Clinicopathological Study of Gastroduodenal Biopsies and to Correlate with Endoscopic Findings in North East India- A 1 Year Cross-sectional Study in a Tertiary Care Centre

Abstract

Background: The gastrointestinal tract (GIT) is a hollow muscular tube which starts from the oral cavity continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus. The most frequently encountered disorder of this region is the Acid peptic disease which is a very common health problem all over the world. The pathogenesis of these disorders involves an imbalance between acid secretion and gastric mucosal defenses. Patients with these disorders are usually investigated by endoscopy. The ability to assess endoscopically the gastrointestinal tract has enabled increased accuracy and earlier histologic diagnosis of mucosal lesions. This is a cross-sectional study done in 100 cases of gastroduodenal biopsies in a 1 year period.

Aims and Objectives: To categorise the histopathological findings of gastro-duodenal biopsies collected by endoscopy and to study the association of gastro-duodenal pathology with the result of endoscopic findings.

Result: The prevalence of gastroduodenal lesion is more common among males around the fifth decade of life. There were 12 cases of normal endoscopic findings, 31 cases of ulcer, 15 cases of erosion, 4 cases of polyp and 38 cases of malignancy respectively. Out of the 38 cases of growth on endoscopy, 10 cases were diagnosed as premalignant, 23 cases were diagnosed as Carcinoma Stomach and 4 cases were diagnosed as Carcinoma Duodenum. Thus, it showed a good correlation between endoscopic and histopathologic findings.

Conclusion: Endoscopic gastroduodenal biopsies helps in detecting benign as well as malignant lesions. A variety of non-neoplastic and neoplastic lesions were reported in the present study across a wide range of age and site distribution. The combination of endoscopy and histopathological study of gastroduodenal biopsy provide a powerful diagnostic tool for better management of patients.

Introduction

Gastrointestinal problems are very common nowadays and most people are likely to experience gastrointestinal symptoms throughout their lives [1]. The most frequently encountered disorder of this region is the Acid peptic disease [2]. Gastrointestinal endoscopy is considered accurate for the diagnosis of acid peptic diseases. It allows the physician to visualize and biopsy the upper gastrointestinal tract including the esophagus, stomach and duodenum [3]. The diseased organs could be identified by the gastro pathologist only after the organ was removed from the body of the patient before the invention of endoscope. In 1960s, the introduction of fibre-optic endoscopes has greatly improved the diagnostic facility for various gastrointestinal lesions. Therefore, nowadays endoscopy of the upper gastrointestinal tract is considered a routine procedure and it has also superseded the barium meal study as the primary diagnostic option. Also using the biopsy forceps, tissue specimen can be removed from various lesions under direct vision. Apart from diagnostic utility, endoscopic biopsies are also used to monitor the course of the disease, extent of the disease, to detect complications and to assess the response to therapy. Hence, these are considered one of the useful methods for investigation of gastrointestinal lesions [4].

Aim of the Study

The study aims to see the correlation of histopathological findings of gastroduodenal biopsy with the endoscopic findings.

Materials and Methods

This is a hospital based cross sectional study which has been carried out in the Department of Pathology in collaboration with the department of Gastroenterology for a period of 1 year from July 2020 to June 2021. A total of 100 patients with chronic upper abdominal symptoms are selected for the study. The tissue is processed, sections are made of 3 micrometre thickness and then stained with Haematoxylin and Eosin stain.

Exclusion Criteria

Biopsy done for therapeutic purpose, cases where biopsy cannot be done, or where consent not given and autolysed specimen were excluded.

Ethical Issue

The study has been ethically approved by the Institutional ethical committee (letter no- 190/2007/ dt-11/dec-2019/61). The patients were explained about the research project and written consent was taken from patients or guardians in case of minors.

Results

A total number of 100 patients who underwent gastroduodenal biopsies and fulfilled the inclusion criteria as per stated were enrolled during the study. The age of the patients varied from 25 to 84 years with peak incidence in the 5^th decade. 59 cases were from gastric region and rest 41 cases were from the duodenum.

31 cases were diagnosed as ulcer on endoscopy, 15 cases as erosion, 4 cases as polyp and 38 cases as growth. 12 cases were found to have normal endoscopic finding (Table 1).

Table 1. Distribution of the Cases According to Endoscopic Finding.

