M. Siurala

Chronic Gastritis: Dynamic and Clinical Aspects

A simple method for grading gastritis is to assess the severity of round cell infiltration and the loss of normal glands, and this may be applied to both antral and body changes. However, there is, as yet, no satisfactory classification of gastritis. In population samples, gastritis shows a linear increase in age-specific prevalence so that the annual increase in the body atrophic gastritis pool up to geriatric age is constant (1.5%). In the elderly, there appears to be a retardation of the process, particularly in the antral mucosa, where some healing trend is demonstrable. This dynamic behaviour is qualitatively similar in all population samples collected in Finland and Estonia. On the other hand, the dynamic behaviour of gastritis in different subpopulations differs markedly from that in the population at large. In pernicious anemia patients and their first-degree relatives, the progression of body atrophic gastritis in its final stages is about 20 times more rapid than in a general population, while, simultaneously, antral gastritis displays a distinct healing tendency. A behaviour opposite to that in pernicious anemia is seen in patients with active or healed duodenal ulcer disease and in duodenitis: antral gastritis behaves, on the whole, similarly to that in the general population, but in the body mucosa there occurs virtually no progression with age, and the mucosa generally remains normal or at the stage of superficial gastritis. However, after antrectomy body gastritis progresses rapidly in the remnant at first, but it slows down later and then closely resembles that in the general population.(ABSTRACT TRUNCATED AT 250 WORDS)

The sequelae and course of chronic gastritis during a 30- to 34-year bioptic follow-up study.

Three hundred and seventy-seven subjects with different conditions of the gastric body mucosa have been followed up for 30-34 years, first by the blind suction biopsy method and since 1973-1976 by the direct-vision endoscopic method. Body gastritis revealed a distinct worsening trend during the whole follow-up period. However, during the last follow-up period some slowing down of the process was also discernible. In the antrum there was a distinct healing trend during that period. Thus all cases of distinct atrophic gastritis limited to the antrum and found at the re-examination in 1973-1976 had disappeared during the last follow-up period owing to regression of the antral or continuation of the body process. On the other hand, a considerable proportion of cases of diffuse antrofundal atrophic gastritis found in 1973-1976 appeared in 1983-1984 in the pure body atrophic gastritis group, obviously due to regression of the antral process. This indicates the existence of an alternative pathway via diffuse antrofundal atrophic gastritis for the development of atrophic gastritis limited to the body area. The occurrence of parietal cell antibodies was on the whole a poor indicator of the progression of atrophic gastritis. However, the development of the end-stage (severe) atrophic gastritis was significantly associated with their presence. Atrophic changes of the body mucosa were not found in 1983-1984 in any cases of duodenal ulcer disease, whereas in patients with gastric polyps atrophic gastritis affecting only the body was, as a rule, present. No case of gastric carcinoma was detected during the last follow-up examination.

Fasting Levels of Serum Gastrin in Different Functional and Morphologic States of the Antrofundal Mucosa: An Analysis of 860 Subjects

The relationship of fasting serum gastrin (FSG) levels to the histologic state of antral and body mucosa and to the stimulated acid output (PAO) was examined in 860 subjects. The FSG levels correlated with PAO and atrophy of the body mucosa: the FSG increased linearly with an increase in the grade of body atrophy and increased exponentially when the PAO decreased from normal (greater than 10 meq/h) to zero. In subjects with achlorhydria or marked hypochlorhydria (PAO less than 1.1 meq/h) accompanying moderate or severe atrophy in the gastric body mucosa, FSG decreased linearly with increasing grade of atrophy in the antral mucosa. No such relationship between antral atrophy and FSG was found in subjects who had a PAO above 1.1 meq/h or who had non-atrophic gastric body mucosa. We conclude that the state of the antral mucosa influences the FSG level, but only when the function of antral G cells is maximal--that is, in achlorhydric or nearly achlorhydric conditions in which the inhibitory effect of intragastric acidity on the G cells secretion of gastrin into the circulation is minimal.

