Keywords
Endoscopy Upper GI Tract - Precancerous conditions & cancerous lesions (displasia
and cancer) stomach - Diagnosis and imaging (inc chromoendoscopy, NBI, iSCAN, FICE,
CLE)
Introduction
Autoimmune atrophic gastritis (AIG) is a chronic autoimmune disease characterized
by inflammation and atrophy of the gastric mucosa. It is a rare condition with a reported
prevalence of less than 2% in the general population, but it is more common in certain
populations such as the elderly and those with other autoimmune diseases [1]. Despite its clinical significance, AIG is often underrecognized, potentially leading
to underdiagnosis and mismanagement, which increases risk of developing advanced gastric
cancer [2]. AIG can result in impaired gastric acid secretion, leading to malabsorption of
nutrients, iron deficiency anaemia, and an increased risk of gastric neoplasia [3].
There are numerous endoscopic signs that have been described in the gross description
of gastric atrophy (GA). The most characteristic endoscopic finding of AIG is corpus-dominant
advanced atrophy accompanied by non- or less-atrophic patterns in the antrum (reverse
atrophy) [4]. Other findings include loss of gastric folds, dense adherent mucus, marked vascular
appearance in the body, and nodular remnant mucosa ([Fig. 1]). The updated Kimura-Takemoto Classification (KTC) is the commonly employed system
for macroscopically characterizing the extent of atrophy, comprising two primary categories:
closed type atrophy and open type atrophy [5]. The former is defined as atrophic change restricted to the lesser curvature of
the stomach, whereas the latter encompasses atrophic change affecting both the lesser
and greater curvatures of the stomach body.
Fig. 1 Macroscopic findings in AIG. a Normal gastric body without AIG. b AIG with loss of gastric folds. c AIG with marked vascular visibility. d Dense adherent mucus. e Xanthomas. f Nodular remnant normal mucosa. The small inset on the left highlights the area indicated
by the red arrow, showing a BLI view of the normal nodular remnant mucosa against
a background of atrophic mucosa.
Microscopic or magnifying endoscopic findings of the gastric body in AIG have not
been extensively described. However, in the Japanese literature, three main magnifying
patterns of gastric body atrophy have been reported: foveolar (also known as “cast-off
skin appearance” [4]), oval/slit, and ridge/villous (also known as groove) types [6]
[7]
[8]
[9].
Despite the importance of endoscopically identifying AIG, there is a paucity of literature
on the macroscopic and microscopic (magnifying endoscopy) findings of this condition,
particularly in the western population. Therefore, the aim of this study was to present
a cohort of 63 consecutive patients with AIG in a tertiary care center, focusing on
the endoscopic, clinical, and laboratory findings.
Patients and methods
The objective of this retrospective cohort study was to examine individuals diagnosed
with AIG at Kingston Health Sciences Centre, Canada, from January 1, 2016, to December
31, 2023 by a single endoscopist RB). A total of 4,345 esophagogastroduodenoscopies
(EGDs) were reviewed for patient eligibility from an administrative database. In our
study, the diagnostic criteria for AIG were based on both endoscopic and serological
findings, as per the guidelines outlined in the Diagnostic Criteria and Endoscopic
and Histological Findings of Autoimmune Gastritis in Japan [10]. Specifically, participants had to exhibit severe mucosal atrophy predominantly
from the gastric body to the fundus on endoscopy, or have histological findings consistent
with AIG, or both, and be positive for gastric autoantibodies (either anti-parietal
cell or anti-intrinsic factor antibodies, or both). All participants in our study
met these inclusion criteria. Patients who did not meet the criteria or who had exclusion
factors such as Helicobacter pylori infection were not included in the administrative database, and their numbers were
not tracked. Consequently, our study predominantly included cases at an advanced stage
of AIG. Patient inclusion and data collection were overseen by a single endoscopist
experienced in magnifying endoscopy (RB).
The study received approval from the local ethics committee, and the reference is
TRAQ: 6039408 approved on the August 3, 2023. Medical records were reviewed to collect
data including age, sex, presenting symptoms, laboratory findings such as serum anti-parietal
cells antibodies, anti-intrinsic factor antibodies, hemoglobin, vitamin B12, and ferritin,
endoscopic findings, histopathology reports, and concomitant autoimmune diseases.
