What is the management plan for a patient with Sydney protocol gastric atrophy, including treatment and surveillance to reduce the risk of complications such as gastric cancer?

Management of Sydney Protocol Gastric Atrophy

All patients with gastric atrophy confirmed by Sydney protocol biopsies must undergo H. pylori eradication if infected, followed by risk-stratified endoscopic surveillance every 3 years for those with severe atrophy or multifocal/incomplete intestinal metaplasia, with shorter intervals considered for patients with additional risk factors such as family history of gastric cancer. 1

Initial Diagnostic Confirmation and Staging

When gastric atrophy is suspected, systematic biopsy using the Sydney protocol is mandatory for proper diagnosis and risk stratification:

• Obtain a minimum of 5 biopsies from the antrum/incisura (jar 1) and corpus (jar 2) in separately labeled containers, with any suspicious areas biopsied and labeled separately 1
• Work with your pathologist to ensure documentation includes: H. pylori status, severity of atrophy/metaplasia, and histologic subtyping of gastric intestinal metaplasia (complete vs incomplete type) 1
• Use high-definition white-light endoscopy with image enhancement (narrow band imaging or linked color imaging) to improve detection of atrophic changes and intestinal metaplasia 1

H. Pylori Eradication: Essential First Step

H. pylori eradication is mandatory and serves as primary prevention, though it does not eliminate the need for surveillance in patients with established atrophy. 1

Treatment Protocol:

• Bismuth quadruple therapy for 14 days (not 7 days): bismuth subcitrate 120 mg four times daily + two antibiotics from the "Access group" (amoxicillin, tetracycline, or metronidazole) + high-potency PPI 2
• High-potency PPI options: esomeprazole 20-40 mg twice daily, rabeprazole 20 mg twice daily, or lansoprazole 30 mg twice daily 2
• Confirm eradication 4-6 weeks after completing therapy using non-invasive testing (urea breath test or monoclonal stool antigen test) 2, 3

Critical caveat: Even after successful H. pylori eradication, patients with established atrophic changes remain at risk for neoplastic progression and require ongoing surveillance 1

Risk Stratification for Surveillance

All patients with confirmed gastric atrophy must undergo formal risk stratification to determine surveillance needs 1:

High-Risk Features Requiring Surveillance:

• Severe atrophic gastritis involving both antrum and corpus 1, 3
• Multifocal or incomplete (colonic-type) intestinal metaplasia - carries 3-fold higher cancer risk than complete type 2, 4
• Anatomically extensive intestinal metaplasia - approximately 2-fold higher risk than limited disease 4
• First-degree relative with gastric cancer - increases risk 4.5-fold 4
• Persistent H. pylori infection despite eradication attempts 1

Surveillance Protocol:

• Endoscopic surveillance every 3 years for patients with severe atrophic gastritis and/or multifocal/incomplete intestinal metaplasia 1, 3
• Consider shorter intervals (potentially annual or biennial) for patients with multiple risk factors, such as severe intestinal metaplasia that is anatomically extensive plus family history 1, 3
• Continue surveillance indefinitely, as the cumulative 10-year gastric cancer risk is approximately 1.6% 4

Lower-Risk Patients:

• If index endoscopy shows no atrophy, intestinal metaplasia, or neoplasia, continue screening every 3-5 years only if the patient has family history of gastric cancer or multiple risk factors 1

Management of Dysplasia

Low-Grade or Indefinite Dysplasia:

• Confirm with experienced GI pathologist - these lesions are difficult to diagnose reproducibly 1
• If H. pylori positive: eradicate infection, confirm eradication, then repeat endoscopy with biopsies by experienced endoscopist (inflammation can obscure accurate diagnosis) 1
• Refer to center with expertise in gastric neoplasia management 1

High-Grade Dysplasia or Early Gastric Cancer:

• Immediate referral for endoscopic submucosal dissection (ESD) at expert center with goal of en bloc, R0 resection 1
• Eradicate H. pylori but do not delay endoscopic intervention 1
• Ongoing surveillance required after successful resection 1

Micronutrient Management

Screen for and treat deficiencies that commonly occur with gastric atrophy:

• Iron deficiency - particularly with extensive atrophic changes 2
• Vitamin B12 deficiency - screen regularly and supplement as needed 2, 5
• Consider screening for autoimmune thyroid disease in patients with corpus-predominant atrophy 5

Special Consideration: Type I Gastric Carcinoids

• Lesions <1 cm: may observe or resect 1
• Lesions 1-2 cm: endoscopic resection recommended 1
• Lesions >2 cm: obtain cross-sectional imaging and refer for surgical resection due to metastatic risk 1
• All patients require surveillance, though intervals are not well-defined 1

Critical Pitfalls to Avoid

• Do not rely on symptom resolution alone - confirm H. pylori eradication with objective testing 2
• Do not use inadequate antibiotic duration - must be 14 days, not 7 days 2
• Do not fail to obtain separate antral and corpus biopsies in labeled jars - this is essential for assessing disease extent 1, 2
• Do not assume H. pylori eradication eliminates cancer risk - established atrophic changes require ongoing surveillance regardless of eradication success 1
• Do not use PPIs inappropriately - they are not indicated for hypochlorhydric patients with advanced atrophy 5