gastroduodenal ulcer (ulcer in duodenum and/or stomach), as well as the risk of DU or GU, was dependent upon the presence and grade of gastritis in antrum and body mucosa. The risk of coexisting ulcer, as expressed as an age adjusted relative risk (RR) and calculated as odds ratio of gastritis in cases and controls, was significantly increased in the presence of superficial antral and body gastritis (RR=8.5 (7'0-20 0) in men; RR=5.8 (33-10.2) in women), as compared with the risk of ulcer in subjects with histologically normal mucosa (RR=1). The risk of ulcer, and the risk of GU in particular, increased further with increasing severity of antral gastritis. In such patients with moderate or severe atrophic antral gastritis the RR of http://gut.bmj.com/ coexisting ulcer even exceeded 20 in men and 10 in women (RR=25.6 (9'0-72.7) in men; RR=11.7 (5.9-23.0) in women). On the other hand, the RR ofulcer, and the RR ofDU in particular, was below 1 in the presence of atrophic gastritis in the gastric body, irrespective of the grade of gastritis in the antrum. We conclude that the type and grade of gastritis strongly predicts the risk of coexisting peptic ulcer, and that the risk of coexisting DU or GU increases with an increase in grade of AG of the antrum but decreases with an increase in grade of AG of the gastric body. on September 28, 2021 by guest. Protected copyright. Chronic (atrophic) gastritis is common in active age,'2-'4 and occurs as different topographic types - peptic ulcer disease. Antral gastritis occurs in that is, as different combinations (phenotypes) of 75-95% of patients with duodenal ulcer (DU) and grade and extent of inflammation and atrophy of nearly always in patients with gastric ulcer (GU).'-` antral and body mucosa.'1' Little is known about the Although the causal relationship between gastritis relationship between peptic ulcer and different types and ulcer diseases is unclear and controversial, or grades of gastritis. Based on case control design gastritis may play a role in the pathogenesis of DU and on consecutive endoscopic series of outpatients and GU diseases and may impair the resistance of the with active DU or GU and non-ulcer controls, we gastric mucosa and consequently increase the risk of calculated the mean risks of coexisting ulcer in ulcer."' On the other hand, atrophic gastritis in the patients showing different grades and types of gastric body has a negative effect on acid and pepsin gastritis. secretion, and may subsequently decrease the risk of subjects to contract an active ulcer." Methods Gastritis is also common in the general population. It progresses in grade and prevalence with increasing PATIENTS Address for correspondence: Dr P Sipponen, Department of Pathology, Jorvi The patient series (cases) consists of 571 patients with Hospital, SF-02740 Espoo. Finland. endoscopically verified active ulcer in duodenum Accepted for publication 28 November 1988. and/or stomach. The series was consecutively and 922 Gut: first published as 10.1136/gut.30.7.922 on 1 July 1989. Downloaded from Gastritis and ulcer 923 prospectively collected from outpatients who under- available in 996 (93%) cases, only from the antrum in went routine diagnostic upper gastrointestinal 42 (4%) cases and only from the body in 36 (3%) endoscopy in 1982-1985 in Jorvi Hospital (Espoo), cases. The distribution of the controls into men and Kuusankoksi District Hospital (Kuusankoski) and a women and into different age groups is presented in private clinic (Endoskopia OY; Helsinki, Finland). Table 3. All patients underwent gastroscopy with routine multiple biopsy specimens from antrum and body. INTERPRETATION OF CHRONIC GASTRITIS High quality, well oriented specimens from both sites Chronic (atrophic) gastritis in antrum and body was were available in 489 (86%) patients, and only from interpreted from endoscopic biopsy specimens by antrum or body in 59 (10%) and 23 (4%) cases, using the histological criteria originally presented by respectively. Patients with gastric cancer or patients Schindler"2 and modified by Siurala et al'1 14 The with ulcer in the cardiac region of the stomach were criteria correspond with those published by other excluded, as were also patients who had ulcer scars