Available online at www.sciencedirect.

com
Digestive and Liver Disease 40 (2008) 650658
Mini-Symposium
OLGA staging for gastritis: A tutorial
M. Rugge
a,b,
, P. Correa
c
, F. Di Mario
d
, E. El-Omar
e
, R. Fiocca
f
,
K. Geboes
g
, R.M. Genta
h
, D.Y. Graham
i
, T. Hattori
j
, P. Malfertheiner
k
,
S. Nakajima
l
, P. Sipponen
m
, J. Sung
n
, W. Weinstein
o
, M. Vieth
p
a
Department of Medical Diagnostic Sciences & Special Therapies (Pathology Section), University of Padova, Italy
b
Veneto Institute of Oncology (IOV-IRCSS), Padova, Italy
c
Division of Gastroenterology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
d
Department of Clinical Sciences, Section of Gastroenterology, University of Parma, Italy
e
Department of Medicine & Therapeutics Institute of Medical Sciences, Aberdeen University, UK
f
Department of Surgical, Morphological & Integrated Disciplines (Anatomic Pathology Section), University of Genova, Italy
g
Department of Pathology, Catholic University of Leuven, Belgium
h
Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
i
Michael E. Debakey VA Medical Center & Baylor College of Medicine, Houston, TX, USA
j
Department of Pathology Shiga University Medical Sciences, Shiga, Japan
k
Department of Gastroenterology Hepatology And Infectious Diseases, Otto-Von-Guericke-University, Magdeburg, Germany
l
Department of Medicine, Gastroenterology and Healthcare Social Insurance Shiga Hospital, Shiga, Japan
m
Division of Pathology, HUSLAB, Helsinki University Hospital, Helsinki, Finland
n
Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, China
o
Department of Medicine Division of Digestive Diseases, UCLA Center for Health Sciences, USA
p
Institute of Pathology Klinikum Bayreuth, Bayreuth, Germany
Received 1 February 2008; accepted 18 February 2008
Available online 17 April 2008
Abstract
Atrophic gastritis (resulting mainly from long-standing Helicobacter pylori infection) is a major risk factor for (intestinal-type) gastric
cancer development and the extent/topography of the atrophic changes signicantly correlates with the degree of cancer risk.
The current format for histology reporting in cases of gastritis fails to establish an immediate link between gastritis phenotype and risk
of malignancy. The histology report consequently does not give clinical practitioners and gastroenterologists an explicit message of use in
orienting an individual patients clinical management.
Building on current knowledge of the biology of gastritis and incorporating experience gained worldwide by applying the Sydney System
for more than 15 years, an international group of pathologists (Operative Link for Gastritis Assessment) has proposed a system for reporting
gastritis in terms of stage (the OLGA staging system). Gastritis staging arranges the histological phenotypes of gastritis along a scale of
progressively increasing gastric cancer risk, from the lowest (stage 0) to the highest (stage IV).
This tutorial aims to provide unequivocal information on howto consistently apply the OLGAstaging systemin routine diagnostic histology
practice.
2008 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
Keywords: Atrophic gastritis; Gastritis staging; OLGA staging

Corresponding author at: Chair, Anatomic Pathology, Universit` a degli

Studi di Padova, Istituto Oncologico del Veneto IOV-IRCCS, Via Aristide
Gabelli 61, 35121 Padova, Italy.
E-mail address: massimo.rugge@unipd.it (M. Rugge).
1. Introduction
Chronic (Helicobacter-associated) gastritis is a crucial
step in the natural history of gastric oncogenesis and its epi-
demiological link with gastric carcinoma is well established
[1,2].
1590-8658/$30 2008 Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l.
doi:10.1016/j.dld.2008.02.030
M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658 651
Upper gastrointestinal endoscopy with biopsy sampling is
the denitive diagnostic procedure whenever a gastric malig-
nancy is suspected. Its use for the secondary prevention of
gastric cancer (GC) is generally limited because of its inva-
siveness andcost, but for selectedhigh-riskpatients it remains
the only available strategy [3,4].
