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Chapter 28 (page 133)
By means of fibreoptic gastroscopy Whitehead et al. (l972) obtained fresh, multiple full-
thickness biopsy specimens from all parts of the gastric mucosa in a large number of
patients. They proposed a classification of chronic gastritis applicable to all zones of the
mucosa, based on the following features: First, the mucosal type had to be established,
e.g. pyloric mucosa had to be differentiated from pseudopyloric metaplasia of body
mucosa. Second, the grade had to be determined; chronic atrophic gastritis (in which
there was atrophy of tubules) could be subdivided into mild, moderate and severe grades.
Third, the stage of activity had to be established; both superficial and atrophic gastritis
could be either active or quiescent. Fourth, the presence and type of metaplasia had to be
determined; it was acknowledged that difficulties could arise in recognizing mucosal
type when severe gastritis was associated with metaplasia or atrophy. In their
classification the degree of atrophy, rather than the degree of chronic cellular infiltration,
was graded. It was also established that intestinal metaplasia nearly always occurred in
mucosa which was the site of atrophic gastritis.
Strickland and Mackay (l973) reviewed the nature of chronic atrophic gastritis in relation
to the structure and function of the pyloric antrum, where "antrum" was equated with the
pyloric mucosal zone. Two distinct types of atrophic gastritis were recognized. In Type
A, tests for parietal cell autoantibody and intrinsic factor antibody were positive; there
was sparing of antral mucosa, with diffuse changes in the corpus, and severe impairment
of gastric secretion. In Type B, parietal cell autoantibody and intrinsic factor antibody
reactions were negative; there was definite antral involvement with focal changes in the
corpus, and moderate impairment of gastric secretion. Benign gastric ulceration of the
corpus was found to be associated with Type B atrophic gastritis; the more proximally
the ulcer was located in the stomach, the more extensive the gastritis and the more severe
the impairment of acid secretion proved to be. Chronic atrophic gastritis persisted after
ulcer healing, supporting the view that gastric ulcer originated from chronic gastritis.
Rao et al. (l975) stated that the term chronic gastritis carried different connotations for
the clinician, the pathologist and the radiologist. Previously little attention had been
given to determining the degree of chronic cellular infiltration involving the full thickness
of the gastric mucosa. They supported the use of terms which described the
morphological abnormalities found in mucosal biopsies, namely the degree of cellular
infiltration of the whole mucosa and the presence or absence of atrophy. A simple
descriptive classification of chronic gastritis into mild, moderately severe and severe
grades, with or without atrophy or metaplasia, was recommended. Mucosal biopsies in
241 patients with a variety of upper abdominal conditions showed chronic gastritis in
184. Only 3 of the patients were diagnosed as true superficial gastritis, where the cellular
infiltration was limited to the lamina propria between the pits.
Op den Orth and Dekker (l976) described erosions as superfical mucosal defects which
did not penetrate the muscularis mucosae. A flat erosion was a mucosal defect without
reaction in the adjacent parts, while a varioliform or complete erosion indicated a
mucosal defect surrounded by an elevated zone; the elevated zone had been variously
interpreted as a circular contraction of the muscularis mucosae, oedema, leucocytic
infiltration, or fibrosis. It was pointed out that erosions could occur as solitary lesions or
in combination with other upper gastro-intestinal pathology, e.g. gastric or duodenal
ulceration; whether a gastric erosion itself ever developed into a gastric ulcer was
controversial. Because of the raised zone surrounding it, an erosion could be visualized
fairly easily with double-contrast radiography as a tiny, constant fleck of barium
surrounded by a radiolucent halo; some erosions tended to be linear rather than circular.
In some cases erosions in the prepyloric area were associated with prominent or irregular
mucosal folds; the radiographic diagnosis of erosions was found to be reliable, and
correlated well with their endoscopic demonstration.
Roesch (l978) pointed out that gastric erosions occurred very commonly and were often
multiple. In the acute type the epithelial defect was not surrounded by inflammatory
reaction, while the chronic type had an elevated, bulging border. Only the chronic type
was detectable radiologically, presenting as a small fleck with a surrounding halo.
Endoscopy showed that almost 60 percent of chronic erosions occurred in the antral
region, and that they were often associated with prominent mucosal folds. Radiological
demonstration of these bead-like prepyloric folds was highly suspicious of chronic
erosions, even in the absence of a central punctate barium-filled depression. Where
erosions were followed-up for 5 years or longer, the transformation of multiple antral
erosions into hyperplastic folds could often be seen.
Morson and Dawson (l979) reiterated that the most accurate diagnosis of gastritis was
made on biopsies taken under direct vision through a fibrescope. Their classification,
which was made on histological grounds, entailed 3 types, namely chronic superfical
gastritis, atrophic gastritis (both of which might be either active or quiescent), and gastric
atrophy. Active superficial gastritis might be accompanied by small erosions. In
atrophic gastritis the essential feature was not the increase in inflammatory cells in the
lamina propria, but the reduction or atrophy of the deep glands, accompanied by
intestinal metaplasia in the "antrum". Attention was drawn to the fact that in both
superficial and atrophic gastritis, submucous fibrosis and thickening of the muscularis
externa had been reported, giving rise to "antral" deformity which was recognizable
Freise et al. (l979) did four year follow-up studies in 64 patients with gastric erosions.
The most common site of multiple erosions was the "antral" region. Erosions were
frequently seen in combination with other upper gastrointestinal conditions such as
gastric or duodenal ulceration or hiatus hernia. In 10 percent of cases chain-like multiple
erosions developed into a persistent, prominent gastric mucosal fold, usually in the
"antrum". When such a fold was seen, it could be taken to be the result of a chain of
erosions. There was no evidence that erosions led to chronic gastric ulceration, polyps or
Karvonen et al. (l983) classified erosions according to their endoscopic morphology. In
the complete type there was a surrounding elevated border; incomplete or flat erosions
were surrounded by a red halo, and haemorrhagic erosions were punctate bleeding spots.
In 86 percent of 117 patients with gastric erosions (but without other upper
gastrointestinal pathology), the lesions occurred only in the antral or prepyloric part of
the stomach, and in the majority of patients presented as multiple erosions. Some showed
features of both the complete and incomplete types, and were characterized by their
location on prominent prepyloric mucosal folds.
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