Decreased Incidences of Intestinal and Diffuse Types of Gastric Carcinoma in Finland during a 20-Year Period

The incidence of gastric carcinoma (GCA) has decreased throughout the world. This decrease is attributed to a decline in incidence of the intestinal type of GCA (IGCA), whereas the diffuse (DGCA) type of GCA is considered to be endemic in nature and more stable in incidence. In the present study we have estimated how much the incidences of IGCA and DGCA have decreased in percentage in Finland from 1952-61 to 1972-81. Our calculations are based on the Finnish Cancer Registry data of new GCA cases, on population statistics in Finland, and on the percentage distribution of GCA subtypes in three consecutive samples of GCA patients collected in the time periods 1952-61 (reference series) and 1972-81 (two separate samples: series A and B). The samples totaled 1837 GCA cases. We calculated that the incidence of IGCA had decreased from 1952-61 to 1972-81 by 62-71% (reference series versus series A - reference series versus series B) among men and by 69-70% among women. Correspondingly, the incidence of DGCA was calculated to have decreased by 30-39% among men and 37-42% among women. We conclude that not only has the incidence of IGCA decreased in percentage approximately twice as much as the incidence of DGCA but DGCA has also distinctly decreased in incidence in Finland from 1952-61 to 1972-81.

Long-Term Follow-up of Subjects with Superficial Gastritis or a Normal Gastric Mucosa

A total of 377 subjects with different conditions of the gastric body mucosa have been followed up over a long period. In the present study 168 subjects with a normal gastric mucosa and 93 with superficial gastritis were followed up for 16–20 years. Bioptical follow-up examinations revealed that gastritis tends to persist or to progress, and that atrophic gastritis seems to develop from superficial gastritis. In a number of subjects with a normal gastric mucosa this remained normal in spite of advanced age and a long period of observation. In one subject with superficial gastritis in 1952, atrophic gastritis was found in 1961 and signs of gastric carcinoma in 1969.

Progression of antral and body gastritis in patients with active and healed duodenal ulcer and duodenitis

The dynamics of the antral and body mucosa has been studied in biopsy specimens obtained during endoscopy of patients with duodenal ulcer (103 cases), patients with duodenal ulcer scars (108 cases), and patients with duodenitis (44 cases). A representative Finnish population sample consisting of 434 subjects was used as reference material. The antral mucosa of all patient series showed an increase in the severity and prevalence of gastritis similar to that of the general population, whereas virtually no progression of gastritis with age was seen in the body mucosa, which remained normal or at the stage of superficial gastritis up to geriatric age. In contrast, in the present controls and in all earlier population samples studied by us so far, there was a significant and steady increase in the severity and prevalence of body gastritis with age. It is concluded that the age behavior of the antral and body mucosa was in duodenal ulcer scars and duodenitis similar to that of patients with active duodenal ulcer. The persistence of normal conditions in the acid-secreting area may serve as one explanation of the strong tendency of the disease to recur. In addition, it is tentatively concluded that in duodenal ulcer disease there are factors that have a protecting influence on the body glands and which are abolished by antrectomy, according to our earlier studies.

Characteristics of Gastric Mucosa Which Precede Occurrence of Gastric Malignancy: Results of Long-Term Follow-up of Three Family Samples

The aim of the study was to evaluate what family characteristics and what morphological, functional and immunological changes of the gastric mucosa precede the development of gastric malignancy in a follow-up of 11-14 years. The material consisted of 301 first-degree relatives of gastric carcinoma patients, 183 relatives of pernicious anaemia patients, and of 358 control relatives of probands computer matched from the general population by age and sex for the carcinoma probands. All subjects were endoscopically examined in 1973-1976 and followed up to the end of 1987. According to cancer registry data, 11 cases of malignant gastric tumours (9 carcinomas, one carcinoid tumour and one anaplastic tumour with suspicion of Hodgkins disease) had been diagnosed during the follow-up: 6 belonged to gastric carcinoma, 2 to pernicious anaemia and 3 to control families. The occurrence of malignancy was significantly related to the presence of advanced gastritis with atrophy and of intestinal metaplasia before the start of the follow-up. In relatives with achlorhydria and low serum pepsinogen I levels the incidence of malignancy did not significantly differ from that in controls of similar age and sex distribution. The risk of getting malignancy was about four-fold in female members of gastric carcinoma and pernicious anaemia families but was not increased in control families. The risk was increased only in female members and concerned only gastric malignancy being the expected one or even lower than the expected in regard to malignancies of other location.

