When should a patient with gastritis be referred to a Gastroenterologist (GI)?

When to Refer a Patient with Gastritis to Gastroenterology

Refer patients with gastritis to a gastroenterologist if they are ≥45 years old with severe dyspeptic symptoms, have any alarm symptoms regardless of age, have treatment-resistant symptoms after first-line therapy, or if there is diagnostic uncertainty. 1, 2

Age-Based Referral Thresholds

Patients Under 45 Years

• Do not refer patients under 45 years (or in their early 40s) with dyspeptic symptoms and no alarm features who test positive for H. pylori for the first time—these can be managed in primary care with test-and-treat strategies. 1, 2
• The exception is if the patient has risk factors for gastric malignancy, such as family history of gastro-esophageal cancer or comes from a region with increased gastric cancer risk. 1, 2

Patients 45 Years and Older

• Strongly recommend referral for all patients ≥45 years with severe dyspeptic symptoms for endoscopy, as the standardized incidence of gastric cancer rises significantly in this age group (19 per 100,000 for men, 9 per 100,000 for women in the European Community). 1
• Urgent endoscopy is warranted for patients ≥55 years with dyspepsia and weight loss, or those >40 years from high-risk areas or with family history of gastro-esophageal cancer. 1
• Non-urgent endoscopy should be considered for patients ≥55 years with treatment-resistant dyspepsia or dyspepsia with raised platelet count, nausea, or vomiting. 1

Alarm Symptoms Requiring Immediate Referral (Any Age)

Refer immediately if any of the following are present, regardless of patient age: 1, 2

• Anemia
• Unintentional weight loss (especially ≥5% in previous 6 months)
• Dysphagia
• Palpable abdominal mass
• Malabsorption
• Persistent vomiting

Special Consideration for Older Adults

• For patients ≥60 years with abdominal pain and weight loss, urgent abdominal CT scanning should be considered to exclude pancreatic cancer. 1

Treatment-Refractory Cases

Referral is appropriate when: 1

• Symptoms are severe or refractory to first-line treatments (including H. pylori eradication if positive, proton pump inhibitors, or H2-receptor antagonists)
• There is diagnostic doubt about whether the patient truly has functional dyspepsia versus organic pathology
• The individual patient requests a specialist opinion

Gastric Ulcer History

• All patients with known history of gastric ulcer should be referred and undergo repeat endoscopy with biopsy until healed, as malignancy may be present. 1
• This is distinct from duodenal ulcer disease, which can be managed in primary care if uncomplicated. 1

Important Caveats

PPI Use and Diagnostic Accuracy

• Chronic PPI use can mask H. pylori infection and promote misdiagnosis of non-H. pylori gastritis, while increasing the risk of intestinal metaplasia. 3, 4
• If a patient has been on long-term PPIs and tests negative for H. pylori, consider referral for endoscopy with biopsy to assess for atrophic gastritis or intestinal metaplasia, particularly if they are older or have persistent symptoms. 3

Long-term Atrophic Gastritis Risks

• Severe atrophic gastritis and acid-free stomach represent the highest independent risk conditions for gastric cancer. 5
• Progressive atrophic gastritis can result in malabsorption of vitamin B12, iron, calcium, magnesium, and zinc. 5

Regional Variations

• The age cutoff for referral may need to be below 45 years depending on regional differences in gastric malignancy incidence. 1
• Local and national guidelines for colorectal and gastric cancer screening should always be followed. 1

Primary Care Management Before Referral

For appropriate patients under the referral threshold, initial management includes: 1, 2

• Full blood count in patients ≥55 years
• Non-invasive H. pylori testing (13C-urea breath test or stool antigen test preferred over serology)
• H. pylori eradication therapy if positive
• Empirical acid suppression with PPIs if H. pylori negative
• Regular aerobic exercise and dietary counseling