Does a small biopsied gastric specimen limit the usage of two directional transnasal esophagogastroduodenoscopy?

AbstractBackground and Aims:  It is difficult to approach certain gastric regions due to the limited bending ability of transnasal esophagogastroduodenoscopy (TN‐EGD). We analyzed the TN‐EGD biopsied specimens according to where they were obtained inside the stomach.Methods:  Two hundred and eighty‐nine gastric biopsy specimens were obtained during diagnostic TN‐EGD. The gastric biopsied specimens were quantified according to their diameter and depth in micrometers, and depth in layers (superficial mucosa, deep mucosa, muscularis mucosa and submucosa). The quality was measured by the degrees of anatomical orientation (good, intermediate and poor), presence of crush artifact (none to minimal, mild and moderate) and overall diagnostic adequacy (adequate, suboptimal and inadequate).Results:  Poor orientation, presence of crush and overall diagnostic inadequacy were present in 33 (11.4%), 26 (9.0%) and 37 (12.8%) of the 289 specimens, respectively. Deep mucosa was present in 211 specimens (73.0%), while muscularis mucosa was present in only 75 specimens (26.0%). Specimens taken from the posterior aspect of the cardia exhibited the shallowest depth (P = 0.011), poorest orientation (P < 0.001) and poorest diagnostic adequacy (P < 0.001). Fluoroscopic findings demonstrated that the posterior aspect of the cardia was difficult to approach closely and perpendicularly because of the anatomical configuration of the stomach in nature.Conclusion:  TN‐EGD biopsied specimens obtained from the posterior aspect of the cardia exhibit limitations in both quality and quantity. When performing a biopsy using two directional TN‐EGD, special attention should be paid to gastric lesions located on the posterior aspect of the cardia.