What are the diagnosis, treatment, and management options for an older adult with suspected gastric atrophy, particularly those with a history of chronic gastritis or autoimmune disorders?

Gastric Atrophy: Diagnosis, Treatment, and Management

Diagnostic Approach

All older adults with suspected gastric atrophy require upper endoscopy with systematic topographical biopsies from both the gastric body and antrum placed in separately labeled jars for histopathological confirmation and risk stratification. 1

Endoscopic Recognition

Recognize these characteristic endoscopic features during examination: 1

• Pale appearance of gastric mucosa with loss of normal pink coloration
• Increased visibility of submucosal blood vessels due to mucosal thinning
• Loss of gastric rugal folds in affected areas
• Light blue crests and white opaque fields when intestinal metaplasia is present (best seen with narrow-band imaging)

Biopsy Protocol

Obtain biopsies from at minimum the gastric body and antrum/incisura in separately labeled jars to assess topographic distribution and severity. 1 Target any additional mucosal abnormalities identified during examination. 1

Pattern Recognition for Etiology

The distribution pattern distinguishes the two main etiologies: 1

• H. pylori-associated atrophic gastritis: Begins in the antrum and progresses proximally, potentially involving the entire stomach in severe cases
• Autoimmune gastritis: Corpus and fundus predominant with characteristic antral sparing

Etiologic Workup

H. pylori Testing

All patients with atrophic gastritis must be tested for H. pylori infection using non-serological methods such as urea breath test or monoclonal stool antigen tests. 1, 2 If positive, eradicate H. pylori with bismuth quadruple therapy for 14 days and confirm successful eradication 4-6 weeks after completing antibiotics using non-invasive testing. 1, 2

Autoimmune Gastritis Evaluation

When histology shows corpus-predominant atrophy, check: 1

• Antiparietal cell antibodies (present in ~90% of autoimmune gastritis)
• Anti-intrinsic factor antibodies (more specific but less sensitive)
• Complete blood count to assess for macrocytic anemia
• Vitamin B-12 and iron levels (deficiencies are common)

Risk Stratification

The presence of intestinal metaplasia on gastric histology almost invariably implies the diagnosis of atrophic gastritis. 1 Extensive atrophy and metaplasia are associated with increased gastric cancer risk. 1

Use OLGA (Operative Link for Gastritis Assessment) or OLGIM (Operative Link for Gastric Intestinal Metaplasia Assessment) staging systems to stratify cancer risk based on anatomic extent and histologic severity. 1 Advanced stages (III/IV) carry significantly higher cumulative gastric cancer risk. 1

Treatment

H. pylori Eradication

For H. pylori-positive patients, bismuth quadruple therapy for 14 days is the preferred treatment: 2

• Bismuth subcitrate 120 mg four times daily
• Two antibiotics from the "Access group" (amoxicillin, tetracycline, or metronidazole)
• High-potency proton pump inhibitor (esomeprazole 20-40 mg twice daily, rabeprazole 20 mg twice daily, or lansoprazole 30 mg twice daily) 2, 3

Continue PPI therapy during and after H. pylori eradication for typically 4-8 weeks total. 2

Common pitfall: Do not use 7-day antibiotic courses—14 days is required for adequate eradication. 2 Do not rely on symptom resolution alone without confirming H. pylori eradication. 2

Micronutrient Management

Screen and treat iron and vitamin B-12 deficiencies in all patients with atrophic gastritis, especially those with corpus-predominant disease. 1, 2 This is critical as both H. pylori-associated and autoimmune gastritis cause hypochlorhydria, impairing micronutrient absorption. 4, 5

For autoimmune gastritis patients with pernicious anemia, lifelong vitamin B-12 replacement is necessary. 1, 5

Autoimmune Disease Screening

Screen patients with autoimmune gastritis for concomitant autoimmune thyroid disease, as this association is common. 1 Consider screening for other autoimmune conditions including celiac disease and type 1 diabetes. 4, 6

Surveillance Strategy

Advanced Atrophic Gastritis (H. pylori-associated)

For patients with advanced atrophic gastritis (OLGA/OLGIM stage III/IV), perform surveillance endoscopy every 3 years. 1 This recommendation is based on the significantly elevated gastric cancer risk in this population. 1

Autoimmune Gastritis

For autoimmune gastritis, perform surveillance endoscopy every 3-5 years based on individualized assessment. 1, 4 Screen specifically for type 1 gastric neuroendocrine tumors during surveillance. 1

If neuroendocrine tumors are detected, remove them endoscopically and perform surveillance endoscopy every 1-2 years depending on tumor burden. 1

Pernicious Anemia

Patients with newly diagnosed pernicious anemia who have not had recent endoscopy require upper endoscopy with topographical biopsies to confirm corpus-predominant atrophic gastritis, perform risk stratification, and rule out prevalent gastric neoplasia including neuroendocrine tumors. 1

Critical Management Considerations

Do not use proton pump inhibitors for symptom management in hypochlorhydric patients with advanced atrophic gastritis, as they provide no benefit and may worsen micronutrient absorption. 4

Coordinated efforts between gastroenterologists and pathologists are essential to improve documentation of atrophy severity and extent, particularly when marked atrophy is present. 1

H. pylori eradication may modify the natural history of atrophy but does not reverse established intestinal metaplasia. 4 Nevertheless, eradication should still be pursued as it may prevent progression and reduce cancer risk. 1, 2