What is the treatment for atrophic gastritis?

Treatment of Atrophic Gastritis

The treatment of atrophic gastritis should focus on addressing the underlying etiology (H. pylori or autoimmune), eradicating H. pylori infection if present, managing micronutrient deficiencies, and implementing appropriate surveillance for neoplastic lesions. 1, 2

Etiology-Based Treatment Approach

H. pylori-Associated Atrophic Gastritis

• All patients with atrophic gastritis must be assessed for H. pylori infection using non-serological testing modalities 1
• If H. pylori positive, eradication therapy should be administered promptly 1, 2
• Successful eradication must be confirmed using non-serological testing methods 1, 2
• H. pylori eradication may modify the natural history of atrophy, though it has less effect on intestinal metaplasia 2, 3

Autoimmune Atrophic Gastritis

• Confirm diagnosis through antiparietal cell antibodies and anti-intrinsic factor antibodies 1
• Screen for associated autoimmune disorders, particularly autoimmune thyroid disease 1
• Consider evaluating for other autoimmune conditions (type 1 diabetes mellitus, Addison's disease) if clinically indicated 1, 4

Management of Micronutrient Deficiencies

• Evaluate all patients with atrophic gastritis for iron and vitamin B-12 deficiencies, especially if corpus-predominant 1
• Iron deficiency is common (up to 50% of patients with corpus-predominant atrophic gastritis) and often presents earlier than B-12 deficiency 1, 4
• Provide appropriate supplementation for identified deficiencies 3, 4
• Proton pump inhibitors are not indicated in hypochlorhydric atrophic gastritis patients 3

Surveillance for Neoplastic Lesions

General Surveillance

• Consider surveillance endoscopy every 3 years for patients with advanced atrophic gastritis, based on anatomic extent and histologic grade 1, 2
• Risk stratification should use histological staging systems (OLGA or OLGIM) 3
• Higher risk factors for progression to gastric neoplastic lesions include:
  • Age over 50 years (HR 8.8) 5
  • Atrophic pangastritis (HR 4.5) 5
  • Severe intestinal metaplasia in the gastric body (HR 4.0) 5

Surveillance for Autoimmune Gastritis

• Patients with a new diagnosis of pernicious anemia should undergo endoscopy to confirm corpus-predominant atrophic gastritis and rule out gastric neoplasia 1
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy 1, 2
• Small neuroendocrine tumors (<1 cm) should be removed endoscopically 1
• Consider surveillance endoscopy every 1-2 years depending on the burden of neuroendocrine tumors 1
• For gastric NETs >1-2 cm, consider endoscopic ultrasound to assess invasion depth and presence of local metastasis 1
• Surgical resection is appropriate for NETs >2 cm, with invasion past submucosa, or with evidence of lymph node metastasis 1

Management of Coexisting Conditions

• In patients with autoimmune gastritis, screen for autoimmune thyroid disease 1
• Consider evaluating for other associated autoimmune diseases if clinically indicated 1, 4
• Patients with atrophic gastritis may have dyspeptic symptoms, though optimal treatment remains to be defined 3, 6

Pitfalls and Caveats

• Atrophic gastritis is often underdiagnosed due to subtle endoscopic features and inconsistent histopathological reporting 1, 6
• Ensure proper biopsy sampling (minimum from body and antrum/incisura in separate jars) for accurate diagnosis and risk stratification 1
• There are differences between European and American guidelines regarding surveillance strategies - European guidelines recommend systematic surveillance for severe atrophic gastritis while American guidelines focus on intestinal metaplasia 7
• The risk of gastric adenocarcinoma might be highest within the first year of pernicious anemia diagnosis, warranting prompt endoscopic evaluation 1