authors.'1 The grading was done by one of the authors without an active ulcer. Correspondingly, patients (PS), as follows: normal (N): normal mucosa. No with superficial ulcerations, such as erosions or acute inflammation, no atrophy; superficial chronic mucosal lesions without ulcer, were excluded from gastritis (S): chronic inflammation without loss of the patient series but were included in the control normal glands; mild, moderate or severe (total series. atrophy) atrophic gastritis (Al, A2, A3, respect- The distribution of the patients of the ulcer series ively): mild, moderate or severe (total) loss of according to age, sex and site of the ulcer (the most normal glands; varying degrees of inflammation and proximal ulcer in cases with two or more ulcers) are metaplasias. presented in Tables 1 and 2. Ulcer was multiple (two Chronic gastritis has been shown to be an age or more ulcers) in 91 (16%/) cases. dependent, progressive process."i It begins as a superficial gastritis and progresses stepwise from CONTROLS grade to grade, similar in the antrum and body, and The control series consists of a prospective sample of among men and women.'"'0 Different grades of 1074 non-ulcer patients from the same sources as the gastritis are well related to function of the stomach - ulcer patients, collected consecutively in 1985. for example, to acid secretion, serum pepsinogen or http://gut.bmj.com/ Patients with gastric cancer or ulcer scars were gastrin levels." excluded from the control series. The controls were Examples of the different degrees of antral and endoscoped as for the ulcer patients. High quality, body gastritis are presented and illustrated else- well oriented biopsy specimens from both sites were where. 14 Table 1 Distribution ofthe ulcer patients into age groups STATISTICAL ANALYSIS The risk of coexisting gastroduodenal ulcer in on September 28, 2021 by guest. Protected copyright. Men Women different grades and types of gastritis was expressed Age group as a relative risk (RR) and was estimated as a Mantel- (yr) n (%) n (0) Haenszel estimate (RRmh) by using the histologically normal 20-39 6() (18.3) 21 (8.6) stomach as a baseline (RR= 1).' The RRmh'S 4(049 76 (23.2) 40 (16.5) 50-59 93 (28-4) 53 (21 8) 60-69 57 (17.4) 56 (23-0) Table 3 7(- 42 (12.8) 73 (30(0)) Distribution ofulcerpatients by sex and their mean Total 328 (100) 243 (1(X)) ages in relation to location* ofthe ulcer Men Women Table 2 Distribution ofthe non-ulcer controls into age groups n (%) Mean age n (On) Mean age LocatioPi of uilcer yr (SD) yr (SD) Men Women Age group Duodenum 145 (44-2) 48 (13) 66 (27-2) 56 (16) (yr) n (%) n (%) Pylorus 40 (12-2) 51 (12) 29 (11-9) 59 (13) Prepylorus 38 (11-6) 55 (12) 30 (12-3) 59 (14) 2(}-39 145 (32 2) 189 (30.2) Antrum 40-49 12 (3-7) 55 (12) 25 (10.3) 59 (17) 103 (22.9) 109 (17-5) Angulus 61 (18-6) 58 (12) 54 (22-2) 59 (12) 50-59 83 (18-4) 124 (19.8) Body 32 60-69 64 (9-8) 62 (12) 39 (16-0) 63 (13) (14.2) 104 (16.7) Total 328 (100) 53 (13) 243 (100) 59 (14) 70- 55 (12-2) 98 (15-7) Total 450 (100) 624 (100) *The most proximal ulcer in cases with two or multiple ulcers. Gut: first published as 10.1136/gut.30.7.922 on 1 July 1989. Downloaded from Table 4 Age adjusted relative risk (RRm.h) ofduodenal or gastric ulcer in men with different grades ofchronic (atrophic) gastritis in antral or body mucosa 32- Men Antrum State ofantral mucosa 16- - Wm.0 Wo, N S Al A2-A3 Total Cases 15 197 63 42 317 Controls 184 196 33 19 432 U Total 199 393 96 61 749 4- 0 RRmh 1.0 11-7 22-2 18-8 ._. X2 97-86 87-12 65-30 0) 2- Significance p<0-001 p<0-001 p<0-001 CD C195 7-2-19-9 117-42.294-37.7 ._ Test for heterogeneity; X2 4-78 (NS) 1-52 (NS) 6.03 (NS) 0: 1- Global test of Ho: x2=126.8 (p<0 001). Test for trend: x2=102.6 (p<0 001). 05- State ofbody mucosa Body 0.25- N S Al A2-A3 Total Cases 69 211 15 3 298 Men Controls 221 155 30 23 429 0.125- Total 290 366 45 26 727 RRmh 1.0 3-9 1-1 0-2 X2 63-09 0-002 9-39 N S Al A2-A3 Significance p<0-001 NS p<0-01 State of the mucosa C195 28-5.6 0-5-2-1 0-06-0-6 Test for heterogeneity; x2 9-32 (NS) 7-69 (NS) 5.65 (NS) Figure Mean relative risks ofduodenal or gastric ulcer in men and women with different grades ofchronic gastritis in Global test of H.: x2=86.41 (p<0-001).