CLASSIFICATION AND DIAGNOSIS OF GASTRITIS AND

GASTROPATHY

Authors:
Mark Feldman, MD, MACP, AGAF, FACG
Pamela J Jensen, MD
Section Editor:
J Thomas Lamont, MD
Deputy Editor:
Shilpa Grover, MD, MPH, AGAF

Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Mar 2019. | This topic last updated: Nov 07, 2017.

INTRODUCTION
Gastritis is predominantly an inflammatory process, while the term gastropathy
denotes a gastric mucosal disorder with minimal to no inflammation. The term
gastritis is occasionally used to denote inflammation associated mucosal injury.
However, epithelial cell injury and regeneration are not always accompanied by
mucosal inflammation. This distinction has caused considerable confusion since the
term "gastritis" is often used to describe endoscopic or radiologic characteristics of
the gastric mucosa rather than specific histologic findings. Epithelial cell damage
and regeneration with minimal or no associated inflammation is properly referred to
as "gastropathy." An etiology-based classification of gastropathy and gastritis is
presented.

The causes, natural history, and therapeutic implications of gastropathy differ from
gastritis:

●Gastritis is commonly secondary to infectious or autoimmune etiologies.

 ●Gastropathy is commonly secondary to endogenous or exogenous irritants,
such as bile reflux, alcohol, or aspirin and nonsteroidal antiinflammatory drugs.
However, gastropathy can also be secondary to ischemia, physical stress, or
chronic congestion.

"Gastritis" is a term often used by endoscopists to describe an abnormal-appearing

gastric mucosa rather than representing a particular endoscopic entity. A gastric
mucosal biopsy is necessary to establish a definitive diagnosis of gastritis versus
gastropathy.

This topic review will discuss the classification and diagnosis of gastritis and
gastropathy. The causes of acute and chronic gastritis are presented separately.

CLASSIFICATION OF GASTRITIS AND GASTROPATHY

There is no universally accepted classification of gastritis/gastropathy, although
several classifications (such as the Sydney system and the Operative Link for
Gastritis Assessment [OLGA] staging system) have been proposed. The updated
Sydney system does not yield actionable prognostic information concerning cancer
risk in cases of chronic atrophic gastritis. The OLGA staging system may provide
information about the risk of secondary gastric cancers in autoimmune gastritis. The
OLGA staging system, which was proposed by an international group of pathologists
for use in standardizing classification of atrophic gastritis, incorporates histologic
phenotypes with extent of disease to aid in prediction of cancer risks [9]. High stage
disease (OLGA III/IV) is associated with a high risk of gastric cancer. Operative Link
on Gastric Intestinal Metaplasia Assessment (OLGIM), another proposed system,
shows less interobserver variability and is prognostically useful. However, OLGIM
may be less sensitive than OLGA in identifying high-risk gastritis, and some experts
recommend using a combination of OLGA and OLGIM for staging of chronic gastritis.
Gastritis has been classified by histologic features, time course (acute versus
chronic), etiology, and proposed pathophysiology.

However, classification remains controversial because of gaps in knowledge of

etiology and pathogenesis, variation in nomenclature, and the frequent coexistence
of more than one type of gastritis or gastropathy in individual patients. Furthermore,
the entities overlap morphologically, and so some conditions are classified by
etiology and others by morphologic pattern. Thus, comparisons across studies using
different nomenclature can be difficult. There are many cases with a diagnosis of
chronic gastritis (often mild) for which a specific etiology cannot be determined by
histopathologic examination.

Most classification systems distinguish acute, short-term disease from chronic, long-
term disease. The terms acute and chronic are also used to describe the type of
inflammatory cell infiltrate. Acute inflammation is represented by neutrophilic
infiltration, while chronic inflammation is characterized by a mixture of mononuclear
cells, chiefly lymphocytes, plasma cells, and macrophages.

A clinicopathologic framework for the classification of gastritis and gastropathy

based upon these factors has been proposed.

DIAGNOSIS
A mucosal biopsy is required to distinguish between acute, chronic active, or chronic
gastritis from gastropathy, since the endoscopic and radiologic features may be
similar and clinical features are often inaccurate for predicting histologic findings.
Histologic findings can vary over a wide spectrum ranging from epithelial hyperplasia
to extensive epithelial cell damage with infiltration by inflammatory cells.

An illustrative study included 488 adults who were randomly selected from the
general population and were screened by gastroscopy and biopsy. The authors
determined the sensitivity and specificity of macroscopic features (including
erythema, mucosal erosions, the absence of rugal folds, and the presence of visible
vessels) compared with histologic findings. None of these endoscopic findings had
sensitivity greater than 57 percent for determining the presence of gastritis
or Helicobacter pyloriinfection. Another problem with relying on endoscopy alone is
the interobserver variability for some features of gastropathy, such as erythema.
Laboratory evaluation — Two types of laboratory tests have proven to be useful
for predicting gastric mucosal findings: noninvasive testing for H. pylori infection and
serologic biomarker measurements, both biochemical and immunologic.

Helicobacter pylori testing — Noninvasive testing for H. pylori has high sensitivity
and specificity for gastritis.

