What are the differences in treatment approaches for chronic gastritis and atrophied gastritis?

Treatment Approaches for Chronic Gastritis vs. Atrophic Gastritis

The primary difference in treatment between chronic gastritis and atrophic gastritis is that while H. pylori eradication is central to both, atrophic gastritis requires additional management of micronutrient deficiencies and surveillance for neoplastic complications.

Etiology and Diagnosis

• Chronic gastritis is primarily caused by H. pylori infection, resulting in inflammation of the gastric mucosa without significant glandular loss 1
• Atrophic gastritis is defined as the loss of gastric glands with or without metaplasia, in the setting of chronic inflammation, primarily due to H. pylori infection or autoimmunity 1
• Diagnosis of both conditions should be confirmed by histopathology with biopsies from both gastric body and antrum/incisura 1, 2
• The presence of intestinal metaplasia on gastric histology almost invariably implies the diagnosis of atrophic gastritis 1

Treatment Approach for Chronic Gastritis

• H. pylori eradication is the cornerstone of treatment for H. pylori-positive chronic gastritis 1, 2
• Successful eradication should be confirmed using non-serological testing modalities 2
• H. pylori eradication may increase, decrease, or have no overall effect on acid secretion depending on the initial pattern of gastritis 1
• For functional dyspepsia with H. pylori infection, eradication leads to a 25% reduction in dyspepsia consultations between 2-7 years of follow-up 1

Treatment Approach for Atrophic Gastritis

H. pylori Eradication

• All individuals with atrophic gastritis should be assessed for H. pylori infection 1, 2
• If positive, H. pylori eradication treatment should be administered and successful eradication confirmed 1, 3
• H. pylori eradication may reduce the risk of gastric cancer even in patients with established atrophic gastritis, although most patients may have passed a "point-of-no-return" where gastric mucosal damage cannot be completely reversed 1, 3

Management of Micronutrient Deficiencies

• Patients with corpus-predominant atrophic gastritis should be evaluated for iron and vitamin B-12 deficiencies due to reduced gastric acid secretion and intrinsic factor 1, 2
• Iron deficiency is common, occurring in up to 50% of patients with corpus-predominant atrophic gastritis 1
• For autoimmune atrophic gastritis, vitamin B12 supplementation is often necessary 2, 4

Surveillance for Neoplastic Complications

• Endoscopic surveillance should be considered every 3 years in patients with advanced atrophic gastritis 1
• For autoimmune atrophic gastritis, surveillance intervals should be based on individualized risk assessment 1
• In patients with newly diagnosed pernicious anemia, upper endoscopy should be considered within 6 months of diagnosis to evaluate for prevalent gastric neoplasia and neuroendocrine tumors 1

Management of Gastric Neuroendocrine Tumors

• Gastric NETs associated with atrophic gastritis represent approximately 80-90% of all gastric NETs 1
• Small NETs (<1 cm) should be resected endoscopically with surveillance endoscopy every 1-2 years 1
• For gastric NETs >1-2 cm, endoscopic ultrasound should be considered to assess depth of tumor invasion 1
• Surgical resection is appropriate for NETs >2 cm, with invasion past the submucosa, or with evidence of lymph node metastasis 1

Special Considerations for Autoimmune Atrophic Gastritis

• In patients with histology compatible with autoimmune gastritis, check antiparietal cell antibodies and anti-intrinsic factor antibodies 1, 2
• Screen for autoimmune thyroid disease and other autoimmune disorders 1
• Proton pump inhibitors are not indicated in hypochlorhydric atrophic gastritis patients 5

Risk Stratification and Surveillance

• Risk stratification should be based on the severity and distribution of atrophic lesions using systems like OLGA or OLGIM 6, 5
• Patients with advanced stages of atrophic gastritis (Stage III/IV OLGA or OLGIM) should undergo endoscopic surveillance every three years 5
• Patients with autoimmune atrophic gastritis should undergo surveillance every three to five years 5

Common Pitfalls and Caveats

• Proton pump inhibitors can raise both circulating chromogranin A and gastrin, potentially complicating the diagnosis of gastrinoma in patients with atrophic gastritis 1
• PPIs should be withdrawn with caution and ideally stopped 10 days to 2 weeks before any planned estimation of circulating fasting gastrin 1
• Initial endoscopy may underestimate disease-associated risk in up to one-third of patients classified as low-risk 6
• Despite successful H. pylori eradication, patients with extensive or moderate to severe atrophy still require endoscopic surveillance due to persistent elevated cancer risk 1