What is the recommended treatment for a patient with atrophic gastritis, possibly with a history of H. pylori infection?

Treatment of Atrophic Gastritis

All patients with atrophic gastritis must be tested for H. pylori using non-serological methods, and if positive, should receive prompt eradication therapy with confirmation of successful treatment, while simultaneously evaluating and correcting micronutrient deficiencies (iron and vitamin B12) and establishing appropriate endoscopic surveillance based on disease severity. 1

Eradication of H. pylori Infection

Testing and Treatment

• Test all patients with atrophic gastritis for H. pylori using non-serological testing methods (avoid serology as it remains positive after spontaneous or treated eradication). 2, 1
• If H. pylori positive, administer eradication therapy immediately using quadruple therapy with bismuth as first-line treatment due to increasing clarithromycin resistance. 3, 4
• Confirm successful eradication using non-serological testing methods after treatment completion. 2, 1

Rationale and Expected Outcomes

• H. pylori eradication may modify the natural history of atrophy and halt progression, though it has less effect on reversing established intestinal metaplasia. 1
• Eradication resolves inflammation and may normalize gastric functions, though complete reversal of atrophic changes is variable. 4
• Treatment is essential even in patients with corpus-predominant atrophy where reduced gastric acid secretion may affect standard proton pump inhibitor-based regimens. 4

Management of Micronutrient Deficiencies

Mandatory Screening

• Evaluate all patients with atrophic gastritis for iron and vitamin B12 deficiencies, regardless of whether anemia is present. 2, 1
• Iron deficiency occurs in up to 50% of patients with corpus-predominant atrophic gastritis and often presents earlier than B12 deficiency. 1
• Screen for anemia and provide appropriate supplementation when deficiencies are identified. 3, 5

Additional Considerations

• In corpus-predominant or autoimmune atrophic gastritis, evaluate calcium and vitamin D status. 3
• Patients with autoimmune atrophic gastritis require vitamin B12 supplementation due to loss of intrinsic factor. 6

Autoimmune Atrophic Gastritis-Specific Management

Diagnostic Confirmation

• Confirm autoimmune atrophic gastritis diagnosis through antiparietal cell antibodies (PCA) and anti-intrinsic factor antibodies (IFA) testing in patients with endoscopic and histologic findings consistent with corpus-predominant pattern and antral sparing. 2, 1

Associated Autoimmune Conditions

• Screen all patients with autoimmune atrophic gastritis for autoimmune thyroid disease. 2, 1
• Maintain a low threshold to evaluate for other autoimmune diseases based on clinical presentation, including type 1 diabetes mellitus. 2, 5

Endoscopic Surveillance Strategy

Advanced Atrophic Gastritis

• Perform surveillance endoscopy every 3 years in patients with advanced atrophic gastritis (defined by anatomic extent and histologic grade using OLGA or OLGIM staging systems). 2, 1, 3
• Advanced atrophic gastritis includes Stage III/IV OLGA or OLGIM classifications. 5
• The annual risk of gastric adenocarcinoma ranges from 0.1% to 0.87% depending on severity and extent of atrophy. 3, 7

Autoimmune Atrophic Gastritis

• Surveillance intervals should be individualized based on risk assessment, typically every 3-5 years. 2, 5
• In patients with newly diagnosed pernicious anemia, perform upper endoscopy for risk stratification and to evaluate for prevalent gastric neoplasia and neuroendocrine tumors (NETs). 2, 1
• The risk of gastric adenocarcinoma may be highest within the first year of pernicious anemia diagnosis, warranting prompt endoscopic evaluation. 1

Neuroendocrine Tumor Surveillance

• Screen for type 1 gastric NETs with upper endoscopy in patients with autoimmune atrophic gastritis (incidence rate 0.4-0.7% per year). 1, 3
• Remove small NETs (<1 cm) endoscopically. 1
• Consider surveillance endoscopy every 1-2 years depending on NET burden in autoimmune atrophic gastritis patients. 1
• For NETs >1-2 cm, perform endoscopic ultrasound to assess invasion depth and local metastasis. 1
• Surgical resection is indicated for NETs >2 cm, those invading past the submucosa, or with lymph node metastasis. 1

Diagnostic Biopsy Protocol

Proper Sampling Technique

• Obtain topographical biopsies using the updated Sydney protocol: 2 biopsies from the antrum, 2 from the corpus, and 1 from the incisura angularis, placed in separate labeled containers. 2, 3
• This systematic approach determines anatomic extent and histologic severity for accurate risk stratification. 2, 1
• Proper biopsy sampling is critical as atrophic gastritis is often underdiagnosed due to subtle endoscopic features and inconsistent histopathological reporting. 1

Important Clinical Pitfalls

Diagnostic Challenges

• Atrophic gastritis is frequently underdiagnosed due to subtle endoscopic features requiring high-definition white light endoscopy and narrow-band imaging for optimal detection. 1
• Previous H. pylori infection-induced atrophic gastritis (spontaneously resolved or unintentionally eradicated) represents an understudied population requiring the same surveillance as intentionally treated cases. 7

Treatment Considerations

• Proton pump inhibitors are not indicated in hypochlorhydric atrophic gastritis patients and should be avoided. 5
• In corpus-predominant atrophic gastritis with reduced gastric acid secretion, bismuth-based therapy may be more effective than standard PPI-based regimens. 4