Management and Treatment of Atrophic Gastritis
All patients with atrophic gastritis must be tested for H. pylori infection and treated if positive, with confirmed eradication using non-serological methods, while simultaneously evaluating for iron and vitamin B-12 deficiencies and establishing endoscopic surveillance based on disease severity. 1, 2
Immediate Diagnostic Workup
Confirm Etiology
- Test all patients for H. pylori using non-serological methods (stool antigen or urea breath test), as this is the most common cause and eradication is essential 1, 2, 3
- For corpus-predominant atrophy, check antiparietal cell antibodies and anti-intrinsic factor antibodies to diagnose autoimmune gastritis 1, 2
- Obtain topographical biopsies (minimum: two from corpus body, two from antrum, one from incisura) in separate jars for accurate staging 1
Assess Micronutrient Status
- Evaluate iron and vitamin B-12 levels in all patients, especially with corpus-predominant disease 1, 2
- Iron deficiency occurs in up to 50% of corpus-predominant cases and typically presents before B-12 deficiency 1, 2, 3
- Complete blood count to assess for anemia 3
Treatment Algorithm
H. pylori-Positive Atrophic Gastritis
- Administer H. pylori eradication therapy immediately using appropriate antibiotic regimen 1, 2, 3
- Confirm successful eradication with non-serological testing (not serology, as antibodies persist) 1, 2
- H. pylori eradication may modify the natural history of atrophy but has less effect on established intestinal metaplasia 2, 3
Autoimmune Atrophic Gastritis
- Screen for autoimmune thyroid disease (TSH, anti-thyroid antibodies) in all patients 1, 2, 3
- Maintain low threshold to evaluate for type 1 diabetes mellitus and Addison's disease if clinically suggested 1
- Replace iron and vitamin B-12 deficiencies as corpus-predominant disease causes reduced gastric acid secretion and intrinsic factor 1, 2, 3
Endoscopic Surveillance Strategy
Advanced Atrophic Gastritis
- Perform surveillance endoscopy every 3 years for advanced disease (extensive anatomic distribution and/or moderate-to-severe histologic grade) 1, 2, 3
- The gastric cancer risk is 0.1-0.3% per year, similar to Barrett's esophagus 3
Autoimmune Gastritis-Specific Surveillance
- Screen for type 1 gastric neuroendocrine tumors (NETs) with upper endoscopy 1, 2
- NET risk is 0.4-0.7% per year in autoimmune gastritis 3
- Remove small NETs (<1 cm) endoscopically, followed by surveillance every 1-2 years depending on tumor burden 1, 2, 3
Pernicious Anemia
- Patients with new pernicious anemia diagnosis require endoscopy with topographical biopsies to confirm corpus-predominant atrophy and rule out gastric neoplasia including NETs 1, 2
- The gastric cancer risk may be highest within the first year of pernicious anemia diagnosis 2
Management of Neuroendocrine Tumors
Small NETs (<1-2 cm)
Larger NETs (>1-2 cm)
- Perform endoscopic ultrasound to assess depth of invasion and lymph node involvement 1, 2, 3
- Surgical resection is indicated for NETs >2 cm, invasion beyond submucosa, or lymph node metastasis 1, 2, 3
Critical Pitfalls and Caveats
Diagnostic Challenges
- Atrophic gastritis is frequently underdiagnosed due to subtle endoscopic features (pale mucosa, visible vasculature, loss of rugal folds, light blue crests with intestinal metaplasia) 1, 2
- The presence of intestinal metaplasia on histology almost invariably implies atrophic gastritis, even if atrophy is not explicitly mentioned 1, 3
- Proper biopsy technique is essential: obtain specimens from body and antrum in separate jars for accurate staging 1, 3
Medication Considerations
- Proton pump inhibitors elevate chromogranin A and gastrin levels, potentially complicating NET diagnosis 3
- Stop PPIs 10-14 days before measuring fasting gastrin levels 3
- Long-term PPI use can cause corpus atrophy and fundic gland polyps 4