Increase of Serum Pepsinogen I with Age in Females with Normal Gastric Mucosa but not in Males, Possibly Due to Increase in Acid-Pepsin Secreting Area

The mean pepsinogen I (PG I) level in a Finnish family sample was different in males and females and the difference was statistically significant. After exclusion of subjects with gastritis there remained 67 females and 68 males with morphologically completely normal antral and corpus mucosa. In females there was a significant increase of PG I with advancing age, the regression coefficient being 0.37 and statistically significant (p less than 0.01). In males no such increase was found, and individual cases revealed an almost random distribution with age. A similar increase with age has been noted in gastric acid output in females but not in males. Assuming that there is a linear relationship between PG I levels and the total chief cell mass, the PG I level would be determined by three main variables: thickness of the glandular layer, density of chief cells, and area occupied by chief cells. Of these variables the thickness and chief cell density showed neither in females nor in males any statistically significant increase with age, leaving the area as the variable which would account for the increase of PG I.

Helicobacter pylori and Duodenal Ulcer. A Study of Duodenal Ulcer Patients and Their First-Degree Relatives

Out of 59 duodenal ulcer (DU) probands and their 199 first-degree relatives Giemsa-staining for the determination of Helicobacter pylori (HP) was performed in 51 probands and 155 relatives. Controls were matched by age and sex from a family sample representing the same geographical area. In all, 155 controls were found for the probands and relatives. The occurrence and score of HP density showed an excellent correlation with morphology of the mucosa, signs of acute inflammation and presence of gastric metaplasia in the duodenal bulb. The prevalence of HP was 94% in DU probands and significantly higher than in their relatives and controls. In sibs of DU probands the prevalence of HP (64%) was also significantly higher than in controls (51%) obviously due to the presence of a subgroup of sibs with signs of active or past duodenal ulcer disease, which show higher than expected prevalence of HP, and of acid hypersecretion and high levels of serum pepsinogen I (PG I). Peak acid output (PAO), serum pepsinogen I and II and fasting serum gastrin levels were in relatives without atrophy higher in HP positive than negative cases but significant differences were present only with regard to the pepsinogens. The occurrence of HP positivity as well as of high PAO and pepsinogen levels might be considered risk factors of DU disease in close relatives of DU probands. On the other hand, the significance of HP positivity as cause of abdominal complaints is doubtful, in view of the complete lack of correlation between HP and morphology and complaints in the present study.

Enrichment of Combined Antral and Corpus Atrophic Gastritis (“Combined AG”) in Sibs of Gastric Carcinoma Patients

The occurrence of different combinations of antral and corpus atrophic gastritis (AG) was studied in 127 sibs and 159 children of 73 gastric carcinoma patients. Seventy-three control probands, age- and sex-matched for the carcinoma probands, and their 379 first-degree relatives were used as controls. Sibs of gastric carcinoma patients revealed a significant enrichment of AG affecting simultaneously both antrum and corpus (combined AG), while no such enrichment could be demonstrated in children, who behaved on the whole similarly to the controls. In addition, sibs of gastric carcinoma patients showed a significant aggregation of combined AG also when compared with children of similar age. This suggests that genetic factors in addition to environmental ones participate in the accumulation of combined AG in sibs. The lack of phenotype AB in children excludes the possibility of dominant Mendelian inheritance, but leaves the possibility of a recessive autosomal or multigenetic inheritance. The enrichment of combined AG in sibs of gastric carcinoma patients could be one of the factors involved in the increased liability of close relatives of gastric carcinoma patients to contract gastric malignancy.