Category	No of cases (N=100)	Percentage (N=100) (%)
Normal	12	12
Ulcer	31	31
Erosion	15	15
Polyp	4	4
Growth	38	38

Maximum number of dyspeptic patients presented as ulcer on endoscopy. Maximum number of pain abdomen patients presented as growth on endoscopy. Thus when we have correlated the finding of endoscopy with clinical presentation, the association is found to be statistically significant (χ2 value 114.6, p value is <0.0001) (Table 2).

Table 2. Distribution of Cases Correlating Clinical Presentation with Endoscopic Findings.

Presenting complaints			Endoscopic findings
	Normal	Ulcer	Erosion	Polyp	Growth
Pain abdomen (n=48)	1	7	5	3	32
Dyspepsia (n=32)	7	13	6	2	4
Vomitting (n=25)	0	6	4	3	12
Nausea (n=25)	3	11	4	2	5
Loss of weight (n=27)	0	0	2	0	25
Loss of appetite (n=33)	3	1	5	1	23
Epigastric pain (n=11)	2	7	2	0	0
Heart burn (n=10)	1	8	1	0	0
Belching (n=7)	0	2	0	0	5
Hematemesis (n=7)	0	3	1	0	3
Jaundice (n=2)	0	0	0	0	2

χ² value 114.6, p value <0.0001

The age group 41-50 years had the highest number of cases of ulcer. The age group 31-40 years had the highest number of cases of erosion. The age group 51-60 years had the highest number of malignant cases.

Out of the 31 cases of ulcer, 16 cases were diagnosed as Gastritis and 15 cases were diagnosed as Duodenitis on histopathological examination. Out of the 15 cases of erosion, 8 cases were diagnosed as Gastritis, 3 cases were diagnosed as Duodenitis and 1 case as premalignant on histopathological examination. Out of the 4 cases of polyp, 3 cases were diagnosed as polyp and 1 case as Duodenitis on histopathological examination. Out of the 38 cases of growth, 10 cases were diagnosed as premalignant, 23 cases were diagnosed as Carcinoma Stomach and 4 cases were diagnosed as Carcinoma Duodenum (Table 3) (Figures 1-4).

Table 3. Distribution of Cases with Respect to Endoscopic Findings and Histopathological Findings.

Endoscopic findings					Histopathological findings (N=100)
N= 100	Normal	Gastritis	Duodenitis	Polyp	Celiac Disease	Metaplasia	Dysplasia	Carinomna Stomach	Carcinoma Duodenum
Normal	6	1	2	0	3	0	0	0	0
Ulcer	0	16	15	0	0	0	0	0	0
Erosion	0	8	3	0	3	1	0	0	0
Polyp	0	0	1	3	0	0	0	0	0
Growth	0	1	0	0	0	1	9	23	4
Total (n=100)	6	26	21	3	6	2	9	23	4

χ² value 235.7, p value is <0.0001

Figure 1. Well Differentiated Adenocarcinoma of Stomach .

Figure 2. Moderately Differentiated Adenocarcinoma of Stomach .

Figure 3. Diffuse Adenocarcinoma with Signet Ring Cells of Stomach .

Figure 4. Periampullary Adenocarcinoma of Duodenum .

Out of the 12 normal endoscopic cases, 2 cases were diagnosed as Duodenitis, 1 case as Gastritis on histopathological examination.

When we correlate endoscopic findings with histopathological findings, the association was found to be statistically significant (χ2 value 235.7, p value is <0.0001).

The sensitivity, specificity and positive predictive value of endoscopy and histopathological correlation are 100%, 94.5% and 87.1% respectively. The accuracy is 96%.

Maximum cases (87%) of gastric carcinoma presented as ulcerative growth on endoscopy followed by polypoidal growth (4.3%) and diffuse growth (8.7%) (Table 4).

Table 4. Distribution of the Cases According to Endoscopic Appearance of Gastric Carcinoma in Our Study.

Endoscopic Appearance	Total cases (N=23)	Percentage (n=100)
Ulcerative	20	87
Polypoid	1	4.30
Diffuse	2	8.70
Nodular	0	0
Total	23

Discussion

The upper GI endoscopy is the diagnostic tool of choice to detect gastroduodenal diseases. Endoscopic examination should always be accompanied by biopsy.Current data suggest that gross visualization alone cannot detect gastric mucosal diseases, only histologic examination can provide accurate diagnosis.In the present study, out of the 100 gastroduodenal biopsies, 59 cases were from gastric region and rest 41 cases were from the duodenum. The present study is consistent with the studies made by Shanmugasamy K et al [5], Vijayabasker Mithun KR et al [6], S. Hirachand et al [7], Deepa Rani et al [8] and Veenaa Venkatesh et al [9] which shows that gastric biopsies are more common compared to duodenal biopsies.

