| Abstract|| |
Aim of Study: Chronic gastritis is defined as the presence of chronic mucosal inflammatory changes leading eventually to mucosal atrophy and epithelial metaplasia. This condition constitutes a background for dysplasia and thereby carcinoma. Detection of exact histopathology of inflammatory process is necessary in biopsy specimen. We designed the current study to determine the value of taking more sections in small gastric biopsies for better histopathologic evaluation. Materials and Methods: Gastric biopsy specimen of children who suffered from gastrointestinal (GI) symptoms was sent in 10% formalin to our laboratory. After routine processing, three slides with several sections on them were taken from the specimen: t0 he first was named the superficial section, the second was stained by Giemsa and the third was named deep section (further sections after this slide will diminish in size). The slides were not taken exactly consecutively but several sections were discarded between them. The purpose of this study is to compare the superficial and deep sections for detection of inflammatory processes. Results: In 1062 specimens the results of superficial section and deep section were the same (87.1%) and in 158 specimens the results were different. In 88 (7.2%) specimens deep section was diagnostic. The difference was seen usually as normal tissue in superficial sections but presence of lymphoid follicle in deep sections. The difference between superficial and deep sections was statistically significant. Although obtaining more sections will put an economic burden on the laboratory, we propose that in small gastric biopsies, it is helpful in better evaluation of histopathological changes.
Keywords: Deep section, follicular gastritis, gastric biopsies
|How to cite this article:|
Mahjoub F, Khademalhosseini M, Monajemzadeh M, Sani MN. Significance of deep section in small gastric biopsies. Indian J Pathol Microbiol 2009;52:310-2
|How to cite this URL:|
Mahjoub F, Khademalhosseini M, Monajemzadeh M, Sani MN. Significance of deep section in small gastric biopsies. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Dec 12];52:310-2. Available from: http://www.ijpmonline.org/text.asp?2009/52/3/310/54982
The roots of gastritis research stretch far back into the 19 th century and into early decades of the 20 th century. Modern aspects in the classification of gastritis and knowledge of the biologic course of chronic gastric inflammation and of the links of chronic gastritis with many important gastric disorders were well known even at the time of discovery of Helicobacter pylori ( H. pylori)in 1982. Chronic gastritis became a curable disease with known etiology and well-established links to main gastric diseases including gastric cancer. 
The available classifications of gastritis are inconsistently used, possibly because none provides immediate prognostic/therapeutic information to clinicians. Gastritis staging, combined with H. pylori status, provided clinically relevant information on the overall status of the gastric mucosa with implications for prognosis, therapy and management. 
Gastritis has a broad histopathological and topographical spectrum and leads to patterns of disease that have been well recognized and characterized.
In an attempt to remove the diagnostic confusion, a working party met before the world congress of gastroenterology in Sydney in 1990 to establish guidelines for the classification and grading of gastritis. The resulting Sydney System had both endoscopic and histological division. The histological arm emphasized the importance of combining topographical, morphological, and etiological information into a schema that would help generate reproducible and clinically useful diagnosis. ,
Chronic gastritis is separated into two major categories based on the presence or absence and topographic distribution of atrophy. In addition, several well-characterized special forms are also enumerated. Follicular gastritis is a chronic gastritis in which there are large numbers of prominent lymphoid follicles in addition to the mononuclear infiltrate. Because H. pylori infection is also regularly present, it is considered the underlying cause of follicular gastritis. Lymphoid aggregate with germinal centers are characteristic of chronic H. pylori gastritis and a hallmark of this diagnosis. There is sampling error in determining their prevalence but if sufficient biopsy specimens are examined, they are found in 100% of H. pylori -positive cases. , Grading a feature whose prevalence is determined by the number of biopsy specimens taken is not indicated; however, the presence of follicle should be noted in the microscopic description. Lymphoid follicles in H. pylori -negative cases suggest that the organisms have been missed (either overlooked or not present because of sampling errors) or that the infection has been cleared.  If large or irregularly shaped lymphoid follicles are noted or large portions of the mucosa are occupied by a dense population of lymphocytes, the possibility of a mucosa-associated lymphoid tissue (MALT) lymphoma should be considered. ,
Our experience shows that sometimes superficial sections of the specimen do not show true and complete pathological features and deep sections of specimen can change our diagnosis. The level of the section that we prepare from the specimens may influence the diagnosis. In this study we wanted to assess the significance of deep section in gastric biopsies which to our knowledge has not been studied as yet.
| Materials and Methods|| |
We studied all the children who were referred with different gastrointestinal complaints to our center (children's tertiary care hospital) and underwent endoscopy and gastric biopsy during the period of three years from 2003 to 2007.
Gastric biopsy specimens were sent in buffered 10% formalin to our laboratory. After routine processing, three slides with several sections on them were taken from the specimen: t0 he first was named the superficial section, the second was stained by Giemsa and the third was named deep section (further sections after this slide will diminish in size).
The slides were not taken exactly consecutively but several sections were discarded between them.
