What is the treatment for atrophic gastritis?

Treatment of Atrophic Gastritis

The treatment of atrophic gastritis should include H. pylori eradication if positive, vitamin B12 and iron supplementation for deficiencies, and endoscopic surveillance every 3 years for advanced atrophic gastritis to monitor for malignancy development. 1

Diagnosis and Initial Assessment

When atrophic gastritis is suspected, the following steps should be taken:

1. Confirm diagnosis with endoscopy and biopsies:

   • Obtain biopsies from suspected atrophic/metaplastic areas
   • At minimum, biopsies from both body and antrum/incisura in separately labeled jars
   • Target any other mucosal abnormalities 1

2. Determine etiology:

   • Test for H. pylori infection using non-serological methods
   • For suspected autoimmune gastritis, check antiparietal cell antibodies and anti-intrinsic factor antibodies 1

3. Assess for micronutrient deficiencies:

   • Iron status (particularly in corpus-predominant atrophic gastritis)
   • Vitamin B12 levels 1

4. Risk stratification:

   • Determine anatomic extent and histologic grade of atrophy
   • Classify using OLGA/OLGIM staging system 1

Treatment Algorithm

1. H. pylori Eradication (if positive)

• All patients with atrophic gastritis should be tested for H. pylori
• If positive, administer appropriate eradication therapy (typically 14-day regimen)
• Confirm successful eradication using non-serological testing at least 4 weeks after treatment 1, 2
• Even if atrophy persists after eradication, H. pylori treatment reduces gastric cancer risk 1

2. Management of Nutritional Deficiencies

• For vitamin B12 deficiency: vitamin B12 supplementation
• For iron deficiency: iron supplementation
• Regular monitoring of these parameters, especially in corpus-predominant atrophic gastritis 1

3. Endoscopic Surveillance

For H. pylori-related atrophic gastritis:

• Consider endoscopic surveillance every 3 years for advanced atrophic gastritis (OLGA/OLGIM stage III/IV) 1, 3
• Adjust intervals based on individual risk factors (family history of gastric cancer, immigration from high-risk regions, persistent H. pylori, smoking) 1

For autoimmune atrophic gastritis:

• Surveillance endoscopy every 3-5 years 1, 3
• For patients with pernicious anemia without recent endoscopy, perform endoscopy to confirm corpus-predominant atrophic gastritis and rule out neoplasia 1

4. Management of Neuroendocrine Tumors (NETs)

• Screen for type 1 gastric NETs with upper endoscopy in autoimmune gastritis patients 1, 4
• For small NETs (<1 cm): endoscopic resection followed by surveillance every 1-2 years 1
• For NETs >1-2 cm: consider endoscopic ultrasound to assess depth and local metastasis 1
• For NETs >2 cm or with submucosal invasion/lymph node metastasis: surgical resection 1

5. Management of Associated Conditions

• Screen for autoimmune thyroid disease in patients with autoimmune gastritis 1, 3
• Consider evaluation for other autoimmune conditions (type 1 diabetes, Addison's disease) if clinically indicated 1

Special Considerations

1. Proton pump inhibitors (PPIs):

   • Not indicated in hypochlorhydric atrophic gastritis patients 3
   • Should be stopped at least 2 weeks before H. pylori testing 2

2. Monitoring progression:

   • Long-term follow-up is necessary as autoimmune atrophic gastritis is linked to pathologic progression of NETs and gastric adenocarcinoma 4
   • NETs arising in autoimmune atrophic gastritis are typically well-differentiated with low Ki-67 index 4

3. Risk of malignancy:

   • Autoimmune atrophic gastritis is associated with increased risk of type I NETs (2.8% per person/year) and gastric cancer (0.5% per person/year) 5
   • Patients with advanced stages of atrophic gastritis (Stage III/IV OLGA or OLGIM) require more vigilant surveillance 1, 3

By following this treatment approach, clinicians can effectively manage atrophic gastritis, prevent complications, and monitor for potential malignant transformation.