Staging gastritis: an international proposal.

The goals of obtaining and examining biopsy material are to acquire diagnostic and prognostic information to be used in patient management. In particular, the histological examination of gastric biopsies should answer 3 basic questions: (1) Are there inflammatory lesions?; (2) What is their possible etiology?; and (3) Are there mucosal lesions associated with increased cancer risk?1 The report ought to have informative relevance for the specialist, the general practitioner (who is often its ultimate recipient) and, hopefully, the patient. Internationally accepted staging systems are required for the effective communication of this information among clinicians and researchers. For example, the establishment of an internationally accepted staging method for hepatitis: (a) simplifies the message of the histology report; (b) increases the interobserver agreement in liver biopsy assessment; and (c) allows consistent comparisons of results obtained both by studies of natural history and therapeutic trials. The Sydney System and its Houston updated version [2] and [3] provided a uniform nomenclature for gastritis, as well as visual analogue scales for the grading of inflammation, atrophy, metaplasia, and Helicobacter pylori density. The system, however, lacks the element of prognosis and the same pathologists who use it in their research activities find it too cumbersome for routine diagnostic activities. In April 2005, an international group of gastroenterologists and pathologists (Operative Link for Gastritis Assessment [OLGA]) met in Parma, Italy, with the aim of reassessing critically the Updated Sydney System guidelines for reporting chronic gastritis and to determine whether staging could be added.4 As the risk of gastric cancer directly relates to the extent of gastritis and gastric mucosal atrophy, an atrophy-based staging system would provide implications for the prognosis and, possibly, the management of patients. Atrophy is defined as loss of appropriate gastric glands.5 In the gastric corpus, atrophy occurs as a distal to proximal replacement of oxyntic mucosa by pseudopyloric (ie, antral) or intestinal metaplasia. Pseudopyloric metaplasia affects native corpus glands, which assume the phenotype of muco-secreting antral glands, but can still retain pepsinogen I expression (normally featured by native oxyntic glands). The proposed Staging System (Figure 1) combines the antral and oxyntic mucosal atrophy scores as assessed according to the Updated Sydney System visual analog scales.