Post on 05-Jul-2015
description
A study on histological chronic gastritis in A study on histological chronic gastritis in the East Coast of Peninsular Malaysia – the East Coast of Peninsular Malaysia – correlation with endoscopic findings, causes correlation with endoscopic findings, causes
and helicobacter pyloriand helicobacter pyloriYeong Yeh Lee
MD MRCP(UK) MMED
ORAL PRESENTATION APDW 2007
INTRODUCTIONINTRODUCTIONThe prevalence of chronic atrophic gastritis (CAG) varied inThe prevalence of chronic atrophic gastritis (CAG) varied in
different geographical areas of the world with the Japanesedifferent geographical areas of the world with the Japanese
and Chinese among the highestand Chinese among the highest11..
Chronic atrophic gastritis was associated with 5 folds increasedChronic atrophic gastritis was associated with 5 folds increased
risk of gastric cancerrisk of gastric cancer22. . Helicobacter pyloriHelicobacter pylori infection was associated infection was associated
with 2.9 times higher risk for gastric cancerwith 2.9 times higher risk for gastric cancer33..
1 Melanie NW, Hermann B; Prevalence of CAG in different parts of the world; Ca Epid Biomarkers Prev 20062 Kato I et al. A prospective study of atrophic gastritis and stomach cancer risk; Jpn J Cancer Res 19923 Uemura N et al. H pylori infection and development of gastric cancer; N Eng J Med 2001
INTRODUCTIONINTRODUCTION
The incidence for gastric cancer in Malaysia was 4.3/100,000The incidence for gastric cancer in Malaysia was 4.3/100,000in 2003in 200344. A higher incidence was seen in older age >60 years,. A higher incidence was seen in older age >60 years,Chinese and males.Chinese and males.
The prevalence rate for The prevalence rate for helicobacter pylorihelicobacter pylori infection in the east infection in the eastcoast of peninsular Malaysia was one of the lowest reportedcoast of peninsular Malaysia was one of the lowest reportedin the literature (4.2% among 496 blood donors and 4.8%in the literature (4.2% among 496 blood donors and 4.8%among 921 subjects who attended health screening clinicsamong 921 subjects who attended health screening clinics55).).
4Second Report of National Cancer Registry, Malaysia 20035 Uyub AM, Raj SM. Helicobacter pylori infection in north-eastern peninsular Malaysia. Evidence for an unusually low prevalence, Scand J Gastroenterol 1994
OBJECTIVESOBJECTIVES11.. To determine the prevalence of chronic atrophic To determine the prevalence of chronic atrophic
(CAG) and non-atrophic (CNAG) antral gastritis (CAG) and non-atrophic (CNAG) antral gastritis
2.2. To determine the association of chronic atrophic To determine the association of chronic atrophic antral gastritis with the risk of metaplasia and antral gastritis with the risk of metaplasia and dysplasiadysplasia
3.3. To determine the association between patient To determine the association between patient demographics, causes of gastritis and demographics, causes of gastritis and helicobacter helicobacter pylori pylori with the risk of metaplasia and dysplasia in with the risk of metaplasia and dysplasia in CAGCAG
4.4. To correlate the endoscopic findings with To correlate the endoscopic findings with histological gastritishistological gastritis
METHODOLOGYMETHODOLOGY
A total of 234 consecutive histological reports of biopsiesA total of 234 consecutive histological reports of biopsies
taken from endoscopic antral gastritis were reviewed andtaken from endoscopic antral gastritis were reviewed and
analyzed from January until December 2006.analyzed from January until December 2006.
METHODOLOGYMETHODOLOGY
A total of 4 biopsies were taken from the antrum or incisuraA total of 4 biopsies were taken from the antrum or incisura
with endoscopic gastritis.with endoscopic gastritis.
Histological gastritis was classified into atrophic and non-Histological gastritis was classified into atrophic and non-
atrophic gastritis based on Sydney system and Atrophy Clubatrophic gastritis based on Sydney system and Atrophy Club
definitions.definitions.
Helicobacter pylori Helicobacter pylori was detected using CLO test and histology. was detected using CLO test and histology.
METHODOLOGYMETHODOLOGY
Data was analyzed using SPSS software version 12.0.1.Data was analyzed using SPSS software version 12.0.1.
P-value of 0.05 was considered significant and a kappa valueP-value of 0.05 was considered significant and a kappa valuebetween 0.4 to 1.0 was considered good agreement.between 0.4 to 1.0 was considered good agreement.
Univariate analysis was carried out using Fischer-Exact orUnivariate analysis was carried out using Fischer-Exact orChi-Square test. Multivariate analysis was carried out usingChi-Square test. Multivariate analysis was carried out usingmultiple logistic regression (forward LR).multiple logistic regression (forward LR).
