Assessment of Endoscopic Gastric Atrophy according to the Kimura-Takemoto Classification and Its Potential Application in Daily Practice

Abstract

The assessment of endoscopic gastric atrophy (EGA) according to the Kimura-Takemoto classification has been reported to correlate well with histological assessment. Although agreement among beginner endoscopists was less than that among experienced endoscopists, it has been shown that agreement level could markedly improve and remained stable after proper training. Several cohort studies have consistently shown that the severity of EGA at baseline is significantly associated with the presence of advanced precancerous gastric lesions and gastric cancer, as well as the development of gastric cancer in future. Patients with moderate-to-severe EGA still have high risk of gastric cancer even after successful Helicobacter pylori eradication and should be candidates for gastric cancer surveillance. The assessment of EGA, therefore, could be used as a preliminary tool to identify individuals at high risk for gastric cancer. In this paper, we review the agreement on mucosal atrophy assessment between the Kimura-Takemoto classification and histology as well as the potential application of this endoscopic classification to identify precancerous gastric lesions and gastric cancer in daily practice.

Keywords: Endoscopy; Gastric cancer; Helicobacter pylori; Screening; Surveillance.

Fig. 1.

Atrophic border on the greater curvature (A) and lesser curvature (B). The gastric mucosa shows differences in level and color between the 2 sides of the atrophic border. The endoscopic atrophic border represents both the transition from non-atrophic gastric mucosa to atrophic gastric mucosa and the transition from fundic glands to pyloric glands in a non-atrophic stomach [6]. Its presence, however, does not always mean that a patient has gastric mucosal atrophy. The term “atrophic border” is not accurate and might cause some misunderstanding, but is still used in daily practice due to its historical meaning.

Fig. 2.

Extension of the atrophic border (red line) and patterns of endoscopic gastric atrophy as classified by Kimura and Takemoto [13].

Fig. 3.

A 24-year-old Vietnamese female underwent upper gastrointestinal endoscopy for epigastric pain. The patient had no alarming features. (A, B) White-light endoscopy clearly demonstrated moderate endoscopic gastric atrophy (type O-1), even with an older-generation gastroscope (Olympus EXERA-GIF 160 Video Gastroscope; Olympus Co., Tokyo, Japan), which prompted the endoscopist to search carefully for gastric cancer. (C) An easily-missed subtle change (yellow box) could be identified on the greater curvature of the corpus. (D) The gastroscope was advanced closer to the suspicious area and more air was insufflated. A small 0-IIc lesion hidden beneath gastric mucosal folds was identified. This lesion was diagnosed as undifferentiated adenocarcinoma on pathology.