A cut-off value for anti-parietal cell antibodies of 1:80 in serum and a cut-off value
for anti-intrinsic factor antibodies of 1:40 in serum, were established for definitive
diagnosis of AIG in our study. Data about total upper endoscopies performed were retrieved
from the administrative billing database, and the patients with AIG were identified
from the administrative upper endoscopy surveillance database. Data from all patients
with AIG are entered into an administrative database to ensure they receive surveillance
endoscopies. The charts of these patients were then retrospectively reviewed to collect
the aforementioned data. Diagnosis of AIG was based on typical histological findings
of biopsies of the antrum and corpus as outlined in the literature [11]. Descriptive statistics were used to analyze the data, with continuous variables
presented as mean ± standard deviation and categorical variables as frequency and
percentages. We reported our findings following the Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement. Prior to endoscopy, patients did not undergo stomach cleaning with any solution. The
procedures utilized a consistent set of endoscopes, specifically, either Fujifilm
EG-760Z or Pentax EG-2990Zi, which were employed by the same endoscopist throughout
the study (RB). The procedures involved conscious sedation, and the mucosa was carefully
observed for relevant features and all cases were photographed for reference. Blue
laser imaging (BLI) (Fujifilm, Japan) or Optical Enhancement Mode 1(OE-1)(Pentax,
Japan) was employed for all patients in this study and areas pertinent to atrophy
were particularly targeted. An Olympus black cap for lesion characterization and zoom
endoscopy (MAJ-1990) was used in all cases. Mucosal characterization was successfully
achieved in all patients included in the study. The endoscope used throughout the
study maintained a medium to high magnification of 80–135× (using a 19-inch monitor).
The biopsy protocol for autoimmune AIG involved obtaining multiple biopsies from the
gastric body and antrum during routine endoscopy. BLI or OE-1 was employed to enhance
the micro surface and microvasculature visualization. Biopsies were taken as per Sydney
Protocol on index endoscopy and only targeted on subsequent endoscopy as indicated.
Three dedicated gastrointestinal pathologists reviewed all biopsy specimens for consistent
diagnosis of AIG based on histological features. KTC was used to describe the extent
of GA, and the dominant magnification pattern of atrophy in the body was also recorded.
In AIG, the whole body of the stomach shows atrophic mucosa and no gland border is
detected, which is called O-p, meaning ‘pan-atrophy’ (or O-4); this was used in our
analysis [12]. Furthermore, presence and type of neoplasia were documented.
The definition and diagnosis of neoplasia in this study were based on endoscopic and
histopathological assessments. Endoscopic findings suggestive of neoplasia, were further
confirmed through histopathological examination of biopsy specimens. Management of
identified neoplastic lesions, including neuroendocrine tumors (NETs), adenomas, and
early gastric cancers, underwent individualized treatment strategies. Specific interventions
varied based on the type, size, and stage of the neoplastic lesion. Common management
approaches included endoscopic resection for early-stage lesions and surgical interventions
or other therapeutic modalities for more advanced cases.
Magnifying patterns of gastric atrophy
Our study defined three main magnifying patterns of gastric body atrophy, which have
been reported: foveolar (also known as “cast-off skin appearance” [3]), oval/slit, and ridge/villous (also known as tubular/ glandular or groove) [6]
[7]
[8]
[9]. In the foveolar type, the micro surface and microvascular appearance is very similar
to the normal gastric body ([Fig. 2]
a), the subepithelial capillary network is visible; however, due to mucosal atrophy,
the various layers of microvasculature are also visible whereas the crypt opening
is less prominent ([Fig. 2]
b). This foveolar type is the typical finding of AIG. The oval/slit type is essentially
a variation of foveolar type in that the gastric crypt opening ([Fig. 2]
c) has an oval or slit-like appearance. In the ridge/villous type ([Fig. 2]
e,
[Fig. 2]
f), the appearance is more similar to that of the antrum ([Fig. 2]
d). In this type, the pit is not clearly visible due to its oblique orientation, whereas
the subepithelial capillary network (SECN) is observed coiled with surrounding marginal
crypt epithelium.
Fig. 2 Magnifying finds in AIG. a Normal micro surface and microvasculature in gastric body showing the traditional
“honeycomb” pattern. b Foveolar pattern. c Oval/slit pattern. d Ridge/villous pattern without intestinal metaplasia. e Ridge/villous pattern with light blue crest sign (intestinal metaplasia). f White globe appearance.
