What is the treatment for atrophic gastritis?

Treatment of Atrophic Gastritis

The treatment of atrophic gastritis must be tailored to its etiology, with H. pylori eradication as the cornerstone for H. pylori-associated atrophic gastritis and management of micronutrient deficiencies for autoimmune atrophic gastritis. 1

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 2
• Successful eradication must be confirmed using non-serological testing methods 2
• Bismuth quadruple therapy is recommended as first-line treatment due to increasing clarithromycin resistance 3
• Concomitant 4-drug therapy is an alternative when bismuth is not available 3
• H. pylori eradication may modify the natural history of atrophy, though it has less effect on intestinal metaplasia 1

Autoimmune Atrophic Gastritis

• Confirm diagnosis through antiparietal cell antibodies and anti-intrinsic factor antibodies 2, 1
• Screen for associated autoimmune disorders, particularly autoimmune thyroid disease 1
• No specific treatment exists to reverse the autoimmune process, so management focuses on complications 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
• Vitamin B12 supplementation is essential for patients with pernicious anemia 4
• Regular monitoring of hematologic parameters is recommended for early detection of deficiencies 4

Surveillance for Neoplastic Lesions

• Consider surveillance endoscopy every 3 years for patients with advanced atrophic gastritis, based on anatomic extent and histologic grade 2
• Patients with a new diagnosis of pernicious anemia should undergo endoscopy to confirm corpus-predominant atrophic gastritis and rule out gastric neoplasia 2
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy in patients with autoimmune atrophic gastritis 1
• 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

Endoscopic Evaluation and Biopsy Protocol

• Perform high-quality endoscopic examination following a systematic approach to maximize diagnostic yield 2
• Ensure excellent mucosal visualization with adequate air insufflation and mucosal cleansing 2
• Consider using defoaming and mucolytic agents such as simethicone and 1% N-acetylcysteine 2
• Obtain biopsies from the suspected atrophic/metaplastic areas for histopathological confirmation and risk stratification 2
• At minimum, biopsies from the body and antrum/incisura should be obtained and placed in separately labeled jars 2
• Targeted biopsies should additionally be obtained from any other mucosal abnormalities 2

Emerging Therapeutic Targets

• Recent research has identified several signaling pathways involved in the development of chronic atrophic gastritis, including NF-κB, PI3K/AKT, Wnt/β-catenin, MAPK, Toll-like receptors, Hedgehog, and VEGF 5
• These pathways may serve as future therapeutic targets for specific drugs to treat chronic atrophic gastritis 5

Pitfalls and Caveats

• Atrophic gastritis is often underdiagnosed due to subtle endoscopic features and inconsistent histopathological reporting 1
• The risk of gastric adenocarcinoma might be highest within the first year of pernicious anemia diagnosis, warranting prompt endoscopic evaluation 1
• Antibiotic resistance is an emerging problem requiring accurate knowledge of local eradication rates 6
• Standard triple therapy should be abandoned in regions with high clarithromycin resistance 6
• In patients with atrophic gastritis involving the corpus, reduced gastric acid secretion may affect the efficacy of common treatment regimens combining proton pump inhibitors with antibiotics 7
• Bismuth-based therapy may be particularly effective in the specific setting of atrophic gastritis 7