While many aspects of the biology of gastritis remain
to be elucidated, a large body of information indicates that
gastric atrophy is the single most powerful predictor of the
onset of intestinal-type GC [59]. Intestinal metaplasia is
generally considered as the eld cancerisation in the gas-
tric mucosa and, at cell level, intestinalised glands provide
the cellular substrate on which gastric non-invasive neo-
plasia (NiN) develops [10,11]. There is some evidence to
show that intestinal metaplasia can be reversed (by clearing
H. pylori infection or applying chemoprevention strategies),
but the chances of aborting the progression of NiN to can-
cer are considerably lower, and that high-grade NiN will
evolve into invasive adenocarcinoma is a virtual certainty
[9].
In spite of the greater consistency brought about by
the Sydney System and its updated 1996 Houston ver-
sion, the commonly-used nomenclature for gastritis remains
inconsistent and individual, non-standard styles of histology
reporting for gastritis are still widely used to the conster-
nation of clinicians [1215]. Many practitioners are unable
to perceive the different cancer risk associated with multi-
focal atrophic gastritis, corpus predominant gastritis, or
antrum-predominant H. pylori chronic active gastritis, and
even well-informed specialists are often frustrated by a ter-
minology that makes it difcult to identify candidates for
endoscopic surveillance [1,7,13,1518].
Building on current knowledge of the natural history of
gastritis and the associated cancer risk, an international group
of gastroenterologists and pathologists (the Operative Link
for Gastritis Assessment [OLGA]) has proposed a system
for reporting gastritis in terms of stage (the OLGA staging
system), which arranges the histological phenotypes of gas-
tritis along a scale of progressively increasing GC risk, from
the lowest (OLGA stage 0) to the highest (OLGA stage IV)
[19,20]. The staging framework is borrowed from the oncol-
ogy vocabulary and applies the histology reporting format
successfully employed for chronic hepatitis to the gastritis
setting too [21,22]. Just as brosis is the main lesion used
to weigh the risk of liver cirrhosis, gastric mucosal atrophy
is considered the marker of cancer risk. Additionally, just as
a given number of portal tracts are required for the accurate
staging of hepatitis, a well-dened biopsy sampling proto-
col (as recommended by the Sydney System) is considered a
minimum requirement for the reliable staging of gastritis
[13,2325].
The stage of gastritis results from the combination of the
extent of atrophy (scored histologically) with its topograph-
ical location (resulting from the mapping protocol) [26]. In
line with the Sydney recommendations, the OLGA staging
system also includes information on the likely aetiology of
the gastric inammatory disease (e.g. H. pylori, autoimmune,
etc.).
This tutorial aims to expand on the available information
with a view to a consistent application of the OLGA stag-
ing system. The provided clues are founded basically on the
current denition of gastric atrophy and on the worldwide
experience accumulated by practicing the Houston-updated
Sydney System.
2. Denition of atrophy in the gastric mucosa
Normal gastric biopsy samples (from adolescents and
adults) feature different populations of glands (mucosecret-
ing or oxyntic), appropriate for the functional compartment
(antrum or corpus) from which the specimen has been
obtained (i.e. appropriate glands) [27,28] (Fig. 1). Occa-
sionally, minuscule foci metaplastic (goblet) cells may be
encountered, particularly in the foveolar epithelium, but
the overall density of appropriate glands is not affec-
ted.
In the gastric mucosa, atrophy is dened as the loss of
appropriate glands. Different phenotypes of atrophic trans-
formation may be encountered, i.e.
(a) vanishing, or evident shrinkage of glandular units asso-
ciated with (brotic) expansion of the surrounding lamina
propria. Such a situation results in a reduced glandular mass,
but does not imply any modication of the original epithelium
phenotype (Fig. 1);
(b) metaplastic replacement of the native glands by glands
featuring a new cellular commitment (= intestinal and/or
pseudopyloric metaplasia). The number of glands is not
necessarily lower, but the metaplastic replacement of the
original glandular units results in a smaller population of
the native glands (which are appropriate for the com-
partment considered). Such a condition is also consistent
with the general denition of loss of appropriate glands
(Fig. 1).
Sometimes (particularly in H. pylori-associated gastri-
tis), severe inammation makes it impossible to determine
whether glands that appear to be lost are merely obscured
by the inammatory inltrate or whether they have genuinely
vanished. In such cases, a temporary diagnosis of inde-
nite for atrophy can be made, deferring the nal judgment
until the inammation has resolved (e.g. after eradication of
the H. pylori infection). This indenite category, borrowed
from the classication of intra-epithelial neoplasia (dyspla-
sia) in the gastrointestinal tract, is not intended to represent
a biological entity [28].