Results
The present study aimed to describe clinical characteristics, laboratory findings,
and endoscopic features of patients with AIG at our center. Between January 1, 2016,
and December 31, 2023, a total of 4,345 individuals were screened and 63 patients
met the criteria for inclusion, resulting in a prevalence rate of 1.449. A total of
63 patients were included in the study, with a mean age of 62.94 years. The majority
of patients were female, constituting 73.02% (n=46) of the population. The most common
indication for endoscopy was iron deficiency, found in 60.32% (n=38) of the patients.
Other indications for diagnosis included foregut symptoms (n=21, 33.33%), screening
for a pre-liver transplant patient (n=1, 1.59%), incidental finding on ERCP (n=1,
1.59%), cirrhosis (n=1, 1.59%), and FOB+ and colon normal (n=1, 1.59%). Of the patients,
25.40% (n=16) were discovered to have positive anti-intrinsic factor (anti-IF) antibodies,
whereas 74.60% (n=47) tested negative for anti-IF antibodies. In contrast, a high
majority of patients, 84.13% (n=53), tested positive for anti-parietal cell (anti-PC)
antibodies, with only 15.87% (n=10) testing negative for anti-PC antibodies.
Approximately half the patients were deficient in vitamin B12 (n=31, 49.21%) and iron
(n=48, 76.19%). In addition, 71.43% (n=45) of the patients were anemic. Concomitant
autoimmune diseases were present in 58.73% of the patients, with hypothyroidism being
the most common (n=24, 38.10%). The remaining autoimmune diseases included non-insulin-dependent
diabetes (n=11, 17.46%), insulin-dependent diabetes mellitus (n=2, 3.17%), rheumatoid
arthritis (n=3, 4.76%), Crohn's disease (n=1, 1.59%), autoimmune polyglandular disease
(n=1, 1.59%), adrenal insufficiency (n=2, 3.17%), celiac disease (n=1, 1.59%), primary
biliary cholangitis (n=1, 1.59%), Sjogren’s disease (n=1, 1.59), and psoriatic arthritis
(n=1, 2.17%).
In our study, we examined gross and magnifying endoscopic features observed in a cohort
of patients. All patients (n=63, 100%) had pan-atrophy and were classified as type
O-P (or O-4) according to the KTC. Notably, the most expected observation, loss of
gastric folds, was evident in all 63 cases (100%), underscoring its consistency and
significance as a hallmark feature of the condition. Additionally, dense mucus was
present in a significant majority of cases, with 76.19% (n=48) displaying this feature.
Notably, marked vascular visibility was also a prominent feature, observed in 41.27%
(n=26) of the cases. White global appearance was identified in 23.81% (n=15) of cases,
indicating a relatively less common occurrence. Xanthomas, on the other hand, were
observed in 26.98% (n=15) of cases, suggesting a moderate prevalence. A nodular remnant
of normal mucosa was only seen in 14.29% (n=9) of cases, representing a rare finding.
The dominant magnification pattern of atrophy in the body was the oval/slit pattern
in 57.14% (n=36) of the patients, followed by the tubular pattern in 30.16% (n=19)
and the foveolar pattern in 12.70% (n=8).
Of the 63 patients, 42.86% (n=27) had neoplasia. Among them, 25.4% (n=16) had neuroendocrine
tumors (NET), 7.94% (n=5) had hyperplastic polyps, 7.94% (n=5) had adenomas, and 9.82%
(n=6) had early gastric cancers, including high-grade dysplasia, intramucosal carcinoma,
and superficial submucosal carcinoma ([Table 1]).
Table 1 Clinical characteristics and endoscopic findings.
|
All data are presented as number and percentage, respectively.
Anti-IF, anti-intrinsic factor antibodies; Anti-PC, anti-parietal cell antibodies;
B12, vitamin B12; ERCP, endoscopic retrograde cholangiopancreatography; FOB+, fecal
occult blood positive; IDDM, insulin-dependent diabetes mellitus; KTC, Kimura-Takemoto
classification; LVI, lymph vascular invasion; NET, neuroendocrine tumor; NIDDM; non-insulin-dependent
diabetes; PsA, psoriatic arthritis; RA, rheumatoid arthritis; SD, standard deviation.