0 20 40 60 80 100
Age
0
10
20
30
40
Fre
que
ncy
Mean = 53.09Std. Dev. = 15.541N = 234
Histogram
RESULTSRESULTS
Figure 1Figure 1: The mean age was 53 ± 15 : The mean age was 53 ± 15 years old (range 15 to 94 years old).years old (range 15 to 94 years old).
Statistics
Age234
0
53.09
1.016
54.00
15.541
241.516
-.135
.159
79
15
94
Valid
Missing
N
Mean
Std. Error of Mean
Median
Std. Deviation
Variance
Skewness
Std. Error of Skewness
Range
Minimum
Maximum
635758
364241
73
87
79
22
8
17
5 4 4
4137
100
0
10
20
30
40
50
60
70
80
90
100
Percentage
Male
Fem
ale
Malay
Chine
se
Oth
ers
Sex Race Total
Demographics
Demographics Vs Histology Findings
atrophic
non-atrophic
Total
Figure 2:Figure 2: There were no differences in the prevalence of both atrophic and non- There were no differences in the prevalence of both atrophic and non-atrophic gastritis between the two genders . The Chinese had more atrophic atrophic gastritis between the two genders . The Chinese had more atrophic gastritis (22%). The Malays had more non-atrophic gastritis (87%). The gastritis (22%). The Malays had more non-atrophic gastritis (87%). The prevalence of CAG was 41%. prevalence of CAG was 41%.
Table 1Table 1: Indications of endoscopy, causes of gastritis and : Indications of endoscopy, causes of gastritis and medications before endoscopymedications before endoscopy
155 (66)
14 (6)
58 (67)
4 (5)
61 (63)
7 (7)
PPI
H2RA
Medications
20 (22)
18 (20)
18 (20)
8 (25)
7 (22)
4 (12.5)
6 (15)
5 (12.5)
11 (27)
NSAID
Antiplatelet
Previous gastric ulcers
Causes
149 (64)
37 (16)
54 (63)
15 (17)
57 (59)
20 (21)
Dyspepsia
Malaena
Indications
Total
N (%)
Non-atrophic
N (%)
Atrophic
N (%)
Variables
Legend: N=number, %=percentage, NSAID=non-steroidal inflammatory drugs, PPI=proton pump inhibitor, H2RA=histamine receptor blocker
Dyspepsia was the commonest symptom in both CAG and non-CAG. Chemical gastritis Dyspepsia was the commonest symptom in both CAG and non-CAG. Chemical gastritis (NSAID and antiplatelet) was more common in non-atrophic gastritis (47% VS 27.5%). (NSAID and antiplatelet) was more common in non-atrophic gastritis (47% VS 27.5%). Proton pump inhibitors were used in 66% of chronic gastritis prior to endoscopy.Proton pump inhibitors were used in 66% of chronic gastritis prior to endoscopy.
Figure 2:Figure 2: The prevalence of The prevalence of helicobacter pylorihelicobacter pylori was n=16 (7%). The was n=16 (7%). The histology test for histology test for helicobacter pylori helicobacter pylori appeared more sensitive than CLO test appeared more sensitive than CLO test in atrophic gastritis (n=7 VS n=1). in atrophic gastritis (n=7 VS n=1).
1
78
4 4
8
5
11
16
0
2
4
6
8
10
12
14
16
No of Patients
Atrophic Non-atrophic Total
Histology Findings
Helicobacter pylori Vs Histology Findings
H pylori CLOH pylori HistologyH pylori Both
RESULTS
Figure 3: There was a significant association between moderate atrophy with : There was a significant association between moderate atrophy with the risk of metaplasia (p=0.006). This was tested with multiple comparisons the risk of metaplasia (p=0.006). This was tested with multiple comparisons between different degree of atrophy and Bonferroni adjustment of p-value. between different degree of atrophy and Bonferroni adjustment of p-value. Moderate atrophy increased the risk of metaplasia by 21%.Moderate atrophy increased the risk of metaplasia by 21%.
93 7
97 3
79 21
0% 20% 40% 60% 80% 100%
Percentage
No
Mild
ModerateA
tro
ph
y
Deg
ree o
f
Atr
op
hy
Association between Atrophic Gastritis and risk of Metaplasia
Metaplasia NoMetaplasia Yes
0.0060.002Mild Vs Moderate
0.0690.023No Vs Moderate
0.5430.181No Vs Mild
Bonferroni AdjustmentP valueComparisons
Figure 4Figure 4: There was significant association between moderate atrophy with : There was significant association between moderate atrophy with the risk of dysplasia (p=0.003). the risk of dysplasia (p=0.003). This was tested with multiple comparisons This was tested with multiple comparisons between different degree of atrophy and Bonferroni adjustment of p-value. between different degree of atrophy and Bonferroni adjustment of p-value. Moderate atrophy increased the risk of dysplasia by 18%.Moderate atrophy increased the risk of dysplasia by 18%.
