Original article / research
Year : 2023 Month : April Volume : 12 Issue : 2 Page : PO50 - PO53 Full Version

Spectrum of Histopathological Lesions in Patients undergoing Gastroduodenal Biopsies in a Tertiary Care Centre in North Karnataka, India
Madhuri Rao, C Bharath
1. Assistant Professor, Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Center, Bangalore, Karnataka, India. 2. Professor, Department of Pathology, Vijaynagar Institute of Medical Sciences, Bellary, Karnataka, India.
 
Correspondence Address :
Madhuri Rao, C Bharath,
Madhuri Rao,
No. 1586, 17th A Main 1st Stage, 5th Block, HBR Layout,
Bangalore-560043, Karnataka, India.
E-mail: dr.madhurirao@gmail.com
 
ABSTRACT
: Introduction: Patients with Gastrointestinal (GI) symptoms usually present with alarming symptoms. The use of modern flexible gastroduodenoscope and the acquisition of the mucosal biopsy specimens have opened a window to the living tissues and have greatly improved the diagnostic facility for the GI lesions. It provides an in depth visual assessment of GI mucosa and allows sampling of tissue to the pathologist for further assessment.

Aim: The aim of this study was to evaluate the spectrum of histopathological incidence of neoplastic and non-neoplastic lesions in patients undergoing gastroduodenal biopsy.

Materials and Methods: This was a prospective study of 100 patients conducted over a period of one year and seven months, December 2010 to June 2012 with symptoms of gastroduodenal diseases who attended endoscopic unit of the tertiary care hospital in Bellary North Karnataka, South India. All biopsies done for various upper abdominal symptoms like pain abdomen, dyspepsia, haematemesis, mass per abdomen, and vomiting were included. Routine haematoxylin and eosin, special stains like Periodic Acid-Schiff (PAS) and Giemsa were done. Histopathological parameters evaluated included mucosa evaluation (ulceration, metaplasia, dysplasia, atrophy), type of inflammatory infiltrate, H.pylori infection and type of tumour. Data was analysed using descriptive analysis.

Results: Among 100 patients, 76 were males and 24 were females. Highest percentage of study participants were 30 (30%) in the age group of more than 58 years. The most common endoscopic presentation was gastric erythema in 42 (42%) cases followed by benign gastric ulcer 16 (16%) cases, ulcero proliferative growth 15 cases, and duodenal erythema 13 (13%) cases. The most common histopathological diagnosis amongst non-neoplastic lesions were chronic gastritis 44 (44%) cases, chronic duodenitis 15 cases, and benign gastric ulcer 11 (11%) cases and amongst neoplastic lesions, most common was gastric adenocarcinoma 15 (15%) cases.

Conclusion: Endoscopy gross findings are not disease specific hence, histopathological study of biopsy specimen can help in confirmation of the diagnosis.
Keywords : Gastric adenocarcinoma, Gastroduodenoscope, Gastric erythema, Neoplasia
DOI and Others : DOI: 10.7860/NJLM/2023/58998.2725 Date of Submission: Sep 15, 2022 Date of Peer Review: Nov 17, 2022 Date of Acceptance: Mar 07, 2023 Date of Publishing: Apr 01, 2023 AUTHOR DECLARATION: • Financial or Other Competing Interests: None • Was Ethics Committee Approval obtained for this study? Yes • Was informed consent obtained from the subjects involved in the study? Yes • For any images presented appropriate consent has been obtained from the subjects. Yes PLAGIARISM CHECKING METHODS: • Plagiarism X-checker: Sep 26, 2022 • Manual Googling: Nov 11, 2022 • iThenticate Software: Feb 04, 2023 (21%) ETYMOLOGY: Author Origin
 
INTRODUCTION
The use of modern flexible gastroduodenoscope and the acquisition of the mucosal biopsy specimens have opened a window to the living tissues and have greatly improved the diagnostic facility for the GI lesions. It provides an in depth visual assessment of GI mucosa and allows sampling of tissue to the pathologist for further assessment (1),(2).

Endoscopic biopsies are helpful in disease diagnosis, disease process monitoring, early assessment of complications as well as early assessment of treatment response. In the adult population, gastroduodenal diseases are commonest with stomach and duodenum disorders being a cause for frequent clinical visit. Clinical symptoms vary from dysphagia to dyspepsia to altered bowel movements, which pathologically could vary between the common non-neoplastic and neoplastic lesions. Dyspeptic symptoms, secondary to Helicobacter pylori (H. pylori) infection can lead to debilitating consequences, particularly increasing the risk of adenocarcinoma (3),(4),(5),(6).

Clinically and endoscopically, disease state can be identified, however, biopsy is necessary for confirmation, to provide an exact diagnosis for further management. Endoscopic biopsy, apart from being diagnostic, also plays a major role in monitoring the course, extent and the response to therapy (1),(2),(5),(6).

The aim of this study was to evaluate the demographical spectrum of incidence of histopathological lesions both neoplastic and non-neoplastic undergoing gastroduodenal biopsy. The primary objective of the study was to study the overall frequency, age and sex distribution of various lesions. The secondary objective included studying spectrum of histopathological lesions, both non-neoplastic and neoplastic in patients undergoing gastroduodenal biopsy.
 
 
Material and Methods
This was a prospective cross-sectional study of 100 patients with symptoms of gastroduodenal diseases who attended endoscopic unit of a tertiary care hospital in Bellary, Karnataka, South India for a period of one year and six months December 2010 to June 2012. Permission for the Ethical committee clearance was not obtained as it did not invlove any interaction with human subjects.

Inclusion and Exclusion criteria: All biopsies done for various upper abdominal symptoms with or without systemic symptoms such as pain abdomen, dyspepsia, haematemesis, mass per abdomen, and vomiting were included in the study. Endoscopy done for therapeutic purposes or cases, where biopsies could not be done was excluded from the study.

