Unifying Concepts

Stage Classification of Gastric Ulcer by Sakita-Miwa

The gastric ulcer are staged, by using of the endoscopic staging system of Sakita, into 3 stages (active, healing, scarring) as follows.

Stages Manifestation
Active stage
A1 The surrounding mucosa is edematously swollen and no regenerating epithelium is seen endoscopically
A2 The surrounding edema has decreased, the ulcer margin is clear, and a slight amount of regenerating epithelium is seen in the ulcer margin. A red halo in the marginal zone and a white slough circle in the ulcer margin are frequently seen. Usually, converging mucosal folds can be followed right up to the ulcer margin
Healing stage
H1 The white coating is becoming thin and the regenerating epithelium is extending into the ulcer base. The gradient between the ulcer margin and the ulcer floor is becoming flat. The ulcer crater is still evident and the margin of the ulcer is sharp. The diameter of the mucosal defect is about one-half to two thirds that of A1
H2 The defect is smaller than in H1 and the regenerating epithelium covers most of the ulcer floor. The area of white coating is about a quarter to one-third that of A1
Scarring stage
S1 The regenerating epithelium completely covers the floor of ulcer. The white coating has disappeared. Initially, the regenerating region is markedly red. Upon close observation, many capillaries can be seen. This is called ‘‘red scar’’
S2 In several months to a few years, the redness is reduced to the color of the surrounding mucosa. This is called ‘‘white scar’’




  1. Kaneko E, Hoshihara Y, Sakaki N, Harasawa S, Ashida K, Asaka M, Asaki S, Nakamura T, Kobayashi K, Kajiyama G, Ogawa N, Yao T, Muto Y, Nakazawa S, Takemoto T. Peptic ulcer recurrence during maintenance therapy with H2-receptor antagonist following first-line therapy with proton pump inhibitor. J Gastroenterol. 2000;35(11):824-31. [Medline]
  2. Matsumoto S, Tsuji K, Shirahama S. Rebamipide enema therapy for left-sided ischemic colitis patients accompanied by ulcers: open label study. World J Gastroenterol. 2008 Jul 7;14(25):4059-64. [Medline]


Created: Jul 23, 2009

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