What is the appropriate management for a patient with antral gastric mucosa showing foveolar hyperplasia, mild chronic inflammation and regenerative changes consistent with reactive gastropathy, without Helicobacter pylori and without intestinal metaplasia?

Management of Reactive Gastropathy Without H. pylori or Intestinal Metaplasia

For a patient with reactive gastropathy showing foveolar hyperplasia and mild chronic inflammation without H. pylori or intestinal metaplasia, initiate proton pump inhibitor (PPI) therapy and identify/eliminate the causative agent—most commonly NSAIDs, aspirin, bile reflux, or other medications.

Immediate Management Steps

1. Identify and Address the Underlying Cause

The pathology describes classic reactive (chemical) gastropathy 1, 2. Your primary task is identifying the culprit:

• Medication review: Stop or reduce NSAIDs, aspirin, anticoagulants, oral iron preparations, or corticosteroids if possible 1, 3
• Bile reflux assessment: Look for history of cholecystectomy, higher BMI, or endoscopic evidence of bile in the stomach 4
• Multiple medications: Children and adults taking multiple drugs are at higher risk 1

The histologic features you describe—foveolar hyperplasia, mild inflammation, and regenerative changes—are the hallmark of chemical injury to gastric mucosa 2, 5.

2. Acid Suppression Therapy

Start PPI therapy (standard dose once or twice daily) for 8 weeks 6, 1. This is the cornerstone of treatment:

• Reduces acid-mediated injury
• Allows mucosal healing
• May help distinguish reactive changes from true dysplasia if present 6

All patients in pediatric series with reactive gastropathy received acid suppression with symptom resolution in 65% and partial improvement in 35% 1.

3. Confirm H. pylori Status

Although your pathology report states "Helicobacter-like organisms are not identified," consider non-invasive H. pylori testing (stool antigen or urea breath test) if not already done 7. Histology can miss patchy infection, and H. pylori eradication is essential for gastric cancer prevention even without current infection 7.

Risk Stratification

No Surveillance Needed in Most Cases

This patient does NOT require endoscopic surveillance based on current evidence 8:

• No intestinal metaplasia present
• No atrophy documented
• No dysplasia
• H. pylori negative

The 2020 AGA guidelines specifically recommend against routine surveillance for patients without gastric intestinal metaplasia 8.

Consider Repeat Endoscopy Only If:

Repeat endoscopy within 1 year may be reasonable through shared decision-making if the patient has 7, 8:

• First-degree relative with gastric cancer
• Immigration from high gastric cancer incidence region (East Asia, Eastern Europe, Central/South America)
• Racial/ethnic minority status
• Persistent symptoms despite treatment
• Concerns about completeness of initial biopsy protocol

If repeat endoscopy is performed, use the updated Sydney System protocol: minimum 5 biopsies (2 from antrum, 1 from incisura, 2 from corpus) in separate jars 7, 9.

Follow-Up Strategy

Clinical Follow-Up at 8-12 Weeks

• Assess symptom response to PPI therapy
• Confirm elimination/reduction of causative medications
• If symptoms persist, consider repeat endoscopy to exclude other pathology

Long-Term Management

• Continue PPI at lowest effective dose if symptoms recur with discontinuation
• Avoid NSAIDs/aspirin when possible; if necessary, use with PPI co-therapy
• Address modifiable risk factors: obesity (associated with bile reflux), smoking cessation
• Regular aerobic exercise recommended for all patients with upper GI symptoms 10

Common Pitfalls to Avoid

1. Don't assume H. pylori negativity on histology alone: Patchy distribution can cause false negatives; consider non-invasive testing
2. Don't initiate surveillance protocols: Reactive gastropathy without atrophy/metaplasia doesn't warrant surveillance 8
3. Don't miss medication culprits: Specifically ask about over-the-counter NSAIDs, aspirin, iron supplements
4. Don't overlook bile reflux: History of cholecystectomy, higher BMI, and endoscopic bile presence are clues 4
5. Don't confuse reactive changes with dysplasia: Regenerative atypia can mimic dysplasia; PPI therapy helps clarify 6

When to Refer to Gastroenterology

Referral is appropriate if 10:

• Symptoms persist despite 8 weeks of PPI therapy and causative agent elimination
• Diagnostic uncertainty exists
• Patient has multiple gastric cancer risk factors and desires specialist evaluation
• Severe or refractory symptoms affecting quality of life

The key distinction here is that reactive gastropathy is a reversible condition when the inciting agent is removed, unlike premalignant conditions (atrophy, intestinal metaplasia) that require surveillance 2, 5.