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Histopathological Assessment of Endoscopic Gastric Mucosal Biopsies of Patients Attending a Tertiary Care Hospital

Rajendra Maharjan1,2 Ashish Rouniyar1,3*

¹Department of Pathology, Manipal College of Medical Sciences, Pokhara, Nepal
²Department of Pathology, Nepal Armed Police Force Hospital, Kathmandu, Nepal
³Department of Microbiology, Nepal Police Hospital, Kathmandu, Nepal

*Corresponding author

*Aashish Gupta, Department of Microbiology, Nepal Police Hospital, Kathmandu, Nepal.

Abstract

Background: Chronic gastritis, an inflammatory condition of the gastric mucosa, can affect different parts of the stomach, causing varying degrees of mucosal damage.The purpose of this study was to determine the prevalence of histopathological abnormalities among outpatients at a tertiary care center.

Methodology: A descriptive cross-sectional study was conducted among outpatients from January 9, 2017, to June 8, 2018, with ethical approval from the Institutional Review Committee (Reference number: 12252016). Biopsy samples were collected from the antral mucosa, corpus area, and angularis incisura mucosa of patients undergoing upper gastrointestinal endoscopies. Socio-demographic details and histopathological findings were documented. Convenience sampling was utilized, and the point estimate and 95% Confidence Interval were calculated.

Result: Out of 385 hospital-visiting individuals, 80 (20.78%) had histopathological abnormalities (19.14-22.42, 95% Confidence Interval). These patients had a mean age of 69.90±15.32 years. All 80 patients (100%) presented with dyspepsia, and 29 (36.30%) had endoscopic findings of ulcers, with higher prevalence in males and those aged 61-70 years. Provisional endoscopic diagnoses indicated malignancies in 32 (40.00%) patients, while histopathological diagnosis revealed chronic gastritis in 40 (50.00%) patients.

Conclusion:In patients undergoing histopathological evaluations, dyspepsia was frequently diagnosed by endoscopy, but chronic gastritis by histopathology, most commonly in men and older adults.The results of this study are consistent with those of previous studies conducted in similar settings.

Keywords: Clinical presentation, diagnoses, endoscopy, histopathology, Nepal.

Introduction

Inflammation of the gastric mucosa, known as chronic gastritis, may cause nausea, vomiting, or epigastric pain, and can destroy glandular structures, leading to gastric atrophy. This condition increases the risk of gastric cancer fivefold.1-3 Globally, gastric cancer kills approximately 700,000 people annually, ranking fourth in incidence and second in mortality.4

Chronic gastritis often begins as an acute condition that typically remains untreated, leading to persistent injuries or sequelae.1 These histopathological abnormalities, including dysplasia and adenocarcinoma, can be easily and quickly detected using endoscopic techniques.4 Unfortunately, lower socioeconomic countries are experiencing a significant number of premature deaths due to gastric cancer and ulcers.2 However, there are very few studies reported in resource-limited countries, including Nepal, that show the prevalence of these abnormalities.

Considering the above, the present study investigated the prevalence of histopathological gastric mucosal abnormalities, along with demographic details and histopathological findings among hospital-visiting patients.

Management and Outcome

Ophthalmological evaluation revealed normal fundus picture. Oto-Acoustic Emission screening test was normal in bilateral ears and follow up BERA test normal. MRI Brain revealed diffuse thinning and partial agenesis of corpus callosum (absent splenium). Metabolic workup was done to rule out other differential diagnoses, including inborn errors of lipid metabolism like Refsum disease, Sjogren Larssen syndrome, and disorders of glycoprotein synthesis– amino acid profile by TMS and urine GCMS were normal. Whole exome and Sanger sequencing was done as shown in Figure 3, and a homozygous single base pair duplication in exon 3 of the SNAP29 gene

(Chr22:g.20881101_20881102dup; Depth: 112x) was detected, with the homozygous c.487 duplication of the coding region, which is the most commonly reported mutation in this syndrome. There isreplacement of the original amino acid serine at position 163 of the protein, by lysine, with a frameshift after this point, with a stop codon introduced at position 6 of the altered protein sequence, 6 amino acids after the frameshift, leading to premature truncation of the protein.

Methods

This descriptive cross-sectional study was conducted in the Department of Pathology at Manipal College of Medical Sciences in Pokhara, Nepal, from January 9, 2017, to June 8, 2018. Ethical approval was granted by the Institutional Review Committee of Manipal College of Medical Sciences (Reference number: 12252016). The study population included patients aged 21–87 who exhibited clinical signs of histopathological gastric mucosal abnormalities. It encompassed all endoscopic gastric biopsies with histopathological features of chronic gastritis received during the study period. Patients who declined to provide consent or whose biopsy samples were insufficient for reporting were excluded. A convenience sampling method was employed.