In tune with the above-mentioned criteria, an Inter-
national Group of Gastrointestinal Pathologists (Atrophy
club) arranged the histological spectrum of atrophic changes
into a formal classication (Table 1). After testing in real
cases, the interobserver consistency in recognizing/scoring
the atrophic lesions was considered more than adequate
[28].
652 M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658
Fig. 1. Normal and atrophic glandular units in the stomach. 1: Normal mucosecreting gland. The glandular structure consists of mucosecreting cells (yellow
line). In this, as in all the other glandular structures, both the supercial layer and proliferative zone are represented as a pink line. 2: Non-metaplastic atrophy
in a mucosecreting gland: the number of glandular coils is decreased and the glands prole has become simpler (shrunk) and does not reach the bottom of
the mucosal layer. 3: Metaplastic atrophy (intestinal metaplasia): the glandular prole is simplied, looking like an intestinal crypt (intestinalized epithelia are
represented as bright blue line). 4: Normal oxyntic gland (green prole). 5: Non-metaplastic atrophy in an oxyntic gland: the glands prole is shorter (shrunk)
and the tubular structure does not reach the bottom of the mucosal layer. 6: Pseudopyloric metaplasia in oxyntic gland: the parietal and chief cells (green
line) are replaced by mucosecreting epithelia (yellow line, as in the antral glands). The intestinalization of a native oxyntic gland is similar to that shown for
mucosecreting glands (see 3).
3. Gastritis staging: the OLGA system
Gastritis can be interpreted on two different levels: (a) a
basic level represented by the elementary lesions; and (b) a
hierarchically higher level (as a stomach disease proper)
depending on the extent and topographic distribution of the
different elementary lesions.
In 1955 Basil Morson said that, the incidence and
the extent of intestinal metaplasia are greatest in stomachs
containing carcinomas and least in those with duodenal
ulcer, with cases of gastric ulcer taking an intermedi-
ate position. Correa later demonstrated that patchy areas
of atrophicmetaplastic changes in the antral and oxyntic
mucosa (i.e. multifocal atrophic gastritis) frequently coex-
ist with gastric ulcer, creating the most frequent setting for
gastric carcinoma [16,29,30].
Based on the assumption that a different extent and
topographical distribution of atrophy expresses a different
clinico-biological situation (associated with a different can-
cer risk), the Houston-updated Sydney System established
that multiple biopsy samples should be obtained to explore
the different mucosa compartments [13]. Different biopsy
locations have been suggested in the international literature
to map the mucosa, all of them consistent with the gen-
eral assumption that both the oxyntic and the antral mucosa
have to be explored, and also considering the incisura
Table 1
Atrophy in the gastric mucosa: histological classication and grading
Atrophy
0 Absent (= score 0)
1 Indenite (no score is applicable)
Histological type Location and key lesions Grading
Antrum Corpus
2 Present 2.1 Non-metaplastic Glands: shirking/vanishing Glands: shirking/vanishing 2.1.1 Mild =G1 (130%)
Lamina propria: brosis Lamina propria: brosis 2.1.2 Moderate =G2 (3160%)
2.1.3 Severe =G3 (>60%)
2.2 Metaplastic Intestinal metaplasia Intestinal metaplasia 2.2.1 Mild =G1 (130%)
Pseudopyloric metaplasia 2.2.2 Moderate =G2 (3160%)
2.2.3 Severe =G3 (>60%)
M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658 653
Fig. 2. Gastric biopsy sampling protocol.
angularis highly informative for the purpose of establish-
ing the earliest onset of atrophicmetaplastic transformation
[24]. The OLGA proposal (basically consistent with the
Houston-updated biopsy protocol [13]) consists in recom-
mending (at least) ve biopsy samples from: (1) the greater
and lesser curvatures of the distal antrum (A1A2 =mucus-
secreting mucosa); (2) the lesser curvature at the incisura
angularis (A3), where the earliest atrophicmetaplastic
changes mostly occur; and (3) the anterior and posterior
walls of the proximal corpus (C1C2 =oxyntic mucosa)
(Fig. 2).
