What are the next steps if endoscopy shows hypertrophic inflamed gastric folds involving the body along with an atrophied fundus?

Hypertrophic Inflamed Gastric Folds in Body with Atrophied Fundus: Diagnostic Approach

This endoscopic pattern—hypertrophic inflamed folds in the gastric body combined with fundal atrophy—suggests autoimmune gastritis (AIG) and requires immediate histopathologic confirmation via systematic biopsies following the updated Sydney protocol, along with serologic testing for antiparietal cell and anti-intrinsic factor antibodies. 1

Understanding This Specific Pattern

The combination you describe is highly characteristic of autoimmune gastritis:

• In AIG, atrophy primarily involves the gastric corpus and fundus with characteristic sparing of the antrum, due to autoantibody-mediated destruction of parietal cells 1
• The hypertrophic inflamed folds in the body likely represent early-phase AIG where mucosal changes include nonspecific erythema and inflammation before complete atrophy develops, while the fundus has progressed to frank atrophy 1
• Early-phase AIG often presents with subtle mucosal changes that can be missed without proper biopsies 1

This differs from Helicobacter pylori-associated atrophic gastritis, which typically initiates in the antrum and expands proximally 1

Immediate Diagnostic Steps

Systematic Biopsy Protocol

Obtain topographical biopsies following the updated Sydney protocol, placing specimens in separately labeled jars: 1

• 2 biopsies from the antrum (lesser and greater curvature, within 2-3 cm of pylorus) 1
• 2 biopsies from the gastric corpus (1 from lesser curvature at 4 cm proximal to incisura angularis; 1 from middle portion of greater curvature at 8 cm from cardia) 1
• 1 biopsy from the incisura angularis (frequently involved in atrophic gastritis/intestinal metaplasia) 1
• Targeted biopsies from the hypertrophic inflamed folds in the body and any other visible mucosal abnormalities 1

At minimum, if cost is prohibitive, separate biopsies into 2 jars labeled "antrum/incisura" and "body" 1

Serologic Testing

If histology confirms autoimmune gastritis, immediately check: 2

• Antiparietal cell antibodies 2
• Anti-intrinsic factor antibodies 2
• Helicobacter pylori testing (serology, stool antigen, or urea breath test—must assess in all individuals with atrophic gastritis) 2

Laboratory Evaluation for Complications

Evaluate for micronutrient deficiencies, which are common in corpus-predominant atrophic gastritis: 1

• Iron deficiency (occurs in up to 50% of patients with corpus-predominant AG, often presents earlier than B12 deficiency) 1
• Vitamin B-12 deficiency (due to reduced intrinsic factor from parietal cell destruction) 1
• Complete blood count (assess for anemia) 2

Excluding Alternative Diagnoses

Rule Out Malignancy

The hypertrophic folds require evaluation to exclude infiltrative malignancy:

• Endoscopic ultrasound (EUS) should be considered if gastric wall thickening exceeds 3.6 mm or if standard biopsies are inconclusive 3
• When EUS abnormalities involve the fourth layer (muscularis propria), malignancy should be strongly suspected even if standard biopsies are negative 3
• If EUS shows abnormalities involving layers 2 and 3, consider large-particle biopsy or endoscopic mucosal resection for deeper tissue sampling 3, 4

Consider Protein-Losing Gastropathy

If hypoproteinemia is present:

• EUS typically shows echogenic thickening of the mucosal layer (13-20 mm diameter folds) with or without cystic components in protein-losing gastropathy 5
• This condition may be H. pylori-associated and can resolve with eradication therapy 5

Risk Stratification and Surveillance

Gastric Cancer Risk Assessment

The severity and topographic distribution of atrophic lesions determine gastric cancer risk: 2

• Use OLGA (Operative Link for Gastritis Assessment) or OLGIM (Operative Link for Gastric Intestinal Metaplasia Assessment) staging systems based on histology 2
• Corpus-predominant atrophy with intestinal metaplasia carries significant cancer risk 1

Surveillance Strategy

For patients with confirmed advanced atrophic gastritis: 2

• Consider surveillance endoscopy every 3 years 2
• For AIG specifically, European guidelines advocate surveillance at 3-5 year intervals 1
• If pernicious anemia is diagnosed, perform upper endoscopy within 6 months of diagnosis 1

Gastric Neuroendocrine Tumor Surveillance

Small gastric NETs (<1 cm) are common in AIG and typically appear as small polypoid lesions in the corpus or fundus: 1

• Resect all small NETs <1 cm endoscopically 1
• Consider surveillance endoscopy every 1-2 years depending on NET burden 1
• For NETs >1-2 cm, perform EUS to assess depth of invasion and lymph node involvement 1

Screening for Associated Conditions

Screen for autoimmune thyroid disease in all patients with confirmed AIG (present in up to one-third of patients) 1, 6

Maintain low threshold to evaluate for: 1

• Type 1 diabetes mellitus 1
• Addison's disease 1

Critical Pitfalls to Avoid

• Do not assume this pattern represents H. pylori gastritis without testing—the corpus/fundus predominance strongly suggests AIG 1
• Do not skip the incisura angularis biopsy—this site is frequently involved in atrophic gastritis/intestinal metaplasia 1
• Do not rely on endoscopic appearance alone—early AIG can have subtle changes requiring histopathologic confirmation 1
• Do not overlook iron deficiency screening—it often precedes B12 deficiency by years 1
• Do not assume hypertrophic folds are benign without adequate tissue sampling—infiltrative malignancy must be excluded 3