Gastrointestinal: Helicobacter pylori gastritis

How should we describe endoscopic features of gastric inflammation and can the presence or absence of these changes predict infection with Helicobacter pylori? In 1991, an international group at the World Congress of Gastroenterology in Sydney recognized the following endoscopic features of inflammation; oedema, erythema, friability, exudate formation, flat erosions, raised erosions, rugal hyperplasia, rugal atrophy, visible vessels, intramural bleeding and nodularity. Combinations of these changes were used to define seven endoscopic categories of gastric inflammation, the commonest being erythematous/exudative gastritis. Unfortunately, the correlation between endoscopic appearances and gastric histology is often poor. For example, it is common for endoscopically normal mucosa to reveal histological gastritis and for erythematous changes to be associated with normal histology. Similarly, a variety of endoscopic categories of inflammation have been associated with discrete causes of gastritis such as non-steroidal, anti-inflammatory drugs, bile reflux and autoimmune disease. In relation to H. pylori, most studies have found that the frequency of endoscopic abnormalities is higher in infected than in non-infected patients. However, common endoscopic categories such as erythematous/exudative gastritis, atrophic gastritis, flat erosive gastritis and raised erosive gastritis show only weak associations with H. pylori. In contrast, stronger associations (higher positive predictive values) have been described for uncommon endoscopic manifestations such as antral nodularity and hyperplasia of folds in the body of the stomach. These features are shown in 1, 2, respectively. Antral nodularity has been described more frequently in infected children than in adults and seems likely to reflect the presence of prominent lymphoid follicles in the lamina propria. Prominent gastric folds are less readily explained but may be a manifestation of exaggerated inflammation or hypersecretion of gastric acid. After eradication of H. pylori, both antral nodularity and prominent folds resolve slowly, often over several months. Contributions to this section are welcomed and should be submitted to the Section Editor, Professor IC Roberts-Thomson, Department of Gastroenterology, Queen Eliza- beth Hospital, Woodville South, South Australia 5011, Australia. Reproduction of colour photographs has kindly been sponsored by a grant from AstraZeneca.