What is the treatment for autoimmune gastritis?

Treatment of Autoimmune Gastritis

Autoimmune gastritis has no disease-modifying therapy; treatment focuses on managing nutritional deficiencies (iron and vitamin B12), endoscopic surveillance for neoplasia, and addressing gastrointestinal symptoms—not immunosuppression. 1

Core Treatment Principles

Unlike autoimmune hepatitis, autoimmune gastritis does not respond to corticosteroids or immunosuppressive therapy. The management strategy is entirely supportive and surveillance-based. 2, 3

1. Nutritional Deficiency Management (Primary Treatment)

Iron Deficiency:

• Evaluate all patients for iron deficiency regardless of anemia presence, as corpus-predominant atrophy impairs iron absorption 1
• Provide adequate iron supplementation when deficiency is identified 4, 2

Vitamin B12 Deficiency:

• Screen all patients for vitamin B12 deficiency and macrocytic anemia 1
• Recognize pernicious anemia as a late-stage manifestation requiring lifelong B12 replacement 1
• Administer vitamin B12 supplementation (typically parenteral in pernicious anemia due to intrinsic factor loss) 4, 2

2. H. pylori Assessment and Eradication

• Test all patients with autoimmune gastritis for H. pylori infection using non-serological methods 1
• If positive, administer H. pylori eradication therapy and confirm successful treatment 1
• This addresses a potentially modifiable risk factor for gastric cancer progression 1

3. Endoscopic Surveillance for Neoplasia

Type 1 Gastric Neuroendocrine Tumors (NETs):

• Screen with upper endoscopy, as hypergastrinemia from achlorhydria drives NET development 1
• Remove small NETs endoscopically when identified 1
• Perform surveillance endoscopy every 1-2 years depending on NET burden 1

Gastric Adenocarcinoma Surveillance:

• Consider surveillance endoscopy every 3 years in patients with advanced autoimmune gastritis 1
• Patients with pernicious anemia who haven't had recent endoscopy should undergo endoscopy with topographical biopsies to rule out prevalent gastric neoplasia 1
• The optimal surveillance interval remains unclear and should be individualized based on risk assessment 1

4. Management of Gastrointestinal Symptoms

Critical Pitfall: Discontinue proton pump inhibitors (PPIs) and other acid suppressants—they are useless in achlorhydric patients and may worsen symptoms. 5, 3

Dyspepsia and Upper GI Symptoms:

• Dyspepsia, heartburn, and regurgitation are common despite achlorhydria 5, 3
• Consider gastric acidification therapy (oral acid administration) for dyspepsia, though evidence is limited to historical reports 5
• Prokinetic agents and antidepressant drugs may provide symptomatic relief, though evidence is weak 3

Gastroesophageal Reflux:

• Confirm reflux with pH-impedance testing (typically weakly acid or alkaline reflux) 5
• Use mechanical prevention: head of bed elevation and alginates 5
• Consider antireflux surgery for severe, confirmed reflux 5

5. Screening for Associated Autoimmune Disorders

• Screen all patients for autoimmune thyroid disease, as up to one-third of patients with thyroid autoimmunity have autoimmune gastritis 1
• Recognize increased prevalence of type 1 diabetes mellitus and other autoimmune conditions 1

What NOT to Do

Do not use immunosuppressive therapy (corticosteroids, azathioprine, or other immunomodulators) for autoimmune gastritis—these are indicated for autoimmune hepatitis, not gastritis. 1

Do not continue acid suppression therapy in confirmed autoimmune gastritis patients, as the stomach cannot produce acid. 5, 3

Long-term Management Algorithm

1. At diagnosis: Check iron, B12, H. pylori status, thyroid function; perform endoscopy with biopsies 1, 6
2. Ongoing: Replace iron and B12 as needed; eradicate H. pylori if present 1
3. Surveillance: Endoscopy every 1-2 years if NETs present, every 3 years for advanced atrophy 1
4. Symptom management: Stop PPIs; use mechanical reflux prevention and consider acid replacement for dyspepsia 5, 3