Endoscopic Assessment of Helicobacter pylori Infection: Validation of a Modified Kyoto Classification System in Real-world Clinical Practice

Background: While Helicobacter pylori remains a cornerstone pathogen in gastric disease pathogenesis, current diagnostic approaches face practical limitations in routine endoscopic practice. The original Kyoto classification system, though valuable, requires refinement for optimal real-world clinical utility in diverse populations. Methods: We retrospectively analyzed endoscopic findings from 276 patients who underwent both gastroscopy and confirmatory H. pylori testing (urea breath test or histopathological examination) between January 2020 and December 2023. Two experienced endoscopists independently scored gastric mucosal features using this modified Kyoto classification system, with discrepancies resolved through consensus review. Results: This modified scoring system demonstrated moderate correlation with laboratory-confirmed H. pylori status (r = 0.366, p < 0.001). ROC analysis revealed an AUC of 0.74, with optimal diagnostic threshold at 6.0 points yielding 59.8% sensitivity and 74.6% specificity. Feature-specific analysis revealed that enlarged gastric folds (r = 0.265) and spotty redness (r = 0.258) were correlated with H. pylori infection status. Interpretation: Despite inherent limitations in endoscopic assessment, this modified classification system offers practical value for real-time H. pylori evaluation during routine gastroscopy. However, clinicians should recognize its complementary rather than replacement role alongside established diagnostic methods.