Objective Visual Analog Scale for Biopsy Diagnosis of Helicobacter pylori Infection in Clinical Practice

Am J Surg Pathol. 2021 May 1;45(5):672-679. doi: 10.1097/PAS.0000000000001681.


Historic and current pathology society guidelines recommend using visual gestalt to identify substantial inflammatory cell infiltrate in Helicobacter pylori gastritis, but these scales were subjectively designed. This study aims to objectively investigate the density of inflammation that justifies additional workup for H. pylori infection. We retrospectively identified 2 patient cohorts who had undergone endoscopy with gastric biopsies; 1 with H. pylori infection (n=66), confirmed with a positive stool antigen test and/or Campylobacter-like organism test, and 1 without infection (n=81). Antral and body biopsies were selected from each case, if available, and stained with MUM-1 to highlight mucosal plasma cells. Digital analysis was performed to calculate the number of plasma cells/mm2, termed the "inflammatory score" (IS). Patients with H. pylori infection had an average of 1289 plasma cells/mm2 in the antrum and 835 plasma cells/mm2 in the body, compared with 346 plasma cells/mm2 in the antrum and 178 plasma cells/mm2 in the body in patients without infection. IS cut-off values for a positive infection were 714 plasma cells/mm2 in the antrum and 316 plasma cells/mm2 in the body, with high sensitivities and specificities in both the antrum (92%, 92%) and body (85%, 84%), respectively. A visual analog scale was created to provide a histologic correlate of the observed IS ranges and cut-offs. This practical and objective scale is associated with a high sensitivity and specificity for diagnosing H. pylori infection and justifies moving away from upfront universal H. pylori testing in routine clinical practice.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Biomarkers / analysis
  • Biopsy
  • Child
  • Child, Preschool
  • Female
  • Gastritis / metabolism
  • Gastritis / microbiology
  • Gastritis / pathology*
  • Gastroscopy
  • Helicobacter Infections / metabolism
  • Helicobacter Infections / microbiology
  • Helicobacter Infections / pathology*
  • Helicobacter pylori / isolation & purification*
  • Humans
  • Immunohistochemistry
  • Interferon Regulatory Factors / analysis
  • Male
  • Middle Aged
  • Plasma Cells / chemistry
  • Plasma Cells / microbiology
  • Plasma Cells / pathology*
  • Predictive Value of Tests
  • Reproducibility of Results
  • Retrospective Studies
  • Stomach / chemistry
  • Stomach / microbiology
  • Stomach / pathology*
  • Young Adult


  • Biomarkers
  • Interferon Regulatory Factors
  • interferon regulatory factor-4