The information obtained enables to place patients at
approximate points along the path where chronic gastritis
advances from the reversible inammatory lesions (mostly
limited to the antrum) at one end to the atrophic changes
extensively involving both functional compartments (antrum
and corpus) and associated with a high risk of GCat the other
[23].
4. How to apply the OLGA staging system for
gastritis
The OLGA staging system integrates the above expe-
riences in an internationally-agreed staging proposal. The
Systemuses gastric atrophyas the lesionmarkingdisease pro-
gression. The stage of gastritis is obtained by combining the
extent of atrophy scored histologically with the topography
of atrophy identied by the multiple biopsies (Fig. 3). The
OLGA histology report also includes the etiological infor-
mation obtainable from the tissue samples available (i.e. H.
pylori infection; autoimmune disease, etc.).
The following paragraphs are intended as a brief OLGA
staging system users manual. Visual Analogue Scales
(VAS) are used to give an example of how the histology
changes featured at single biopsy level can be pieced together
to stage a given patient (Figs. 49).
4.1. Atrophy score
4.1.1. Scoring atrophy (loss of appropriate glands) at
single biopsy level
In each single biopsy, atrophy is scored as a percent-
age of atrophic glands. Ideally, the atrophy is assessed
on perpendicular (full thickness) mucosal sections. Non-
metaplastic and metaplastic subtypes are considered together.
For each biopsy sample (whatever the area it comes from),
atrophy is scored on a four-tiered scale (no atrophy =0%,
score =0; mild atrophy =130%, score =1; moderate atro-
phy =3160%, score =2; severe atrophy =>60%, score =3)
(Figs. 49).
Fig. 3. The OLGA staging frame.
654 M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658
Fig. 4. All 5 biopsy samples (3 from the mucosecreting compartment and 2 from the oxyntic compartment) consist of normal glands. This gure shows a
normal gastric mucosa at both antral and corpus levels. Each strip (=1 biopsy sample) is labeled according to its site of origin (antral/angular =A, corpus =C)
and includes 10 glandular units. Any inammation (lymphocytes, monocytes, plasmacytes, granulocytes) is disregarded. The percentages given on the left refer
to the percentage of atrophic glands at single biopsy level (in this VAS, the percentage of atrophy is 0 in all the available biopsies). The total (compartmental)
prevalence of atrophy is given on the right, distinguishing between antral and corpus compartments; the nal compartment atrophy score is also shown. The
OLGA staging frame is provided in the bottom right-hand corner, where the OLGA-stage is reported (OLGA-stage 0).
4.1.2. Assessing atrophy in each compartment
(mucosecreting and oxyntic)
According to the Sydney protocol, three biopsy samples
should be taken from the mucosecreting area (two antral
samples +one from the incisura angularis), and two from
the oxyntic mucosa. It is important to note that the atrophic
transformation in samples of incisura angularis mucosa
is only assessed in terms of glandular shrinkage/vanishing
(with brosis of the lamina propria) or intestinal meta-
plasia (replacing original mucosecreting and/or oxyntic
glands).
In each of the two mucosal compartments (mucose-
creting and oxyntic), an overall atrophy score expresses
the percentage of compartmental atrophic changes (con-
Fig. 5. Scoring atrophy at each single antral/angular biopsy level (atrophic glands are identied by a red marker): A1 =20%, A2 =20%and A3 =40%. Assessing
atrophy at compartment level (antrum): dividing 80 (=20 +20 +40) by 3 (the number of antral biopsies considered), the nal prevalence of antral atrophy is 27%
(<30%), which means a score of 1. Scoring atrophy at each single corpus biopsy level (atrophic glands are identied by a red marker): C1 =20%; C2 =30%.
Assessing atrophy at compartment level (corpus): dividing 50 (=20 +30) by 2 (the number of corpus biopsies considered), the nal prevalence of corpus atrophy
is 25% (<30%), which means a score of 1. Combining the atrophy scores for the antrum (Antral atrophy score [Aas] =1) and corpus (Corpus atrophy score
[Cas] =1) gives us the OLGA stage, as shown in the reference chart (bottom right-hand corner: OLGA-stage I). H. pylori-status (as histologically assessed by
special stain) has to be reported.