Stomach-specific biochemical markers — Serum pepsinogens (PGs) have been

used to screen patients for gastric atrophy. PG I is secreted only by oxyntic glands
of the gastric fundus and body, whereas PG II is secreted by all gastric glands
(oxyntic, cardiac and pyloric) as well as duodenal (Brunner's) glands. Thus, in
conditions associated with gastritis of the fundus (as in pernicious anemia), PG I
concentrations are decreased relative to PG II.

Low serum PG I levels are also strongly associated with extensive intestinal
metaplasia. Intestinal metaplasia was found in 58 (88 percent) of 66 patients with a
serum PG I value of less than 25 ng per milliliter. The ratio of PG isozymes I and II
in serum has good correlation with presence of metaplastic atrophic gastritis
(principally autoimmune metaplastic atrophic gastritis and pernicious anemia).
Measurement of serum gastrin evaluated in tandem with PG I:II ratio has been
advocated to reflect the degree of inflammation and grade of atrophic gastritis.

The early diagnosis of atrophic gastritis is important as this condition is a significant

independent risk factor for the development of distal gastric tumors, both
adenocarcinoma and carcinoid

The ratio of serum PG I:II in the serum of people with normal gastric mucosa is
approximately 6.2. In one series, the presence of fundic atrophic gastritis was
accurately predicted by the concentration of PG I and the ratio of PG isoenzymes in
approximately 70 percent of patients. The ratio may also be useful for screening
family members of patients with pernicious anemia and for identifying patients at
high risk for gastric cancer in endemic countries or other populations at increased
risk for gastric atrophy. On the other hand, measurement of serum PGs and their
ratio do not accurately discriminate nonatrophic versus antrum-
restricted/predominant atrophic gastritis in an asymptomatic population or first-
degree relatives of patients with gastric cancer.

Serologic immunologic markers — Immunological markers may be useful in

clinically asymptomatic patients with early autoimmune gastritis (AIG). Testing for
antibodies to intrinsic factor, parietal cells, and H. pylori in tandem with serum gastrin
may provide noninvasive early evidence of autoimmune gastritis and facilitate
selection of patients for endoscopic examination.

Biopsy — Accurate histologic assessment of gastritis and gastropathy depends

upon optimizing the site and number of biopsy specimens. Magnification endoscopy
may help in the identification of areas to biopsy.

Biopsy site preferences and number vary in clinical practice. However, there is
general consensus among experts on the following biopsy approach:

●All gross abnormalities should be biopsied and submitted in separate

containers.
●Normal-appearing mucosa adjacent to the lesional tissue should also be
biopsied.

● Multiple biopsies (two to five) of both the corpus and the antrum should be
obtained when attempting to establish the diagnosis of H. pylori or autoimmune
gastritis.

Biopsy of the incisura is also useful since it approximates the transition zone
between the antrum and body, where intestinal metaplasia and atrophy are most
frequently found in patients with environmental metaplastic atrophic gastritis.
However, biopsy of the incisura alone does not provide information on the extent of
metaplastic atrophic gastritis, which is a major parameter in determination of cancer
risk.

In first-degree relatives of patients with early onset gastric carcinoma (age <45
years), endoscopic evaluation with at least four biopsies from the gastric antrum and
corpus is suggested. Multiple biopsies with adequate sampling are necessary for
scoring and staging of premalignant lesions in this subgroup of patients.

Biopsies of the duodenum may also be helpful for diagnosing some forms of chronic
gastritis. As examples, duodenal biopsies may show evidence of Crohn disease in
patients with granulomatous gastritis or of celiac disease in patients with lymphocytic
gastritis.

Communication with the pathologist — Good communication between the

endoscopist and pathologist cannot be overemphasized, and will optimize the
interpretation of the biopsy specimens. This has become greatly facilitated by the
availability of digital endoscopic pictures and readily available endoscopic
procedural dictation in the electronic medical record.

The pathologist should include a morphologic classification of the gastritis or

gastropathy in the biopsy report.

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

●Basics topics (see "Patient education: Gastritis (The Basics)" and "Patient
education: Upper endoscopy (The Basics)")
 ●Beyond the Basics topics (see "Patient education: Upper endoscopy (Beyond
the Basics)")

SUMMARY AND RECOMMENDATIONS

●Gastric inflammatory disease can be broadly categorized into gastritis and
gastropathy. Gastritis is predominantly an inflammatory process while
gastropathy denotes gastric mucosal pathology with minimal to no inflammation.
(See 'Introduction' above.)
●There is no universally accepted classification
of gastritis/gastropathy, although several classifications of gastritis and
gastropathy have been proposed (table 1). (See 'Classification of gastritis and
gastropathy' above.)
●A mucosal biopsy is required to distinguish acute, chronic active, and chronic
gastritis and gastropathy. (See 'Diagnosis'above.)
●There is general consensus among experts on a biopsy approach.
(See 'Biopsy' above.)
●Good communication between the endoscopist and pathologist cannot be
overemphasized, and will optimize the interpretation of the biopsy specimens.
(See 'Communication with the pathologist' above.)