|
|
Patient population
|
|
63
|
100.00
|
|
Age (mean ± sd)
|
|
62.94 ± 10.84
|
|
|
Sex
|
|
Female
|
46
|
73.02
|
|
Male
|
17
|
26.98
|
|
Indication
|
|
Cirrhosis
|
1
|
1.59
|
|
FOB+ and colon normal
|
1
|
1.59
|
|
Foregut symptoms
|
21
|
33.33
|
|
Incidental finding on ERCP
|
1
|
1.59
|
|
Iron deficiency
|
38
|
60.32
|
|
Screening
|
1
|
1.59
|
|
Anti-if
|
|
Positive
|
16
|
25.40
|
|
Negative
|
47
|
74.60
|
|
Anti-pc
|
|
Positive
|
53
|
84.13
|
|
Negative
|
10
|
15.87
|
|
B12 deficient
|
|
31
|
49.21
|
|
Iron deficient
|
|
48
|
76.19
|
|
Anaemic
|
|
45
|
71.43
|
|
Concomitant autoimmune disease
|
|
Autoimmune Polyglandular disease
|
1
|
1.59
|
|
Crohn’s disease
|
1
|
1.59
|
|
Rheumatoid arthritis
|
3
|
4.76
|
|
IDDM
|
2
|
3.17
|
|
NIDDM
|
11
|
17.46
|
|
Hypothyroidism
|
24
|
38.10
|
|
Eczema
|
2
|
3.17
|
|
Psoriatic arthritis
|
1
|
1.59
|
|
Adrenal insufficiency
|
2
|
3.17
|
|
Celiac disease
|
1
|
1.59
|
|
Sjogren’s disease
|
1
|
1.59
|
|
Primary biliary cholangitis
|
1
|
1.59
|
|
None
|
26
|
41.27
|
|
Kimura-Takemoto classification
|
|
O-P
|
63
|
100.00
|
|
Macroscopic endoscopic features
|
|
Loss of gastric folds
|
63
|
100.00
|
|
Dense mucus
|
48
|
76.19
|
|
Marked vascular visibility
|
26
|
41.27
|
|
Xanthomas
|
17
|
26.98
|
|
White global appearance
|
15
|
23.81
|
|
Nodular remnant of Normal mucosa
|
9
|
14.29
|
|
Magnifying pattern of atrophy in body
|
|
Oval/slit
|
36
|
57.14
|
|
Ridge/villous
|
19
|
30.16
|
|
Foveolar
|
8
|
12.70
|
|
Presence of neoplasia
|
|
27
|
42.86
|
|
Type of neoplasia
|
|
NET
|
16
|
25.40
|
|
Hyperplastic polyp
|
5
|
7.94
|
|
Adenoma
|
5
|
7.94
|
|
Early gastric cancer
|
6
|
9.52
|
Discussion
Our study aimed to investigate the clinical and endoscopic characteristics of patients
with AIG in a western center. Our findings are consistent with previous studies that
have reported a female predominance, high prevalence of iron and B12 deficiencies,
and autoimmune diseases in patients with AIG [3]. However, the prevalence of anti-IF antibodies in our study was lower than that
reported in other studies, which may be attributed to the small sample size of our
series. The high prevalence of anti-PC antibodies in our study is in line with previous
reports suggesting that this test has a high sensitivity for AIG diagnosis [13]. Our study also revealed a high prevalence of neoplasia in patients with AIG, with
NET being the most common type. This is consistent with previous studies that have
reported an increased risk of gastric neuroendocrine tumors in patients with AIG [11]
[14].
Our study highlights the importance of considering AIG in the differential diagnosis
of iron and B12 deficiencies particularly with the comorbidities of hypothyroidism
and other autoimmune disorders [3]. Moreover, our findings support the use of anti-PC antibodies as a sensitive and
specific marker for AIG diagnosis [3]. The high prevalence of neoplasia in patients with AIG underscores the need for
regular endoscopic surveillance to detect and resect these lesions at an early stage
[15].
AIG is a systemic disease that requires a comprehensive assessment for diagnosis that
includes a combination of clinical, serological and endoscopic [8]
[16]. Although the diagnosis of AIG in western cultures relies on the presence of anti-IF
and anti-PC antibodies, Japanese guidelines aim to incorporate more endoscopically
viable options to reduce the cost of histopathology [17]
[18]
[19]. In Japan, narrow-band imaging magnifying endoscopic diagnosis of inflammation,
atrophy, and intestinal metaplasia of the gastric mucosa has been reported to be relatively
accurate [4]
[20]
[21].This underscores the recognition of the endoscopic features in AIG diagnosis.
Iron deficiency is a prevalent factor in the assessment of AIG. This condition is
a result of the decreased uptake of inorganic iron due to missing reduction of ferric
iron, missing degradation of iron-protein complexes due to the lack of gastric acid,
and reduced levels of ascorbic acid. Although AIG is associated with iron deficiency,
the development of anaemic indices, whether normocytic or microcytic, varies among
populations of AIG [3]. One study reported that in 160 patients with AIG, only 83 patients presented with
iron deficiency anaemia, indicating that the variability in anaemic indices' development
may be due to multiple factors in the range of disease progression and other factors
[22]
[23].