M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658 655
Fig. 6. Scoring atrophy at each single antral/angular biopsy level (atrophic glands are identied by a red marker): A1 =20%; A2 =30%; A3 =70%. Assessing
atrophy at compartment level (antrum): dividing 120 (=20 +30 +70) by 3 (the number of biopsies considered), the nal prevalence of antral atrophy is 40%
(>30%<60%), which means a score of 2. Scoring atrophy at each single corpus biopsy level (atrophic glands are identied by a red marker): C1 =30%;
C2 =20%. Assessing atrophy at compartment level (corpus): dividing 50 (=30 +20) by 2 (the number of biopsies considered), the nal prevalence of corpus
atrophy is 25%(<30%), which means a score of 1. Combining the atrophy scores for the antrum (Aas =2) and corpus (Cas =1) gives us the OLGA stage, as
shown in the reference chart (bottom right-hand corner: OLGA-stage II). H. pylori-status (as histologically assessed by special stain) has to be reported.
sidering all together the biopsies obtained from the same
functional compartment). The same cut-offs are used at
this hierarchically higher assessment level as for the single
biopsies (no atrophy =0%, score =0; mild atrophy =130%,
score =1; moderate atrophy =3160%, score =2; severe atro-
phy = >60%, score =3). Using this strategy, an overall
atrophy score is obtained that separately summarizes the
scores for the antrum ([Aas] Aas0, Aas1, Aas2, Aas3)
and the corpus mucosa ([Cas] Cas0, Cas1, Cas2, Cas3)
(Figs. 49).
The OLGAstage results fromthe combination of the over-
all antrum score with the overall corpus score (Fig. 3).
Fig. 7. Scoring atrophy at each single antral/angular biopsy level (atrophic glands are identied by a red marker): A1 =40%; A2 =40%; A3 =40%. Assessing
atrophy at compartment level (antrum): dividing 120 (=40 +40 +40) by 3 (the number of biopsies considered), the nal prevalence of antral atrophy is 40%
(>30%<60%), which means a score of 2. Scoring atrophy at each single corpus biopsy level (atrophic glands are identied by a red marker): C1 =30%;
C2 =60%. Assessing atrophy at compartment level (corpus): dividing 90 (=30 +60) by 2 (the number of biopsies considered), the nal prevalence of corpus
atrophy is 45% (>30%<60%), which means a score of 2. Combining the atrophy scores for the antrum (Aas =2) and corpus (Cas =2) gives us the OLGA stage,
as shown in the reference chart (bottom right-hand corner: OLGA-stage III). H. pylori-status (as histologically assessed by special stain) has to be reported.
656 M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658
Fig. 8. Scoring atrophy at each single antral/angular biopsy level (atrophic glands are always identied by a red marker): A1 =0%; A2 =0%; A3 =40%.
Assessing atrophy at compartment level (antrum): dividing 40 (=0 +0 +40) by 3 (the number of biopsies considered), the nal prevalence of antral atrophy
is 13% (<30%), which means a score of 1. Scoring atrophy at each single corpus biopsy level (atrophic glands are identied by a red marker): C1 =90%;
C2 =90%. Assessing atrophy at compartment level (corpus): dividing 180 (=90 +90) by 2 (the number of biopsies considered), the nal prevalence of corpus
atrophy is 90% (>60%), which means a score of 3. Combining the atrophy scores for the antrum (Aas =1) and corpus (Cas =3) gives us the OLGA stage, as
shown in the reference chart (bottom right-hand corner: OLGA-stage III). H. pylori-status (as histologically assessed by special stain) has to be reported. In
this case, the pattern of atrophic gastritis (corpus predominant atrophy) should suggest an autoimmune etiology.
5. From atrophy score to OLGA stage
5.1. Stage 0 gastritis (i.e. non-atrophic mucosa) (Fig. 4)
When the overall score for atrophy is 0 in both the mucose-
creting and the oxyntic compartments (which means that
none of the ve standard biopsy samples show signs of
atrophy), the OLGA stage is obviously 0. The score for
inammatory lesions is independent of said stage, except
in cases considered indenite for atrophy because a orid
inammatory inltrate may prevent the proper assessment of
appropriate gland loss. To avoid confounding the issue, all
the VAS provided have been cleansed of any inammatory
component and no mention is made of any grading of the
Fig. 9. Scoring atrophy at each single antral/angular biopsy level (atrophic glands are identied by a red marker): A1 =70%; A2 =90%; A3 =70%. Assessing
atrophy at compartment level (antrum): dividing 230 (=70 +90 +70) by 3 (the number of biopsies considered), the nal prevalence of antral atrophy is 77%
(>60%), which means a score of 3. Scoring atrophy at each single corpus biopsy level (atrophic glands are identied by a red marker): C1 =40%; C2 =70%.
