What is the diagnosis and treatment for a patient with a gastric tissue biopsy showing active gastric inflammation with pititis, pit abscesses, and a mixed inflammatory infiltrate?

Diagnosis and Treatment of Helicobacter pylori Gastritis

The gastric tissue biopsy shows active Helicobacter pylori gastritis requiring antibiotic eradication therapy with a proton pump inhibitor plus clarithromycin-based triple therapy for 14 days as the optimal treatment. 1

Interpretation of the Biopsy Results

The biopsy findings clearly indicate H. pylori infection with characteristic histopathological features:

• Maintained foveolar architecture with active inflammation (pititis and pit abscesses)
• Mixed inflammatory infiltrate with neutrophils, lymphocytes, and plasma cells
• Visible spiral organisms on the mucosal border

These findings are diagnostic of active H. pylori gastritis. The presence of neutrophilic infiltration in the gastric mucosa, particularly in the necks of glands (pititis), is highly specific for H. pylori infection and rarely occurs without it 2.

Recommended Treatment Algorithm

1. First-line therapy (H. pylori eradication):

   • 14-day course of proton pump inhibitor (PPI) plus clarithromycin-based triple therapy with either amoxicillin or metronidazole 1, 3
   • Standard regimen: PPI twice daily + clarithromycin 500mg twice daily + amoxicillin 1g twice daily (or metronidazole 500mg twice daily if penicillin allergic)

2. Verification of eradication:

   • Urea breath test at least 6 weeks after therapy and 2 weeks after PPI withdrawal 3
   • Alternative: stool antigen test

3. If first eradication attempt fails:

   • Second-line therapy with alternative triple- or quadruple-therapy regimens 1
   • Consider susceptibility testing if available to guide antibiotic selection 1

Clinical Significance and Prognosis

H. pylori gastritis is associated with several important clinical outcomes:

• Peptic ulcer disease: H. pylori is a major cause of gastric and duodenal ulcers
• Gastric cancer risk: Chronic H. pylori infection can lead to atrophic gastritis, intestinal metaplasia, and increased risk of gastric cancer 1
• MALT lymphoma: In rare cases, H. pylori infection can lead to gastric MALT lymphoma 1

Important Clinical Considerations

• Follow-up endoscopy: Consider follow-up endoscopy with biopsies if symptoms persist despite successful eradication
• Antibiotic resistance: The prevalence of antibiotic resistance has increased, particularly to clarithromycin, metronidazole, and fluoroquinolones 1
• Antimicrobial stewardship: Treatment should be optimized to achieve high cure rates (≥95%) 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: 14 days is optimal; shorter courses have lower eradication rates 1
2. Premature testing after treatment: Testing too soon after therapy can lead to false negative results
3. Not confirming eradication: Always confirm successful eradication with a test of cure
4. Ignoring antibiotic history: Previous antibiotic exposure increases the risk of resistance 1
5. Overlooking PPI timing: PPIs should be stopped 2 weeks before urea breath testing to avoid false negative results

H. pylori eradication is crucial as it halts the progression of gastritis, reduces the risk of peptic ulcer disease, and decreases the lifetime risk of gastric cancer 1. The inflammation and epithelial damage seen in your biopsy will resolve within days to weeks of successful treatment.