H Pylori Endoscopy Images: Tissue Patterns and Techniques

Helicobacter pylori (H. pylori) infection is a major cause of chronic gastritis, peptic ulcers, and gastric cancer. Detecting it accurately is critical for guiding treatment and preventing complications. Endoscopy allows direct visualization of the stomach lining, where characteristic changes may indicate infection.

Advancements in endoscopic techniques have improved diagnostic accuracy, making it easier to identify subtle mucosal alterations. Understanding imaging methods, staining options, and biopsy techniques is key to optimizing H. pylori detection.

Visible Tissue Patterns

Endoscopic examination of H. pylori-infected gastric mucosa reveals distinct alterations that aid diagnosis. One commonly observed pattern is mucosal erythema, appearing as diffuse or patchy redness due to increased vascularity and inflammation. This erythema, often in the antrum where H. pylori colonization is concentrated, may accompany a loss of the normal gastric pit pattern. Studies link irregular erythema with histological evidence of active gastritis, making it a useful visual marker.

Mucosal nodularity, particularly in younger patients, is another key finding. This cobblestone-like appearance results from lymphoid follicle hyperplasia, a response to chronic bacterial stimulation. Nodularity is highly specific for H. pylori, with strong histopathological associations. In contrast, atrophic changes—characterized by mucosal thinning and increased visibility of submucosal vessels—are more common in long-standing infections and may indicate progression toward gastric atrophy or intestinal metaplasia.

Enlarged gastric folds, caused by inflammatory edema and glandular hyperplasia, are another notable feature. These thickened folds are typically irregular and asymmetrical, distinguishing them from uniform enlargement seen in conditions like Zollinger-Ellison syndrome. In some cases, focal erosions or small depressed lesions appear, particularly in patients with concurrent peptic ulcer disease. These erosions, when surrounded by inflamed mucosa, suggest active bacterial involvement and warrant further investigation.

Enhanced Imaging Approaches

Standard endoscopy provides valuable insights into H. pylori-related gastric mucosal changes, but advanced imaging techniques enhance diagnostic precision by revealing subtle structural and vascular alterations.

Magnifying Endoscopy

Magnifying endoscopy provides high-resolution visualization of glandular and vascular structures, improving identification of H. pylori-related changes. It detects microvascular abnormalities, such as irregular capillary networks and loss of the normal honeycomb-like pit pattern. Studies show that magnifying endoscopy can identify white opaque substances (WOS), lipid deposits linked to bacterial colonization. A 2021 study in Gastrointestinal Endoscopy found WOS had an 85% sensitivity and 90% specificity for H. pylori infection. Additionally, this technique helps differentiate active infection from post-eradication changes by assessing pit structure restoration, enhancing diagnostic confidence and reducing unnecessary biopsies.

Narrow Band Imaging

Narrow Band Imaging (NBI) enhances mucosal and vascular contrast using specific light wavelengths (415 nm and 540 nm) that penetrate superficial gastric layers. This technique highlights microvascular irregularities and glandular distortions not visible under conventional white-light endoscopy. Infected mucosa often exhibits dense, irregular capillaries and a disrupted subepithelial capillary network. A 2020 meta-analysis in Digestive Endoscopy reported NBI’s diagnostic accuracy at approximately 88% for detecting H. pylori-associated gastritis. NBI also helps distinguish inflamed from atrophic mucosa, providing insights into disease progression and reducing reliance on histological confirmation in some cases.

Chromoendoscopy

Chromoendoscopy enhances mucosal visualization by applying contrast agents or dyes to highlight surface irregularities. Indigo carmine and acetic acid are commonly used to emphasize glandular patterns associated with H. pylori infection. Indigo carmine enhances contrast in depressed or atrophic areas, while acetic acid highlights pit structures by altering mucosal refractive properties. A 2019 study in World Journal of Gastroenterology found that acetic acid chromoendoscopy, when combined with magnifying endoscopy, improved H. pylori detection accuracy to 91%. This technique is particularly useful for identifying early atrophic changes and intestinal metaplasia.

Staining Options

Histopathological examination is a key method for detecting H. pylori, with staining techniques enhancing bacterial visualization. Hematoxylin and eosin (H&E) staining is widely used but has variable sensitivity, particularly in cases with low bacterial density.

Giemsa staining selectively highlights H. pylori as blue or dark purple curved bacilli within the mucosal layer. It is cost-effective and simple but may not always provide optimal differentiation in inflamed samples. Warthin-Starry silver staining offers superior sensitivity by impregnating bacterial cell walls with silver deposits, rendering H. pylori highly visible. However, this method is labor-intensive and requires meticulous processing.

Immunohistochemical (IHC) staining employs antibodies targeting H. pylori antigens, providing high specificity. This technique reduces false negatives, particularly in post-eradication assessments where bacteria may be sparse. Despite its accuracy, IHC is costly and time-consuming. Fluorescent in situ hybridization (FISH) uses fluorescent probes to detect H. pylori DNA within tissue sections, confirming bacterial presence while identifying antibiotic resistance genes.

Biopsy Techniques

Endoscopic biopsy remains the most definitive method for diagnosing H. pylori, but accuracy depends on proper sampling. Bacterial distribution in the stomach is uneven, influenced by acid suppression therapy and disease progression. To maximize yield, biopsies are taken from both the antrum and corpus, as recommended by the Updated Sydney System. Collecting at least two samples from each region accounts for patchy colonization and minimizes false negatives.

Biopsies should be taken with standard forceps, ensuring adequate depth to include the superficial mucosal layer where H. pylori resides. Superficial sampling may lead to inconclusive results, particularly if bacteria are embedded within deeper gastric glands. In cases of atrophic gastritis or intestinal metaplasia, additional biopsies from the lesser and greater curvature improve diagnostic accuracy. Studies show that increasing biopsy sites enhances sensitivity, with five-sample protocols achieving detection rates above 95%.

Laboratory Confirmation

Once biopsy samples are collected, laboratory testing confirms H. pylori infection. Histological examination remains one of the most reliable methods, allowing direct bacterial visualization. Pathologists assess stained specimens for spiral-shaped organisms adhering to epithelial cells, along with inflammatory changes such as neutrophilic infiltration and glandular damage. While histology provides high sensitivity and specificity, accuracy can be affected by bacterial density and prior antibiotic or proton pump inhibitor (PPI) use. Examining multiple biopsy sections improves reliability.

Rapid urease testing (RUT) offers a practical alternative by detecting urease activity produced by H. pylori. This test places gastric tissue in a urea-containing medium, where enzyme presence triggers a pH shift, indicated by a color change. RUT provides results within hours, with 85-95% sensitivity, though accuracy decreases in patients with low bacterial loads or recent antibiotic exposure.

For further confirmation, polymerase chain reaction (PCR) amplifies H. pylori DNA from biopsy samples. PCR not only detects the bacteria but also identifies genetic markers for antibiotic resistance, guiding treatment strategies. While highly precise, PCR’s cost and technical requirements limit its routine use.