Assessing atrophy at compartment level (corpus): dividing 110 (=40 +70) by 2 (the number of biopsies considered), the nal prevalence of corpus atrophy is
55% (>30%<60%), which means a score of 2. Combining the atrophy scores for the antrum (Aas =3) and corpus (Cas =2) gives us the OLGA stage, as shown
in the reference chart (bottom right-hand corner: OLGA-stage IV). H. pylori-status (as histologically assessed by special stain) has to be reported.
M. Rugge et al. / Digestive and Liver Disease 40 (2008) 650658 657
inammatory lesions. The VAS refer to non-atrophic (nor-
mal) mucosa and are given as a standard reference to enable
comparisons to be drawn with the pathological VAS.
5.2. Stage I gastritis (Fig. 5)
Stage I gastritis is the lowest atrophic stage. In most
cases (and especially in H. pylori-infected patients), atrophic
lesions are only detected in some of the biopsy samples.
H. pylori status (positive versus negative) must be reported
explicitly and is an essential part of the OLGA format. H.
pylori may be difcult (or even impossible) to identify his-
tologically at either antral or corpus level (particularly in
patients on proton pomp inhibitors [PPI]), in which case
coexisting inammatory lesions (polymorphs and lymphoid
inltrate) may suggest the bacteriums presence even if it is
not conrmed histologically. A comment on the suspected
aetiology (suspicious for H. pylori infection) should be
added in such cases (whatever their stage).
5.3. Stage II gastritis (Fig. 6)
This may result from a combination of different scores
and locations of atrophic transformation. Atrophy can affect
mucosecreting and/or oxyntic mucosa, but in most cases the
atrophic lesions are detected in the biopsy samples obtained
fromthe mucosecreting area. H. pylori status (positive versus
negative) has to be reported (see above). From preliminary
experience of OLGAstaging, stage II is the most represented
in the low GC risk epidemiological setting [31].
5.4. Stage III gastritis (Figs. 7 and 8)
Stage III gastritis results from at least moderate atrophy at
mucosecreting or oxyntic level. Atrophy is most frequently
identied in the incisura angularis sample and the most
prevalent histological subtype of atrophic transformation is
the metaplastic variant. Any presence of H. pylori needs to
be reported (see above). When stage III is found in patients
with no atrophy (score 0) in the biopsy samples of mucose-
creting mucosa, the aetiological hypothesis of autoimmune
(corpus restricted) atrophic gastritis should be considered.
In most populations at low risk of GC, stage III is only
rarely encountered and may coexist with NiN or even more
advanced (invasive) neoplastic disease [32].
5.5. Stage IV gastritis (Fig. 9)
This means atrophy involving both antral and oxyntic
mucosa, a situation basically corresponding to the pan-
atrophic gastritis phenotype. In patients with H. pylori
infection, extensive metaplastic transformation can interfere
with the histological detection of the bacterium. This stage is
rarely seen in areas with a low incidence of GC. Preliminary
data show a strong association between OLGA stages IIIIV
and GC, so endoscopic surveillance programmes should
focus on stage IIIIV-patients.
6. Conclusions
Recent experience suggests that gastritis staging may
afford a reliable indication of the cancer risk of individual
patients. If this is conrmed, we may be able to add to the
pathologists diagnosis a brief but clinically relevant mes-
sage to help the physician develop a clinical, serological
or endoscopic management plan tailored to each patients
disease.
Practice points
The histological assessment of atrophic
changes within gastric mucosa needs well-
dened criteria. VAS may help in the
consistent assessment of the different phe-
notypes of atrophic transformation.
VAS are illustrated to provide an operative
support in the histological staging of gastritis
(OLGA staging).
Research agenda
To validate the OLGA staging system for gas-
tritis in different epidemiological contexts.
To correlate the different OLGA stages of
gastritis with serological markers of gastric
atrophy.
To validate preliminary information which
associates the OLGAstages III andIVtoa high
risk of gastric epithelial malignancy.
Conict of interest statement
None declared.
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