The sample size was calculated using the following formula:

n= Z2 x p x q / e2

= (1.96)2 x 0.5 x 0.5 / (0.05)2

= 384.16

Where,

n= required sample size

Z= 1.96 at 95% confidence interval (CI)

p = prevalence of histopathological abnormalities

q= 1-p

e= margin of error, 5%

Hence, the minimum sample size required was 385.

The patient information sheet was used to document demographic details and histopathological findings. Incomplete or unclear records were thoroughly clarified through effective communication with the healthcare professionals involved. After obtaining informed consent from participants, all personal identifiers were removed.

We collected five endoscopic biopsy samples: two from the antral mucosa, one from the angularis incisura, and two from the corpus (oxyntic) area. These samples were stored in separate vials, labeled accordingly, and transported to the Department of Pathology. A provisional endoscopic diagnosis was made based on the endoscopic findings. The biopsy specimens were immediately fixed in neutral-buffered 10% formalin for histological examination. From each block, 3-4 micron thick sections were prepared and stained with Hematoxylin and Eosin (H&E) and Giemsa stains. The slides were carefully examined, and detailed notes were made of all histopathological parameters. The cases were reported using the Updated Sydney System.

The data were entered using Microsoft Excel version 10.0, and the analysis was performed using IBM SPSS Statistics version 17.0. A point estimate was calculated, along with a 95% confidence interval.

Results

Out of 385 patients, 80 (20.78%) were found to have histopathological abnormalities (19.14-22.42, 95% CI). Patients' ages ranged from 21 to 87, with a mean age of 69.90 years and a standard deviation of 15.32. Among those with abnormalities, 55 (68.75%) were male and 25 (31.25%) were female. All 80 patients (100%) experienced dyspepsia, 26 (32.50%) had weight loss, and 17 (21.25%) had anorexia. Upper gastrointestinal bleeding was most common in males (n=4, 66.67%) and patients aged 51–60 (n=3, 50.0%). Notably, all clinical presentations were observed in patients aged 81–90 years (n=8, 80.0%).

Table 1: Patients’ demographics based on clinical presentations

UGI*=upper gastrointestinal tract

Table 1: Histopathological diagnoses based on clinical presentations, endoscopic findings, and provisional endoscopic diagnosis

UGI*=upper gastrointestinal tract

Among the patients undergoing histopathological assessments, 40 (50.0%) were diagnosed with chronic gastritis, 23 (28.75%) with low-grade dysplasia, 15 (18.75%) with adenocarcinoma, and 2 (2.50%) with high-grade dysplasia. Dyspepsia was the chief clinical complaint for all patients with any histopathological diagnosis. Weight loss was reported by 8 (30.77%) patients with low-grade dysplasia and 14 (53.85%) patients with adenocarcinoma. Anorexia, abdominal pain, or upper gastrointestinal bleeding were not clinical complaints in patients with high-grade dysplasia (Table 2).

The endoscopic findings included 29 (36.25%) ulcers, 24 (30.0%) cases of erythema, and 13 (16.25%) cases of atrophy. Erythema was most frequently observed in patients diagnosed with chronic gastritis (79.17%), while atrophy (46.15%) and growth (100%) were noted in patients with low-grade dysplasia and adenocarcinoma, respectively. Each patient with high-grade dysplasia showed an ulcer (3.45%) and atrophy (7.69%) on endoscopy (Table 2).

The provisional endoscopic diagnosis of chronic gastritis identified 20 (71.43%) patients with gastritis, 11 (55.0%) with benign gastric ulcers, and 9 (28.13%) with malignancy. Of those initially diagnosed with adenocarcinoma, 12 (37.50%) and 10 (31.25%) patients were classified as malignant based on provisional endoscopy. Additionally, 10 (31.25%) patients initially diagnosed with adenocarcinoma and 7 (25.0%) with low-grade dysplasia were reclassified as having gastritis (Table 2).

