What are the next steps in managing a patient with thickening of the gastric mucosa in the fundus and body?

Management of Gastric Mucosal Thickening in the Fundus and Body

The next step in managing a patient with thickening of the gastric mucosa in the fundus and body should be an upper endoscopy with targeted biopsies for histopathological confirmation and risk stratification.1

Understanding the Clinical Significance

Thickening of the gastric mucosa in the fundus and body can represent several conditions, with atrophic gastritis being a key concern due to its association with increased gastric cancer risk.

• Gastric mucosal thickening in the fundus and body may indicate autoimmune gastritis (AIG), which typically affects these areas while sparing the antrum 1
• Early-phase AIG often presents with subtle mucosal changes, including nonspecific erythema and thickening, and can be missed without proper biopsies 1
• The endoscopic appearance of atrophic gastritis may be subtle and requires high-quality examination following a systematic approach 1
• Gastric wall is considered thickened at endosonography when it is more than 3.6 mm in width 2

Recommended Diagnostic Approach

1. High-Quality Upper Endoscopy

• Perform a high-quality endoscopic examination with adequate air insufflation and mucosal cleansing 1
• Consider using defoaming and mucolytic agents (simethicone, 1% N-acetylcysteine) for optimal mucosal visualization 1
• Examine the entire gastric lumen systematically, including color, texture, appearance of submucosal blood vessels, and architecture of gastric rugae 1
• Use high-definition white-light endoscopy (HD-WLE) or image-enhanced techniques such as narrow-band imaging (NBI) for targeted examination of focal abnormalities 1

2. Biopsy Protocol

• Obtain biopsies from the suspected atrophic/metaplastic areas for histopathological confirmation 1
• At minimum, take biopsies from the body and antrum/incisura and place them in separately labeled jars 1
• Follow the updated Sydney protocol for obtaining topographical biopsies to maximize diagnostic yield 1
• Obtain targeted biopsies from any other mucosal abnormalities identified during endoscopy 1

3. Laboratory Testing

• If histology is compatible with autoimmune gastritis, check antiparietal cell antibodies and anti-intrinsic factor antibodies 1
• Evaluate for anemia due to vitamin B-12 and iron deficiencies, which are common in autoimmune gastritis 1
• Assess for H. pylori infection, as it is a common cause of gastritis and should be treated if present 1

Risk Assessment and Follow-up

• The severity and topographic distribution of atrophic lesions are well-established determinants of gastric cancer risk 1
• Consider using classification systems like Operative Link for Gastritis Assessment (OLGA) or Operative Link for Gastric Intestinal Metaplasia Assessment (OLGIM) for risk stratification 1
• For patients with advanced atrophic gastritis, consider surveillance endoscopy every 3 years 1
• For individuals with autoimmune gastritis, interval endoscopic surveillance should be based on individualized assessment 1

Common Pitfalls to Avoid

• Relying solely on imaging findings without histopathological confirmation can lead to missed diagnoses, as standard biopsies are often necessary to confirm the etiology 3
• Failing to recognize that intestinal metaplasia on gastric histology almost invariably implies the diagnosis of atrophic gastritis 1
• Overlooking the need for proper biopsy technique and specimen handling, which can affect diagnostic accuracy 1
• Not considering H. pylori infection, which should be assessed in all individuals with atrophic gastritis 1

By following this systematic approach, you can accurately diagnose the cause of gastric mucosal thickening and implement appropriate management strategies to reduce morbidity and mortality associated with potential premalignant conditions.