What is the appropriate management for a patient with nodular gastric mucosa found on endoscopy?

Management of Nodular Gastric Mucosa Found on Endoscopy

Nodular gastric mucosa requires targeted biopsies from both the nodules and the intervening depressed mucosa between nodules to evaluate for H. pylori infection, premalignant lesions (atrophic gastritis, intestinal metaplasia, dysplasia), and rare entities like collagenous gastritis. 1, 2, 3

Immediate Endoscopic Assessment

Biopsy Protocol

• Obtain biopsies from both the nodular lesions themselves AND the intervening depressed mucosa between nodules, as this dual approach is critical for detecting conditions like collagenous gastritis where the diagnostic histology may be in the surrounding tissue rather than the nodules 2
• Follow the updated Sydney protocol with 5 separate biopsies placed in appropriately labeled jars: 2 from the antrum (lesser and greater curvature within 2-3 cm of pylorus), 1 from the incisura angularis, and 2 from the gastric body (lesser curvature 4 cm proximal to incisura; greater curvature 8 cm distal to cardia) 4
• This topographical approach achieves nearly 100% sensitivity for H. pylori detection and accurately assesses the extent of atrophic changes 4

Key Endoscopic Features to Document

• Distribution of nodularity: diffuse versus localized (antrum-predominant suggests H. pylori-associated nodular gastritis; body-predominant may suggest other etiologies) 1
• Associated findings: pale atrophic mucosa with visible submucosal vessels, loss of gastric folds, or irregular mucosal patterns suggesting intestinal metaplasia 4
• Nodule characteristics: size, number, and whether they appear inflammatory versus mass-like 1, 2

Differential Diagnosis and Clinical Significance

H. pylori-Associated Nodular Gastritis (Most Common)

• 87.5% of patients with endoscopic nodular gastritis have H. pylori infection compared to 73.8% in controls 3
• Presents with epigastric pain (56%), nausea (75%), vomiting (50%), and abdominal bloating (62.5%) 1
• Critical finding: Dysplasia is significantly more frequent in nodular gastritis (p < 0.001), as is incomplete intestinal metaplasia (p = 0.016) 3
• This represents a premalignant condition requiring treatment and surveillance 3

Heterotopic Gastric Mucosa (Benign Entity)

• When nodularity is located in the proximal duodenum (not stomach), this typically represents heterotopic gastric mucosa of body type 5
• Present in up to 2% of the population and is of no clinical significance 5
• Does not require treatment or surveillance 5

Collagenous Gastritis (Rare but Important)

• Consider in patients with unexplained iron-deficiency anemia with minimal or no GI symptoms 2
• Requires targeted biopsies of the depressed intervening mucosa between nodules, not just the nodules themselves, as the diagnostic thickened subepithelial collagen band may be missed otherwise 2
• Confirm with Masson trichrome staining 2

Treatment Algorithm

If H. pylori Positive (Most Cases)

• Initiate triple therapy immediately: proton pump inhibitor plus two antibiotics for 14 days 1
• Symptoms regress significantly within 2 weeks of starting therapy 1
• Endoscopic features, lymphoid aggregates, eosinophils, atrophy, and intestinal metaplasia improve significantly after eradication (p < 0.05) 1
• Confirm eradication 4-6 weeks after completing therapy using urea breath test or stool antigen test 1

If Premalignant Lesions Detected

For Atrophic Gastritis/Intestinal Metaplasia:

• Risk stratification depends on extent and severity using OLGA/OLGIM staging systems 4
• Extensive atrophy (involving both antrum and body) requires surveillance endoscopy every 3 years 4
• Incomplete intestinal metaplasia carries higher cancer risk than complete type and should be specifically requested in pathology reports 4

For Dysplasia:

• Low-grade dysplasia: Repeat high-quality endoscopy with enhanced imaging immediately to exclude visible lesions; if confirmed non-visible dysplasia on random biopsies, surveillance at 1-year intervals 4
• High-grade dysplasia: Repeat endoscopy within 6 months; all visible dysplasia should be endoscopically resected where appropriate 4
• Consider referral to expert center for management 4

If Collagenous Gastritis Confirmed

• Oral iron replacement therapy for anemia 2
• Consider corticosteroids in severe cases 2
• Surveillance endoscopy intervals not well-established but monitor anemia response 2

Critical Pitfalls to Avoid

• Do not assume nodular gastric mucosa is benign without histologic confirmation, as dysplasia and incomplete intestinal metaplasia are significantly more prevalent in these patients 3
• Do not biopsy only the nodules themselves when evaluating for collagenous gastritis; the diagnostic findings may be in the intervening depressed mucosa 2
• Do not skip the incisura angularis when obtaining biopsies, as atrophy and intestinal metaplasia frequently involve this site 4
• Do not place all biopsies in a single jar; separate antrum/incisura from body biopsies to assess extent of atrophic changes 4
• Do not confuse duodenal nodularity with gastric nodularity; duodenal nodules typically represent benign heterotopic gastric mucosa requiring no intervention 5

Surveillance Strategy Post-Treatment

• Repeat endoscopy 4 weeks after completing H. pylori eradication therapy to assess histologic improvement and confirm eradication 1
• If premalignant lesions persist despite H. pylori eradication, follow surveillance protocols based on the specific histology (atrophy, intestinal metaplasia, or dysplasia) as outlined above 4
• Use high-definition white-light endoscopy with careful inspection; consider narrow-band imaging to improve detection of intestinal metaplasia (light blue crest sign) and dysplasia 4