The significance of diagnosing AIG lies in recognizing that AIG is associated with
gastric cancer, NETs, and other autoimmune diseases, such as thyroid diseases, anaemia,
and neurological symptoms due to impaired absorption of iron and vitamin B12 [4]. Diagnosing AIG involves identifying patients as a high-risk group for the development
of gastric cancer and gastric NETs, detecting autoimmune endocrine diseases, and initiating
therapeutic intervention before anaemia and neurological symptoms develop. In particular,
previous reports from western countries have shown a prevalence of gastric cancer
in AIG ranging from 0.7% to 2.6% [24]
[25]
[26]. In our present study, the prevalence of gastric cancer and gastric adenoma were
quite high: 13.5% and 10.87%, respectively. In our cases, all of them showed O-p in
the KTC showing pan-atrophy, which is a characteristic of end-stage AIG. All our cases
are considered to be end-stage AIG; therefore, this may partially explain the higher
prevalence of gastric cancer. The observed discrepancy between our study, which reports
a gastric cancer comorbidity rate of approximately 10% in H. pylori-negative AIG patients, and the findings of Rugge et al., who suggest that gastric
cancer does not arise from H. pylori-negative AIG, can be attributed to several factors [25]. A significant possibility is the inclusion of unrecognized H. pylori-infected individuals in our cohort, which may inflate the observed cancer rate. Rugge
et al. [25] may have studied a different subset of AIG patients with distinct clinical characteristics
or progression patterns that were not captured in our cohort. In addition, our cohort
included patients referred for assessment of neoplasms, which could account for the
higher prevalence observed.
In our study, we note that awareness of AIG and its association with early gastric
cancer among endoscopist in North America is generally low. This may result in underdiagnosis
and mismanagement of AIG, without appropriate surveillance, thereby increasing risk
of missing early gastric cancers on endoscopy and potentially allowing progression
to advanced gastric cancer. There is a strong association between accurate endoscopic
staging of gastric atrophy and risk of developing gastric adenocarcinoma [2]
[27]
[28]. Notably, interobserver and intraobserver agreement for endoscopic severity assessments,
when performed by experienced endoscopists, is reported to be moderate to excellent
[2]. This suggests that, with proper training and awareness, endoscopic evaluation could
serve as a key tool in identifying patients at higher risk for gastric cancer. However,
given the current low recognition of AIG in North America, potential for misinterpretation
or underassessment of GA severity remains, which could further contribute to missed
opportunities for early cancer detection in this population. Thus, improving endoscopist
awareness and training about the clinical relevance of AIG and its endoscopic features
could enhance risk stratification and facilitate early intervention strategies [2].
Awareness of macroscopic findings in AIG is important for endoscopists if they are
to identify AIG during routine endoscopy [4]
[21]
[29]. We observed noteworthy macroscopic features of AIG, such as corpus-dominant advanced
atrophy accompanied by non- or less-atrophic patterns in the antrum (reverse atrophy),
loss of gastric folds, dense mucous, and marked vascular appearance. Once the endoscopist
suspects atrophy based on macroscopic evaluation, microscopic evaluation becomes pivotal
to confirm or refute suspicion of AIG. In our study, use of high magnification endoscopy
(80–135×) allowed for detailed observation of mucosal and vascular characteristics,
particularly in areas of atrophy. Microscopic findings in AIG include three magnifying
patterns in the gastric body—oval/slit, ridge/villous, and foveolar—which provide
additional evidence for presence of atrophy [4]
[21]. In previous reports, foveolar pattern was said to be the most characteristic feature
in magnified endoscopy in AIG [9]. In the present study, oval/slit pattern was 50% and the prototypical foveolar pattern
was 17.39%. However, because the oval/slit pattern is a variation of the foveolar
type, 67.39% of patients had a foveolar pattern (round-to-oval crypt openings and
marginal crypt epithelium surrounded by subepithelial capillary network), which is
consistent with previous reports [7]
[8]
[9]. In addition, these endoscopic findings correlate with histopathological changes
associated with AIG. The normal “honeycomb” pattern reflects normal oxyntic glands
with little or no atrophy, whereas the foveolar/oval/slit-like pattern indicates non-metaplastic
atrophy of oxyntic glands [7]
[9]. The ridge/villous pattern typically reflects intestinal metaplasia and/or pseudo-pyloric
gland metaplasia in histopathology [7]
[9]. The transition from the foveolar pattern to the oval/slit pattern, and further
to the ridge/villous pattern, correlates with increasing severity of atrophy [7]
[9]. Recognizing and understanding these microscopic features is crucial for endoscopists
to accurately diagnose AIG and identify patients at risk for gastric cancer.