Discussion

The study results indicated that histopathological abnormalities were in 20.78% of cases. Males accounted for twice as many assessments as females (68.75% vs. 31.25%). Most assessments were made in patients aged 61–70 years (23.75%), followed by those aged 71–80 years (21.25%) and 51–60 years (20.0%). Similarly, a study in Nepal and several Southeast Asian countries reported a male-to-female ratio of 1.2 to 1, with the most common age group being 61–70 years (20.93%-28.0%).5-8 In contrast, a study from Pakistan found an equal sex-based prevalence of histopathological abnormalities and a lower mean age of 37.74.9

In this study, the most common clinical presentations were dyspepsia (100%), weight loss (32.50%), and anorexia (21.25%). Dyspepsia was also reported as the most common clinical presentation in most other studies (33.33%–82.0%).6,7,9 However, the incidence of the second most common clinical complaints differed from our study. For instance, loss of appetite was reported in 21.25% of our patients compared to 33.30% in other studies,7 abdominal pain was noted in 12.5% of our patients versus 22.2%–72.0% in other studies,6,9 and bloating was reported in 0% of our patients compared to 62.0% in other studies.9

This study found that the most common endoscopic findings were ulcers (36.25%), erythematous lesions (30.0%), and atrophy (16.25%). Similarly, another study reported erythematous findings (26.70%) as the predominant endoscopic observation, following ulcers (33.30%).7 In this study, the most frequent provisional endoscopic diagnoses were malignancy (40.0%), followed by gastritis (35.0%) and benign gastric ulcers (31.25%). In contrast, another study showed a higher incidence of hyperemia (66.0%) and lower incidences of ulcers (16.0%) and polypoidal growths (16.0%).9 Additionally, a similar study conducted in Nepal reported a higher incidence of gastritis (58.10%) but a lower incidence of ulcers (11.63%) during endoscopic diagnosis.5 This study did not observe cases of gastric carcinoma (9.30%), atrophic gastritis (9.3%), or erosive gastritis (6.9%) that were reported in the Nepalese study.5 Furthermore, the incidence of malignancy (8.30%) reported in another study was much lower than in our study.7 This study did not find any normal mucosa on endoscopy, whereas other studies reported normal mucosa in 4.70% to 19.04% of cases.6-8

In this study, most patients were histopathologically diagnosed with chronic gastritis (50.0%), followed by dysplasia (31.25%) and adenocarcinoma (18.75%). Other studies have also reported chronic gastritis as the most common histopathological diagnosis (88.0%–92.0%), followed by dysplasia (4.0%–9.30%) and adenocarcinoma (2.0%–5.0%).7,9,10 In contrast, one study identified adenocarcinoma as the most common histopathological diagnosis (59.04%), followed by gastritis (36.19%) and intestinal metaplasia (2.85%).8

This study found the highest incidence of ulcers (37.93%) and erythema (79.17%) in patients with chronic gastritis, while atrophy (46.15%) and growth (100.0%) were observed in patients with low-grade dysplasia and adenocarcinoma, respectively. Similar findings have been reported in other studies, which also found a correlation between chronic gastritis and endoscopic erythema or mucosal breaks.6,11 Additionally, another study found a positive correlation between the presence of dysplasia or chronic gastritis and normal mucosa.7

In this study, most patients diagnosed with gastritis (71.43%) and benign gastric ulcers (30.0%) on endoscopy were found to have chronic gastritis on histopathology. Most cases initially identified as malignancies (37.50%) were confirmed as adenocarcinomas histologically. Another study reported that 14.50% of endoscopically diagnosed gastritis cases were histologically identified as adenocarcinoma, 90% of normal-looking mucosa was found to be gastritis, and 50% of gastric ulcers were identified as carcinomas.8 While some studies have shown a strong correlation between provisional endoscopic and histopathological diagnoses, others have reported a poor correlation.5-7

This study has several limitations. First, the findings may have limited generalizability due to the small sample size. Second, the study did not include an examination of acute gastritis or its variants. Lastly, the use of visual analogue scales could be subjective and may not accurately reflect the histopathological appearance of the gastric mucosa.

Conclusion

Studies in similar settings found comparable prevalence rates for histopathological assessments, which were more common in males and in patients aged 61-70 years. Clinically, dyspepsia was the most prevalent symptom, while endoscopic findings predominantly revealed ulcers. Although malignancy was frequently noted in provisional endoscopic diagnoses, chronic gastritis was the most common diagnosis in histopathological evaluations.

Acknowledgements: The author would like to acknowledge Mr. Ajaya Basnet of the Nepal Armed Police Force Hospital, Balambu, Kathmandu, Nepal, for his assistance with statistical analysis and manuscript preparation.

Conflict of Interest: None.

References

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  10. Matsuhisa T, Miki M, Yamada N, Sharma SK, Shrestha BM. Helicobacter pylori infection, glandular atrophy, intestinal metaplasia and topography of chronic active gastritis in the Nepalese and Japanese population: the age, gender and endoscopic diagnosis matched study. Kathmandu Univ Med J. 2007;5(3):295-301.
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Journal of Clinical Case Reports, Medical Images and Health Sciences (ISSN 2832-1286) is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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