Differential Diagnosis of Thickened Gastric Wall Between Hypertrophic Gastritis and Borrmann type 4 Advanced Gastric Cancer

Abstract

Backgrounds Accurately diagnosing diffuse gastric wall thickening is challenging for endoscopists. Hypertrophic gastritis (HG), while benign, mimics the morphology of advanced gastric cancer Borrmann type 4 (AGC B-4). We compared the features of endoscopy and endoscopic ultrasonography (EUS) between HG and AGC B-4.

Methods We retrospectively investigated patients who underwent EUS for thickened gastric wall between January 2000 and December 2021. Among them, those with HG or AGC B-4 were selected. All diagnoses of AGC B-4 were pathologically confirmed. Endoscopy was performed to determine the presence of ulceration and antral wall thickening. In EUS, 5-layered gastric layers at the most thickened fold were evaluated by measuring the thickness of the proper muscle (PM) and total wall layers, and the location of hypoechoic disruption of the 5-layered gastric wall structure was initially assessed.

Results Fifty patients with HG and 115 patients with AGC B-4 were included. Male dominance was observed in AGC B-4, as well as significantly lower hemoglobin, albumin levels. AGC B-4 had a significantly higher rate of antral wall thickening and presence of ulceration than HG. Destruction of the proper muscle (PM) layers was only observed in AGC B-4, and the PM was significantly thicker in AGC B-4. In pathologic diagnosis in AGC B-4, if there were ulcers, forcep biopsy showed excellent success rate. However, since only a 42.6% success rate in patients without ulcers, so additional modalities were required. When we plotted the receiver operating curve to distinguish between AGC B-4 and HG based on PM thickness, 2.39 mm was the cut-off value. The multivariable analysis showed that thickened PM layer and presence of ulceration were significant risk factors for the diagnosis of AGC B-4.

Conclusion Significant differences in baseline characteristics and laboratory findings were observed between HG and AGC B-4. In AGC B-4 without ulceration, other diagnostic modalities than forcep biopsy might be required for pathologic confirmation. PM layer 2.39 mm was the cut-off value to distinguish the diseases and the presence of thickened PM and ulceration should make AGC B-4 more suspicious.