In addition to macroscopic and microscopic findings, our study explored associations
between AIG and certain endoscopic features, such as white globe appearance (WGA)
and xanthomas. WGA appearance has been previously described in association with adenomas
and early gastric cancer and consists of cystically dilated glands containing necrotic
debris. [20]. Xanthomas consist of lipid-filled macrophages in the mucosa and have been described
to in association with H. pylori, gastric cancer, and metabolic dysfunction. The precise pathogenesis of either of
these entities is still unknown. Our study showed a moderate association between AIG
and these endoscopic features, but the exact significance of WGA and xanthomas in
the context of AIG remains unknown.
In our study, patients with evidence of H. pylori on biopsies or positive H. pylori serology were excluded. However, in East Asia, there are numerous cases of AIG combined
with H. pylori-related gastritis due to the high prevalence of H. pylori. There are also reports that H. pylori infection is the cause of AIG [9]
[30]
[31]. In a clinical setting, diagnosis of AIG should be made keeping in mind that AIG
could be combined with H. pylori infection.
Recently, the “Study Group on the Establishment of Diagnostic Criteria for Type A
Gastritis” of the Japan Gastroenterological Endoscopy Society has proposed new diagnostic
criteria for autoimmune gastritis. Based on the diagnostic criteria, diagnosis of
AIG can be made based on characteristic endoscopic findings and/or characteristic
histological findings, accompanied by positive anti-parietal cell antibodies or anti-intrinsic
factor antibodies [10]. The primary characteristic endoscopic finding is severe atrophy predominantly in
the body and fundus of the stomach. Secondary findings include dense adherent mucus,
remnant of oxyntic mucosa, and hyperplastic polyps. These findings from Japanese cohorts
are consistent with the findings that we observed in our western cohort. These new
Japanese diagnostic criteria highlight the importance of endoscopic diagnosis of AIG,
which is indeed also important in the western setting.
In western countries where incidence of gastric cancer is comparatively lower than
in Asia, positioning and recognition of AIG as a risk factor for gastric cancer have
been evolving [32]. Despite the lower overall incidence of gastric cancer in these regions, recent
studies have indicated that AIG may still confer a notable risk. Although AIG-associated
gastric cancer remains relatively less recognized compared with other risk factors
such as H. pylori infection or dietary factors, growing evidence suggests its significance, particularly
in specific populations with predisposing factors such as autoimmune diseases or genetic
susceptibilities [33]. Given the complexity of AIG diagnosis and its association with other autoimmune
conditions, its role as a risk factor for gastric cancer in western contexts requires
further elucidation and heightened clinical awareness to facilitate early detection
and intervention strategies, especially among susceptible subgroups.
Our study has several limitations. First, it was a retrospective cohort with a small
sample size and limited generalizability to other populations. Second, endoscopy was
conducted in a single center by a single operator with a very specialized practice,
which may limit the external validity of our findings. Third, we did not assess long-term
outcomes of patients with AIG, particularly regarding neoplasia development, progression,
and miss rate. Future research should aim to confirm our findings in larger multicenter
North American studies. Long-term follow-up is also necessary to investigate the natural
history of AIG, risk of neoplasia development, and significance of associated findings
such as WGA and xanthomas.
Conclusions
This study demonstrates the distinct macroscopic and microscopic endoscopic findings
that are vital in identification and diagnosis of AIG. Finally, one limitation of
the study is that presence of xanthoma, closely related to H. pylori infection according to KTC, was observed in 25% of cases, potentially indicating
unrecognized H. pylori infection, which could influence the high complication rate of gastric cancer.
In addition, it highlights the high prevalence of neoplasia in this western cohort
with AIG, emphasizing the importance of optical diagnosis and implementation of endoscopic
surveillance for AIG.
Bibliographical Record
Kareem Khalaf, Yusuke Fujiyoshi, Robert Bechara. Endoscopic and clinical characteristics
of autoimmune atrophic gastritis: Retrospective study. Endosc Int Open 2025; 13: a24774666.
DOI: 10.1055/a-2477-4666