97 3
99 1
82 18
0% 20% 40% 60% 80% 100%
Percentage
No
Mild
Moderate
Atr
op
hy
Deg
ree o
f A
tro
ph
yAssociation between Atrophic Gastritis and
risk of Dysplasia
Dysplasia No
Dysplasia Yes
<0.003<0.001Mild Vs Moderate
<0.003<0.001No Vs Moderate
1.00.687No Vs Mild
Bonferroni AdjustmentP valueComparisons
LOGISTIC REGRESSION ANALYSISLOGISTIC REGRESSION ANALYSIS
Variables in the Equation
-2.872 1.163 6.099 1 .014 .057 .006 .553
-.405 .913 .197 1 .657 .667
Hpylori(1)
Constant
Step1
a
B S.E. Wald df Sig. Exp(B) Lower Upper
95.0% C.I.for EXP(B)
Variable(s) entered on step 1: Hpylori.a.
Table 3: Logistic regression analysis (Forward LR) of factors (age, sex, race, causes, helicobacter pylori and atrophy) associated with the risk of Metaplasia
Variables in the Equation
-3.258 1.089 8.951 1 .003 .038 .005 .325
.405 .913 .197 1 .657 1.500
Hpylori(1)
Constant
Step1
a
B S.E. Wald df Sig. Exp(B) Lower Upper
95.0% C.I.for EXP(B)
Variable(s) entered on step 1: Hpylori.a.
Table 4: Logistic regression analysis (Forward LR) of factors (age, sex, race, causes, helicobacter pylori and atrophy) associated with the risk of Dysplasia
Symmetric Measures
-.056 .019 -1.418 .156
234
KappaMeasure of Agreement
N of Valid Cases
ValueAsymp.
Std. Errora
Approx. Tb
Approx. Sig.
Not assuming the null hypothesis.a.
Using the asymptotic standard error assuming the null hypothesis.b.
234183 (78)51 (22)Total
227176 (77)51 (22)Abnormal
77(100)0 (0)Normal
TotalAbnormalNormalN (%)
Endosocopic
findings
Histology Findings
Table 2: Correlation between histological gastritis and endoscopic findings
Normal histology was seen in 22% of abnormal endoscopic findings. The agreement between histological gastritis and endoscopic findings was poor.
05 2 0
30
60
19
1
19
48
31
1 49
3 1
0
10
20
30
40
50
60
No
of P
atie
nts
No Mild Moderate Severe
Endoscopic severity
Endoscopic severity VS histological severity
No
Mild
Moderate
Severe
Figure 6Figure 6: Most endoscopic and histological gastritis were mild to moderate in : Most endoscopic and histological gastritis were mild to moderate in severity. The agreement was however poor with kappa=0.06.severity. The agreement was however poor with kappa=0.06.
Symmetric Measures
.061 .042 1.478 .140
233
KappaMeasure of Agreement
N of Valid Cases
ValueAsymp.
Std. Errora
Approx. Tb
Approx. Sig.
Not assuming the null hypothesis.a.
Using the asymptotic standard error assuming the null hypothesis.b.
CONCLUSIONCONCLUSION
The prevalence for chronic atrophic gastritis in theThe prevalence for chronic atrophic gastritis in the
East coast of peninsular Malaysia was 41%. East coast of peninsular Malaysia was 41%.
Moderate atrophy was significantly related to the riskModerate atrophy was significantly related to the risk
of intestinal metaplasia and dysplasia. of intestinal metaplasia and dysplasia.
CONCLUSIONCONCLUSION
Despite the low prevalence of Despite the low prevalence of Helicobacter pylori Helicobacter pylori inin
this regionthis region, , it was the most important risk forit was the most important risk for
metaplasia and dysplasia in chronic atrophicmetaplasia and dysplasia in chronic atrophic
gastritis. gastritis.
- “ No - “ No helicobacter pylori helicobacter pylori No Cancer” No Cancer”
CONCLUSIONCONCLUSION
There was a poor agreement between the severity ofThere was a poor agreement between the severity of
endoscopic and histological gastritis.endoscopic and histological gastritis.
Follow-up should be recommended for chronicFollow-up should be recommended for chronic
gastritis with moderate atrophy and gastritis with moderate atrophy and helicobacter pylorihelicobacter pylori
using a standardized protocol for biopsy.using a standardized protocol for biopsy.