Original article
Clinical endoscopy
The use of clinical, histologic, and serologic parameters to predict the intragastric extent of intestinal metaplasia: a recommendation for routine practice

https://doi.org/10.1016/j.gie.2008.08.041Get rights and content

Background

Surveillance of intestinal metaplasia (IM) of the gastric mucosa should be limited to patients at high risk of gastric cancer. Patients with extensive IM are at increased cancer risk; however, the intragastric extent of IM is usually unknown at the time of the initial diagnosis.

Objective

To assess the predictive value of clinical, histologic, and serologic parameters for the intragastric extent of IM.

Design and Setting

Prospective, multicenter study.

Patients

Eighty-eight patients with a previous diagnosis of IM of the gastric mucosa.

Intervention

Surveillance gastroscopy with extensive random biopsy sampling.

Main Outcome Measurements

Biopsy specimens were evaluated according to the Sydney classification system. In addition, serologic testing of Helicobacter pylori and cagA status, pepsinogens I and II, gastrin, and intrinsic factor antibodies was performed. The association between the available parameters and extensive IM was evaluated with logistic regression analysis.

Results

In 51 patients (58%), IM was present in the biopsy specimens from at least 2 intragastric locations. The most important predictors of extensive IM were a family history of gastric cancer, alcohol use ≥1 unit/d (1 glass, approximately 10 mL or 8 g ethanol), moderate or marked IM of the index biopsy specimen, and a pepsinogen I to II ratio <3.0. A simple risk score based on these factors could identify extensive IM in 24 of 25 patients (sensitivity 96%).

Limitation

A prospective cohort study should confirm the proposed risk stratification.

Conclusions

A risk score of clinical, histologic, and serologic parameters can predict extensive intragastric IM and may serve as a practical tool to select patients for surveillance endoscopy in routine clinical practice.

Section snippets

Patient selection

Consecutive outpatients with a previous histologic confirmed diagnosis of IM of the gastric mucosa (index diagnosis) were invited to undergo a surveillance endoscopy between March 2006 and June 2007. The surveillance endoscopy was performed within 6 years after the initial diagnosis of IM. Patients with a previous diagnosis of upper-GI malignancy or a history of esophageal or gastric surgery were excluded. The institutional review boards of the participating hospitals approved this study, and

Results

In total, 88 patients (43 men, 45 women; mean age 60.4 years, range 24.0-75.9 years) underwent a surveillance endoscopy at a mean (SD) follow-up interval of 1.7 ± 1.5 years after initial diagnosis. Seventy-one patients (81%) were native Dutch and 17 (19%) were of non-Dutch origin. Previous peptic ulcer disease was reported in the medical records of 25 patients (28%), and H pylori eradication therapy was in the records of 36 patients (41%).

Discussion

This study clearly identifies a family history of gastric cancer, a pepsinogen I to II ratio <3.0, the presence of moderate or marked IM of the index biopsy specimen and alcohol use, with an average of at least 1 unit/d, as important predictive parameters for extensive IM at surveillance endoscopy. Our study adds to existing knowledge of risk factors for progression of premalignant gastric lesions to gastric cancer by combining these individual risk factors into a risk stratification rule that

Conclusion

Patients with extensive intragastric IM are at increased gastric cancer risk. However, the intragastric extent of IM is usually unknown at the time of diagnosis. In this study, we showed that a risk score of clinical, histologic, and serologic parameters can predict the presence of extensive intragastric IM and may serve as a tool to select patients for surveillance endoscopy in routine clinical practice.

Acknowledgments

The authors wish to thank R. J. Th. Ouwendijk, gastroenterologist, Ikazia Hospital, Rotterdam, and the Gastroenterology and Pathology Departments of Erasmus MC University Medical Center, Rotterdam, Rijnstate Hospital, Arnhem, Deventer Hospital, Deventer, and Medisch Centrum Rijnmond Zuid, Rotterdam, for providing their contribution to this study.

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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