What is the management approach for incisura type mucosa in the gastric mucosa?

Management of Incisura Type Mucosa in Gastric Mucosa

Incisura angularis mucosa should be specifically biopsied and evaluated as part of the updated Sydney protocol for comprehensive assessment of gastric mucosal changes and risk stratification for gastric cancer. 1

Understanding Incisura Angularis Mucosa

The incisura angularis is a critical anatomical landmark in the stomach that requires special attention during endoscopic evaluation. In Helicobacter pylori-naïve normal stomachs, the incisura typically contains fundic or transitional-type mucosa rather than pyloric-type mucosa 2. However, this region is particularly susceptible to pathological changes:

• The incisura angularis frequently undergoes more severe atrophic, metaplastic, and chronic inflammatory changes compared to the antrum and corpus 3
• It is often the initial site where atrophic changes arise in H. pylori-associated atrophic gastritis (HpAG) 1
• "Antralization" (replacement with antral-type mucosa) of the incisura is common in H. pylori infection and appears associated with increased risk of atrophic gastritis and intestinal metaplasia 4

Diagnostic Approach

Endoscopic Examination

1. High-quality examination is essential:

   • Ensure excellent mucosal visualization with adequate air insufflation and mucosal cleansing 1
   • Consider defoaming and mucolytic agents (simethicone, 1% N-acetylcysteine) 1
   • Spend sufficient time examining the gastric mucosa systematically 1

2. Advanced imaging techniques:

   • Use high-definition white-light endoscopy (HD-WLE) or image-enhanced techniques like narrow-band imaging (NBI) 1
   • Document the incisura angularis specifically with photographs 1
   • Look for pale appearance, increased visibility of submucosal vessels, and loss of gastric folds in cases of atrophy 1

Biopsy Protocol

1. Follow the updated Sydney protocol:

   • Obtain 5 gastric biopsies, including a specific biopsy from the incisura angularis 1
   • Place specimens in separately labeled jars (at minimum, separate antrum/incisura from body) 1
   • Do not skip the incisura angularis when obtaining biopsies, as atrophic gastritis/intestinal metaplasia frequently involves this site 1, 3

2. Targeted biopsies:

   • Obtain additional biopsies from any visible mucosal abnormalities 1
   • Pay special attention to the incisura area as it's a common site for missed gastric cancers due to exposure errors (48% of missed cancers in one study) 5

Risk Assessment and Management

Risk Stratification

1. Histopathologic evaluation:

   • Assess for atrophy, intestinal metaplasia, and inflammation 1
   • Determine the type of mucosa (fundic, transitional, or pyloric) 2, 4
   • Look for "antralization" of the incisura, which is associated with increased risk of atrophic gastritis and intestinal metaplasia 4

2. Staging systems:

   • Use OLGA (Operative Link for Gastritis Assessment) and OLGIM (Operative Link for Gastric Intestinal Metaplasia Assessment) systems 1
   • Including incisura biopsies prevents downgrading of high-risk OLGA/OLGIM stages by 30-35% 3

Management Recommendations

1. H. pylori testing and treatment:

   • Test all patients with atrophic changes for H. pylori 1
   • If positive, eradicate H. pylori and confirm successful eradication 1
   • H. pylori eradication may reverse antralization at the incisura in some patients 6

2. Surveillance:

   • For patients with extensive or moderate to severe atrophy (OLGA/OLGIM III/IV), endoscopic surveillance is recommended even after successful H. pylori eradication 1
   • Pay particular attention to the incisura angularis during surveillance endoscopies 5

Clinical Pearls and Pitfalls

Pearls

• The incisura angularis is a critical site for evaluating mucosal atrophy and cancer risk 2
• Antralization of the incisura is strongly associated with H. pylori infection (84% in infected vs. 18% in uninfected patients) 4
• Including incisura biopsies significantly improves accuracy of risk stratification 3

Pitfalls

• Missing the incisura during biopsy sampling can lead to underestimation of disease severity 3
• The incisura is a common site for missed gastric cancers due to exposure errors during endoscopy 5
• Inadequate visualization of the incisura can lead to missed diagnoses of early gastric cancer 5

By properly examining and sampling the incisura angularis, clinicians can more accurately assess gastric cancer risk and implement appropriate surveillance strategies to reduce morbidity and mortality associated with gastric cancer.