What is the recommended management for a patient with mild reactive gastropathy and no evidence of Helicobacter pylori infection?

Management of Mild Reactive Gastropathy Without H. pylori Infection

For patients with mild reactive gastropathy and no evidence of H. pylori infection, the recommended management is empirical acid suppression therapy with a proton pump inhibitor (PPI) for 4-8 weeks. 1

Diagnostic Context

• The biopsy findings indicate mild reactive gastropathy with no evidence of H. pylori infection, inflammation, intestinal metaplasia, or dysplasia 2
• Reactive gastropathy represents chemical injury to the gastric mucosa characterized by foveolar hyperplasia, interfoveolar smooth muscle fibers, and other nonspecific changes without significant inflammation 3
• This condition is often associated with nonsteroidal anti-inflammatory drug (NSAID) use or bile reflux, but can be of indeterminate etiology 2, 4

Management Algorithm

First-Line Approach

• Empirical PPI therapy for 4-8 weeks is the most cost-effective first-line approach for patients with dyspeptic symptoms and negative H. pylori status 1
• Full dose PPI therapy (e.g., omeprazole 20 mg once daily) should be used, especially for patients with epigastric pain or ulcer-like dyspepsia 1
• If NSAID use is identified as a potential cause, consider discontinuing or switching to another agent 1

Follow-up Management

• If symptoms resolve with initial PPI therapy, consider a trial of withdrawal with repeat therapy if symptoms recur 1
• For persistent symptoms despite PPI therapy, consider:
  • Switching to a prokinetic agent if symptoms are primarily dysmotility-like (fullness, bloating, satiety) 1
  • Increasing to high-dose PPI therapy for refractory symptoms 1
  • Referral for endoscopic follow-up if symptoms persist despite medication changes 1

Special Considerations

• Ensure that the initial H. pylori testing was accurate, as PPI use prior to testing can lead to false-negative results 1
• If there is concern about previous PPI use affecting H. pylori detection, consider:
  • Stopping PPI for 2 weeks before retesting 1
  • Using validated IgG serology which remains accurate despite PPI use 1

Pitfalls and Caveats

• Reactive gastropathy may be confused with H. pylori gastritis, but they have different mucin expression patterns and pathophysiological mechanisms 2
• The correlation between histological evidence of chemical gastropathy and clinical manifestations (particularly bleeding risk) is not well established 3
• Patients with reactive gastropathy may have altered mucin expression (loss of MUC1, aberrant expression of MUC5AC in pyloric glands) which differs from the pattern seen in H. pylori gastritis 2
• Always consider medication review, as many common drugs can cause reactive gastropathy 5

Long-term Monitoring

• No specific follow-up endoscopy is required for uncomplicated reactive gastropathy without alarm features 1
• For patients over 55 years with persistent symptoms despite therapy, consider follow-up endoscopy 1
• For younger patients without alarm symptoms, endoscopy adds little value if symptoms persist despite therapy 1