In the present study, the number of male patients were 65 and female patients were 35. Male (M): female (F) ratio is 1.85: 1. The present study is consistent with the studies made by Dr Vishwapriya M. Godkhindi et al [10], Poonam Sharma et al [11] and S. Hirachand et al [7] which shows male preponderance in gastroduodenal lesions.

In the present study, the highest number of cases were in the age group of 41-50 years followed by 51-60 years. The present study is consistent with the studies made by Shanmugasamy K et al [5], Manasa P Kumari et al [12], Vijayabasker Mithun KR et al [6] and Kaur Manpreet et al [13] which show that gastrosuodenal lesions are more common in the 5^th and 6^th decade of life.

In the present study, the most common clinical complaint was pain abdomen followed by dyspepsia. The present study is consistent with the studies done by Dr Vishwapriya M. Godkhindi et al [10], Rosy Khandelia et al [14] and Sharma S et al [15] which show that pain abdomen is the most common presenting symptom but not consistent with Sonam Pruthi S et al [16] and Shanmugasamy K et al [5] which show dyspepsia as the most common presenting symptom. This disparity may be due to food habits, geographic variations or social habits. In the present study, the most common endoscopic findings was ulcer followed by erosion. The present study was not consistent with the studies made by Sonam Pruthi S et al [16], Manasa P Kumari et al [12] and Kaur Manpreet et al [13] which showed that the most common endoscopic finding was erosion. This disparity may be due to geographical or topographical variation, food habits or socioeconomic factors.

In the present study, out of the 31 cases of ulcer on endoscopy, 16 cases were diagnosed as Gastritis and 15 cases were diagnosed as Duodenitis on histopathological examination. Out of the 15 cases of erosion on endoscopy, 8 cases were diagnosed as Gastritis, 3 cases were diagnosed as Duodenitis and 1 case as premalignant on histopathological examination. Out of the 4 cases of polyp on endoscopy 3 cases were diagnosed as polyp and 1 case as Duodenitis. Out of the 38 cases of growth on endoscopy, 10 cases (26.3%) were diagnosed as premalignant, 23 cases (60.5%) were diagnosed as Carcinoma Stomach and 4 cases (10.5%) were diagnosed as Carcinoma Duodenum. Thus we found a positive correlation between endoscopic and histopathological findings. The present study is consistent with Grace H elta et al [17], Pailoor K et al [18] and Sharma S et al [15] but not consistent with Sharma S et al [19] and Poudel A et al [20]. This disparacy may also be because of geographic and topographical variations, food habits or personal habits.

In the present study, gastric malignancy endoscopically presented most commonly as ulcerative growth followed by polypoidal growth. The present study is consistent with the studies made by Pailoor K et al [18], Kirana Pailoor et al [21], Sharma S et al [19] and Anunayi Jeshtadi et al [22] which show that the most common endoscopic appearance of gastric carcinoma is ulcerative growth.

Strength of the Study

Premalignant lesions are found among study population which show that early detection with the help of endoscopy and biopsy will help in prompt intervention and better management of the patient.

Weakness of the Study

The limitation of the present study is the sample size which is very less and done for a very short duration. The study is a hospital based study due to which follow up of the cases were not possible.

In conclusion, Endoscopy is a less invasive non-surgical procedure. Endoscopic gastroduodenal biopsies help in detecting benign as well as malignant lesions. Endoscopic examination is recommended as the first line of investigation in the work up of a patient with chronic upper abdominal symptoms. Our study showed better correlation with endoscopic findings in cases of malignant lesions but poor correlation in benign lesions with those of histopathological diagnoses. Endoscopic examination alone might miss out in diagnosing majority of the lesions. The combination of endoscopy and histopathological study of gastroduodenal biopsy provide a powerful diagnostic tool for better management of patients.

Acknowledgments

Statement of Transparency and Principals:

· Author declares no conflict of interest

· Study was approved by Research Ethic Committee of author affiliated Institute.

· Study’s data is available upon a reasonable request.

· All authors have contributed to implementation of this research.