Correlating endoscopic findings with pathology to optimize biopsy strategies in gastritis: insights from a large cohort study

Background – Despite advancements in endoscopic technology, the concordance between endoscopic findings and histopathological diagnoses in gastritis remains inconsistent. This study aimed to evaluate the correlation between endoscopic and histopathological findings, identify predictors of pathological outcomes, and assess the role of biopsies in routine clinical practice. Methods – A retrospective analysis of 4927 gastroscopies with biopsy over 6 years was performed. Demographics, endoscopic features, and histopathological findings were analyzed. Logistic regression identified predictors of Helicobacter pylori infection and precancerous conditions, with predictive accuracy assessed using receiver operating characteristic (ROC) analysis. Endoscopic patterns were categorized according to structured classification systems, with severity and anatomical distribution systematically documented. Results – Normal biopsies were found in 28.6%, H. pylori in 33.6%, and histologically confirmed precancerous conditions – including atrophy, intestinal metaplasia, and low-grade dysplasia – in 13.5% of cases. Nodular gastropathy [odds ratio (OR) = 1.54, P = 0.0006] and erosive raised gastropathy (OR = 1.31, P = 0.037) predicted H. pylori infection, while atrophic-appearing gastropathy (OR = 8.42, P < 0.001) and erosive raised gastropathy (OR = 2.47, P < 0.001) strongly predicted precancerous lesions. Erythematous gastropathy was inversely associated with H. pylori and precancerous conditions. Predictive accuracy was moderate for H. pylori [area under the ROC curve (AUC) = 0.60] and good for precancerous conditions (AUC = 0.74). Conclusion – While certain endoscopic features and patient demographics may assist in identifying individuals at higher risk of significant pathology, their predictive value remains modest. These findings may contribute to future efforts aimed at risk stratification; however, histological assessment remains essential, and prospective validation is warranted before altering current biopsy practices.