Adherence to the Sydney System guidelines increases the detection of Helicobacter gastritis and intestinal metaplasia in 400 738 sets of gastric biopsies

Background The diagnostic yield of individual gastric biopsies and the adherence to the Sydney System guidelines in the United States are unknown. Aims To evaluate the yield of different gastric sampling strategies and determine the adherence to the Sydney System guidelines in a nationwide sample of endoscopists. Methods Using a database of biopsy records diagnosed at a single pathology laboratory, we analysed the results of gastric biopsies taken to evaluate gastric inflammatory conditions in patients with no endoscopic lesions. We then stratified the specimens by site of origin and number of mucosal fragments and calculated the relationship between number and origin of biopsy specimens and detection of Helicobacter pylori and intestinal metaplasia. Results Of 400 738 biopsy sets, 66.0% were submitted as antrum; 17.4% as corpus; 2.6% as cardia; and 24.7% without topographic identifiers. Separate containers with at least two antral and two corpus specimens (Sydney System compliant) were available in 15 645 cases (3.9%). For antrum, corpus, and unspecified sites, each additional tissue fragment was associated with an incremental increase in the yield for both H. pylori and intestinal metaplasia. Sydney System-compliant sets had significantly greater yield than most of the unspecified or single-site sets (14.8% and 6.0% respectively). The incisura angularis, rarely sampled, yielded minimal additional diagnostic information. Conclusions In the absence of lesions, the acquisition of at least two biopsy specimens from antrum and corpus, essentially following the Sydney System recommendations, is a sensible strategy that guarantees the maximum diagnostic yield for the most common gastric inflammatory conditions.