Real-time endoscopic features to guide biopsy site selection for Helicobacter pylori detection: A retrospective cohort study

BACKGROUND: Accurate biopsy-based detection of Helicobacter pylori (H. pylori) is challenging in atrophic gastritis (AG) and intestinal metaplasia (IM). Histologic severity of AG or IM reduces detection rates, but how endoscopic classifications such as Kimura-Takemoto and Endoscopic Grading of Gastric Intestinal Metaplasia (EGGIM) should guide real-time biopsy site selection is uncertain. We evaluated whether these endoscopic features can optimize biopsy strategies for H. pylori. METHODS: This retrospective study analyzed patients with histologically confirmed H. pylori undergoing gastroscopy between June 2023 and September 2024 at a tertiary center in Taiwan. Kimura-Takemoto classification and EGGIM scores (1-4: focal IM; 5-10: extensive IM) were assessed using high-resolution white-light and narrow-band imaging. Biopsies from antrum and corpus were analyzed to determine site-specific detection rate stratified by endoscopic severity. RESULTS: Among 127 patients (63% female; mean age 61.6 years), the overall detection rate was higher in the antrum than the corpus (89.8% vs. 59.1%, p < 0.001) and remained superior across all stages of Kimura-Takemoto classification. However, with increasing IM severity by EGGIM, antral detection declined while corpus detection increased (focal IM: 92.7% vs. 54.5%, p < 0.001; extensive IM: 84.4% vs. 68.8%, p = 0.302). Additionally, patients aged ≥65 years showed significantly reduced antral detection compared to younger patients (80.8% vs. 96.0%, p = 0.013), whereas corpus detection remained unaffected by age. CONCLUSIONS: Endoscopic features can guide biopsy site selection. Although antral biopsies provide the highest yield, adding corpus biopsies is essential for patients with extensive IM (EGGIM ≥5) or age ≥65 years to optimize H. pylori detection.