All the specimens were evaluated by one pathologist. The other purposes of this research are to evaluate the incidence of gastrointestinal symptoms, endoscopic features and presence of H. pylori. We analyzed the data with SPSS (Version 14.0) and used chi square and kappa. P -value less than 0.05 was taken as significant.
| Results|| |
We studied 1220 patients who had gastrointestinal complaints and underwent endoscopy. The most common symptoms were abdominal pain (in 761, 62.3% patients). In 238 (19.5%) the prominent symptom was vomiting. The other symptoms were gastrointestinal bleeding in 97 (7.9%), failure to thrive in 55 (4.5%), diarrhea in 32 (2.6%), constipation in 11 (0.9%), dysphasia in 10 (81%), gastroesophageal reflux disease in 10 (0.81%) and sense of fullness in six (0.49%).
Endoscopic features of the patients were as follows: 324 patients had gastric erythema (26.5%), 173 patients had nodularity (14.1%), 43 had gastritis (3.5%) as reported by the endoscopists, 27 patients had erosion (2.2%), six patients had mucosal pallor (0.5%), 48 patients had erythema and nodularity (3.9%), nine patients had erythema and erosion (0.7%), five cases ulcer (0.4%), two cases mass and polyp (0.16%) and 583 patients had normal endoscopy (48.3%).
Histopathological findings were as follows: 419 patients had normal biopsy (34.3%), 298 patients had mild chronic gastritis (24.1%), 72 cases moderate chronic gastritis (5.8%), 12 cases severe chronic gastritis (0.9%), 281 cases follicular gastritis (22.7%), 51 cases small lymphoid aggregates (4.2%), 39 cases increase in mast cells (3.2%), 27 cases focally enhanced gastritis (2.1%), eight cases mucosal atrophy, six cases fibrosis, four cases granulation tissue and three cases had superficial gastritis (1.7%). Two hundred and fifty (20.5%) cases had H. pylori infection. The most common histopathological finding in patients who had H. pylori infection was follicular gastritis in 160 (64%), and moderate chronic gastritis in 40 (16%), severe chronic gastritis in seven (2.8%), mild chronic gastritis in 26 (10.4%) and focally enhanced gastritis in seven (2.8%). Ten cases had normal gastric histology. The most common histopathologic finding in patients without H. pylori infection was normal histology in 409 (42.1%), and mild chronic gastritis in 272 (28%), follicular gastritis in 121 (12.4%), increase in mast cells in 39 (4%) and other nonspecific changes in 129 (13.2%) patients.
This difference between histological findings in patients with H. pylori infection and those without the infection, was statistically significant ( P < 0.001). In 1062 specimens the results of superficial section and deep section were the same (87.1%) and in 158 specimens the results were different. In 88 (7.2%) specimens deep section was diagnostic
The difference was usually as normal tissue in superficial sections but presence of lymphoid follicles in deep sections [Figure 1] and[Figure 2]; however, in some cases, pathologic finding was seen only in superficial section. The difference between superficial and deep sections was statistically significant (kappa = -0.068, P = 0.016).
| Discussion|| |
Gastritis has a broad histopathological and topographical spectrum and leads to patterns of disease that have been well-recognized and characterized. 
Biopsy is the gold standard for the diagnosis of gastritis. Obtaining good sections of the specimen is important for diagnosis of gastritis. The purpose of this research is to compare the superficial and deep sections for assessing the inflammatory processes in gastric biopsies.
According to the studies on patients who had gastritis the most common symptoms were abdominal pain and vomiting.  In this study, the most common symptoms were abdominal pain and vomiting.
Histopathological study revealed normal histology in 34.3%, mild chronic gastritis in 24.1%, moderate chronic gastritis in 5.8%, severe chronic gastritis in 0.9%, follicular gastritis in 22.7% and other pathologies in 138 cases. The prevalence of normal histology and mild chronic gastritis is rather high in our hospital, as it is a referral and educational center for pediatric gastrointestinal diseases. The third most common histopathologic finding in gastric biopsies was follicular gastritis which is defined as a separate entity in the Sydney System and denotes presence of lymphoid follicles in gastric biopsies which has strong association with H. pylori infection. 
In different studies and according to factors such as age and socioeconomic situation, different prevalence of H. pylori infection was reported. Lamireau et al. studied 130 children who had gastrointestinal symptoms and only 30 patients had H. pylori infection. 
In this study the prevalence was 20% and is similar to the Lamireau study. In patients who have H. pylori infection, the most common pathological finding was follicular gastritis and in patients without H. pylori infection, the most common feature was normal histology.
In a pilot study (not published), we found that in some biopsies the first section was rather normal and after preparing a recut, a lymphoid follicle appeared which resulted in change of previous histopathologic diagnosis, so we decided to assess the significance of deep section in gastric biopsies which has not been studied as yet.
This research shows that in 7.2% of specimens, superficial sections cannot diagnose the correct pathology and this percentage is statistically significant ( P < 0.05), so we recommend to obtain deep sections routinely for gastric biopsies in order to have better histopathological diagnosis.
Although gastric malignancies are rare in children, deep sections can help in better diagnosis and classification of inflammatory processes in gastric biopsies of this age group.
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Markaze Tebbi Koodakan (Children Hospital), Tehran University of Medical Sciences.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]