Study Procedure

In this study, all the 100 patients during the study period with various gastroduodenal symptoms were subjected to upper GI endoscopoc examination and biposy. Out of 100 gastroduodenal biopsies, 81 were gastric biopsies and 19 were duodenal biopsies. Olympus G/F-Q Panendoscope was used for the present study. Once the biopsy was collected, the biopsy tissue was placed on the filter paper and was transferred into the bottle containing 10% neutral formalin. After fixation of the biopsy specimen, it was wrapped in a piece of filter paper and processed in a perforated capsule. Routine haematoxylin and eosin, special stains like PAS, Giemsa were done, and histological diagnosis made. Histopathological parameters evaluated included mucosa evaluation (ulceration, metaplasia, dysplasia, atrophy), type of inflammatory infiltrate, H.pylori infection and type of tumour.

Statistical Analysis

Data was analysed using descriptive analysis.
 
 
Results
Among total study participants, 76 (76%) were males and 24 (24%) were females. Highest percentage of study participants were 30 (30%) in the age group of more than 58 years, 30% (Table/Fig 1). Majority of patients presented with pain abdomen 71 (71%) followed by dyspepsia (34%). Among the commonest site involved in gastroduodenal diseases, the commonest one was pylorus, 37 (37%) (Table/Fig 2). A 60 (60%) of them were smokers and 62% of them were alcoholics. The most common endoscopic presentation was gastric erythema 42 (42%) followed by benign gastric ulcer 16 (16%), ulcero-proliferative growth 15 (15%), duodenal erythema 13 (13%), erosions, malignant gastric ulcer, erosions and infiltrative growth 3 (3%) each, GJ stomal ulcer and antral polyp 1 (1%) each.

The most common histopathological diagnosis amongst non-neoplastic lesions was chronic gastritis 44 (44%) followed by benign gastric ulcer 11 (11%) (Table/Fig 3),(Table/Fig 4),(Table/Fig 5). Amongst neoplastic lesions, it was gastric adenocarcinoma 15 (15%) (Table/Fig 6). Location wise, the most common lesion were in pylorus, body and antrum in the stomach (Table/Fig 7). In the duodenum, the most common lesion amongst non-neoplastic lesions was chronic duodenitis 14 (14%), followed by duodenal ulcer 2 (2%) and amongst neoplastic lesions, it was adenocarcinoma 1 (1%).

The most common site for chronic gastritis was pylorus (47.7%) followed by body (29.5%), antrum and cardiac (Table/Fig 7). The incidence of chronic gastritis and gastric carcinoma were found to be more common in men (67% and 73%, respectively). Out of 44 cases of chronic gastritis, H.pylori positive cases prevalence was 15 (34.09%) cases (Table/Fig 8). Highest percentage of cases having gastric adenocarcinoma was noted in the 6th decade. The most common type of gastric adenocarcinoma was intestinal type (80%) followed by diffuse type (20%).
 
 
Discussion
Sampling of the gastrointestinal mucosa through endoscopic biopsy helps in diagnosis of various lesions at an early stage. Gastro-intestinal biopsy is usually indicated in diagnosis with gastritis with H.pylori status, duodenitis or to differentiate between benign and malignant tumours. Histopathological study helps in confirmation of a benign/inflammatory or malignant condition, allowing for an early management without unnecessary delay. Endoscopy is known to be less discomforting, and well tolerated, with a direct visual of lesion (2),(4),(7).

In the present study, the number of males undergoing upper GI endoscopy was more than the number of females. Similar findings were found in the previous studies as shown in (Table/Fig 9) (8),(9),(10),(11),(12),(13),(14),(15). In all these studies, males outnumbered females, possibly due to increased prevalence of smoking, stressful life, and alcoholism. In our study, the primary habitual factors in patients of gastroduodenal symptoms undergoing endoscopy were smoking and alcoholism, similar to study done by Hirota WK (16).

Majority patients in the present study were more than 58 years of age, similar to the study done by Froehlich F et al., (15). Next highest age group prevalence was noted in fourth decade similar to study done by Modi D et al., and Froehlich F et al., which showed similar findings. Also, similarly, both studies showed least number of cases in the third decade, similar to our study (5),(15).

The most common histological pattern noted in gastric biopsies was chronic gastritis followed by gastric adenocarcinoma, which is similar to other studies as shown followed by gastric adenocarcinoma (Table/Fig 10) (5),(6),(8),(9),(10),(11),(12),(17). In the duodenum, Hirachand S et al., did not find any malignancy, while we reported two cases in our study (9).

The incidence of H.pylori in chronic gastritis was noted in 34.09% cases, which is less than that noticed in other studies (Table/Fig 11) (12),(17),(18),(19),(20). Gastric carcinomas were more common in males than females (2.8:1) in the present study and this correlates with the study done by David A with male:female ratio of 2.5:1 (14). Studies by Thapa R et al., and Hirachand S et al., have also noted higher incidence of adenocarcinoma variant of gastric cancer (90-95%), which is similar to our study that adenocarcinoma account for 90- 95% of gastric cancer (6),(9).

Limitation(s)

The main limitation of the study was the small sample size. Additional Immunohistochemical (IHC) and molecular studies, could have added more to the existing literature.
 
 
Conclusion
Endoscopic biopsy helps in early diagnosis and management. Endoscopy biopsy is particularly indicated in patients with gastroduodenal symptoms beyond the fourth decade to evaluate neoplastic lesions. It was therefore concluded that the gross findings on endoscopy are not disease specific and may be seen in various other upper GI pathologies. Histopathological study of biopsy specimen will confirm endoscopic diagnosis in most of the cases.
 
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