Early diagnosis of gastric cancer is essential for patient prognosis. Currently, endoscopic forceps biopsy (EFB) is an important tool for the diagnosis of gastric cancer. However, it has been shown in relevant studies that there are some differences between EFB-based diagnosis and pathological diagnosis after endoscopic submucosal dissection (ESD), resulting in an underestimation of the patient's condition. No related research has been conducted in northern Shaanxi.

To calculate the rate of pathological upgrading in gastric mucosal lesions after ESD in five hospitals in northern Shaanxi, and to analyze the factors associated with pathological upgrading.

We recruited patients with gastric mucosal lesions who underwent ESD following EFB in five hospitals (Yan'an University Affiliated Hospital, Yan'an People's Hospital, the First Hospital of Yulin, Yan'an Traditional Chinese Medicine Hospital, Zichang People's Hospital) from 2016 to 2021. We classified the pathological results of gastric mucosal lesions into the following categories: chronic gastric inflammatory changes (CIC), low-grade gastric intraepithelial neoplasia (LGIN), high-grade gastric intraepithelial neoplasia (HGIN), early gastric cancer (EGC) and progressive gastric cancer. The difference between EFB-based diagnosis and pathological diagnosis of ESD specimens was analyzed. Pathological upgrading was defined as progression in pathological results. The pathological upgrading in patients with CIC, LGIN or HGIN was counted. The factors associated with pathological upgrading were analyzed.

A total of 241 patients were included. The EFB-based diagnosis of CIC, LGIN, HGIN, and EGC were 84, 75, 65, 17 cases, respectively. Seventy-six (31.5%) were found with pathological upgrading after ESD compared with their EFB-based diagnoses. Binary logistic regression analysis showed that endoscopic classification〔OR=0.134, 95%CI (0.029, 0.617) 〕 and superficial ulceration〔OR=3.595, 95%CI (1.226, 10.536) 〕 were associated with pathological upgrading in CIC by EFB-based diagnosis (P<0.05). Age〔OR=3.961, 95%CI (1.071, 14.650) 〕, endoscopic classification〔OR=0.311, 95%CI (0.127, 0.765) 〕, redness of mucosal surface〔OR=5.830, 95%CI (1.591, 21.355) 〕, and number of specimens〔OR=0.234, 95%CI (0.063, 0.872) 〕 were associated with pathological upgrading in LGIN by EFB-based diagnosis (P<0.05). Lesion size〔OR=3.143, 95%CI (1.003, 9.852) 〕 was associated with pathological upgrading in HGIN by EFB-based diagnosis (P<0.05) .

Medical workers should be alert to the potential possibility of underestimated pathology in EFB if the lesion is CIC suggested by EFB but is endoscopically classified as flat or concave with surface ulceration. And the potential possibility is also should be considered if there is only one biopsy specimen obtained from a patient aged greater than 60 years, and the lesion is LGIN suggested by EFB, but is endoscopically classified as flat with redness of mucosal surface, and an ESD can be underwent if necessary. Moreover, if a lesion greater than 2 cm in size is HGIN suggested by EFB, which is probably EGC, and an ESD is recommended to verify it.

胃癌的早期诊断对患者预后至关重要，目前，内镜下钳夹活检（EFB）是胃癌诊断的重要手段。然而，据相关研究显示，EFB诊断与内镜黏膜下剥离术（ESD）术后病理诊断之间存在一定差异，导致患者病情被低估。陕北地区目前此相关研究较少。

统计陕北地区5所医院因胃黏膜病变经ESD后的病理升级率，并分析病理升级的相关因素。

收集2016—2021年延安大学附属医院、延安市人民医院、榆林市第一医院、延安市中医院、子长市人民医院因胃黏膜病变行ESD治疗的患者，其术前均行EFB。本研究将病理类型分为：慢性炎性改变（CIC）、低级别上皮内瘤变（LGIN）、高级别上皮内瘤变（HGIN）、早期胃癌（EGC）及进展期胃癌。分析患者术前EFB诊断与ESD术后病理诊断的差异，将术后病理诊断发生升级者定义为病理升级。分别对术前EFB诊断为CIC、LGIN、HGIN患者ESD术后病理升级情况进行统计，并分析病理升级的相关因素。

本研究共纳入241例患者。术前EFB诊断为CIC、LGIN、HGIN、EGC分别为84、75、65、17例。术前EFB诊断与ESD术后病理诊断总体升级率为31.5%（76/241）。多因素Logistic回归分析结果显示，内镜下分型〔OR=0.134，95%CI（0.029，0.617）〕和表面溃疡〔OR=3.595，95%CI（1.226，10.536）〕是术前EFB诊断为CIC患者ESD术后病理升级的影响因素（P<0.05）；年龄〔OR=3.961，95%CI（1.071，14.650）〕、内镜下分型〔OR=0.311，95%CI（0.127，0.765）〕、表面发红〔OR=5.830，95%CI（1.591，21.355）〕及取材数目〔OR=0.234，95%CI（0.063，0.872）〕是术前EFB诊断为LGIN患者ESD术后病理升级的影响因素（P<0.05）；病灶大小〔OR=3.143，95%CI（1.003，9.852）〕是术前EFB诊断为HGIN患者ESD术后病理升级的影响因素（P<0.05）。

若术前活检提示为CIC，但内镜下分型为平坦型或凹陷型，病灶有表面溃疡，应警惕病理被低估的可能；术前活检提示为LGIN，但患者年龄>60岁、病灶为平坦型、病灶表面发红且取活检数目只有1块时，不排除术前病理被低估，必要时可行ESD；病灶大小>2 cm时，术前活检诊断HGIN的病灶很可能为EGC，建议行ESD。