What is the treatment approach for atrophic gastritis?

Treatment Approach for Atrophic Gastritis

The treatment of atrophic gastritis should focus on H. pylori eradication when present, micronutrient supplementation, and endoscopic surveillance for neoplastic complications based on risk stratification. 1

Etiology-Based Treatment

H. pylori-Associated Atrophic Gastritis

• First-line treatment: PPI-based triple therapy consisting of:
  • PPI (standard dose twice daily)
  • Amoxicillin (1g twice daily)
  • Clarithromycin (500mg twice daily) for 14 days 2
• For patients with previous clarithromycin failure:
  • PPI (standard dose twice daily)
  • Amoxicillin (1g twice daily)
  • Metronidazole (500mg twice daily) for 14 days 2
• Complete the full 14-day course even if symptoms improve to prevent treatment failure and antibiotic resistance 2
• Confirm eradication with urea breath test or stool antigen test at least 4 weeks after completing therapy 2

Autoimmune Atrophic Gastritis

• No specific treatment to reverse the autoimmune process
• Focus on managing complications and preventing progression 3

Management of Nutritional Deficiencies

• Iron deficiency: Present in up to 50% of patients with corpus-predominant atrophic gastritis 1

  • Oral or parenteral iron supplementation based on severity

• Vitamin B12 deficiency: Common in autoimmune atrophic gastritis 1

  • Parenteral vitamin B12 supplementation
  • Regular monitoring of B12 levels

• Routine screening: Evaluate for iron and vitamin B12 deficiency in all patients with atrophic gastritis, especially if corpus-predominant 1

Endoscopic Surveillance

For Advanced Atrophic Gastritis

• Surveillance interval: Every 3 years for patients with advanced atrophic gastritis 1
• Risk stratification factors to consider for adjusting intervals:
  • Quality of baseline endoscopy
  • Family history of gastric cancer
  • Immigration from high-risk regions
  • Persistent H. pylori infection
  • Smoking history
  • Dietary factors 1

For Autoimmune Atrophic Gastritis (AIG)

• European Society for Gastrointestinal Endoscopy recommends surveillance every 3-5 years 1
• For patients with pernicious anemia (PA):
  • Initial endoscopy within 6 months of PA diagnosis
  • Prompt endoscopy for any new upper GI symptoms 1

Management of Gastric Neuroendocrine Tumors (NETs)

• For NETs <1 cm:

  • Endoscopic resection
  • Surveillance endoscopy every 1-2 years depending on NET burden 1

• For NETs 1-2 cm:

  • Endoscopic ultrasound to assess invasion depth and local metastasis
  • Management based on findings 1

• For NETs >2 cm or with invasion/metastasis:

  • Surgical resection 1

Associated Autoimmune Conditions

• Screen for autoimmune thyroid disease in patients with autoimmune atrophic gastritis 1
• Consider evaluation for other autoimmune diseases (type 1 diabetes mellitus, Addison's disease) when clinically indicated 1

Diagnostic Approach

• Upper endoscopy with targeted biopsies from both antrum and corpus/body 2
• Biopsy protocol should include:
  • Samples from any visible abnormal areas
  • Topographical biopsies to determine anatomic extent and severity 2
• Laboratory evaluation:
  • Complete blood count
  • Iron studies
  • Vitamin B12 levels 2

Pitfalls and Caveats

• Despite H. pylori eradication, many patients have passed a "point-of-no-return" where gastric mucosal damage cannot be reversed, necessitating continued surveillance 1
• Atrophic gastritis is often asymptomatic and underdiagnosed, leading to delayed management of complications 3
• The risk of gastric adenocarcinoma is highest within the first year of pernicious anemia diagnosis 1
• Coordinated efforts between gastroenterologists and pathologists are essential for proper diagnosis and characterization of atrophic gastritis 1