What is the appropriate management for a patient with gastritis when imaging shows no gallstones?

Management of Gastritis Without Gallstones

For patients with gastritis and no gallstones on imaging, the primary management focuses on identifying and treating the underlying etiology—most importantly testing for and eradicating Helicobacter pylori infection, followed by acid suppression therapy and addressing other contributing factors.

Initial Diagnostic Workup

Endoscopic Evaluation and Biopsy

• Upper endoscopy with topographical biopsies is essential to characterize the type and distribution of gastritis, assess for complications (ulcers, metaplasia, dysplasia), and obtain tissue for H. pylori testing 1
• Biopsies should be obtained from both antrum and corpus to distinguish between H. pylori-associated gastritis (typically antral-predominant) and autoimmune gastritis (corpus-predominant) 1
• The updated Sydney System should be used for histological classification to grade the extent and severity of inflammation 2

Helicobacter pylori Testing

• All individuals with atrophic gastritis or chronic gastritis should be assessed for H. pylori infection 1
• Testing modalities include histology from endoscopic biopsies, rapid urease test, stool antigen, or urea breath test 1
• Serological testing for antibodies is not recommended for confirming active infection 1

Laboratory Assessment

• Check serum gastrin levels if corpus-predominant gastritis is suspected (elevated in autoimmune gastritis) 1
• Evaluate for vitamin B-12 and iron deficiencies, particularly in corpus-predominant or atrophic gastritis 1
• If autoimmune gastritis is suspected based on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies 1
• Screen for autoimmune thyroid disease in patients with confirmed autoimmune gastritis, as concomitant autoimmune disorders are common 1

Treatment Algorithm

H. pylori-Positive Gastritis

• Eradicate H. pylori with triple therapy: omeprazole 40 mg/day (in 1-2 divided doses) combined with two antibacterial agents for 7-14 days 3
• Omeprazole-based triple therapy is more effective than comparable regimens containing ranitidine, lansoprazole, or bismuth 3
• Confirm successful eradication using non-serological testing modalities (stool antigen or urea breath test, not serology) 4-6 weeks after completing therapy 1

H. pylori-Negative Gastritis

• Initiate proton pump inhibitor therapy: omeprazole 20-40 mg daily for symptom relief and mucosal healing 3
• Investigate for other causes:
  • NSAID use (discontinue if possible or add PPI prophylaxis) 3
  • Autoimmune gastritis (check antibodies and vitamin levels) 1
  • Bile reflux gastritis (though this is uncommon without prior gastric surgery or cholecystectomy) 2, 4, 5

Autoimmune Gastritis Management

• Surveillance endoscopy every 6-12 months for the first 3 years, then annually if no progression 1
• Gastrin levels remain persistently elevated and are generally uninformative for monitoring 1
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy; small NETs should be removed endoscopically with surveillance every 1-2 years 1
• Provide vitamin B-12 supplementation (oral or parenteral) and iron supplementation as needed 1
• Consider antrectomy only if new lesions or increasing tumor burden develops despite medical management 1

Surveillance Strategy

For Atrophic Gastritis

• Surveillance endoscopy every 3 years should be considered for advanced atrophic gastritis (defined by extensive anatomic distribution and high histologic grade) 1
• The optimal interval is not definitively established and should be individualized based on risk factors including extent of atrophy, presence of intestinal metaplasia, family history of gastric cancer, and ethnicity 1

For Non-Atrophic Gastritis

• After successful H. pylori eradication, repeat endoscopy is generally not required unless symptoms persist or new concerning features develop 1
• Follow-up endoscopy may be indicated if initial biopsies showed intestinal metaplasia or dysplasia 1

Critical Pitfalls to Avoid

• Do not rely on gastrin levels to monitor type 1 autoimmune gastritis, as they remain persistently elevated due to atrophic gastritis and are uninformative 1
• Do not use serological H. pylori testing to confirm eradication, as antibodies persist long after successful treatment 1
• Do not overlook vitamin B-12 and iron deficiency screening in corpus-predominant gastritis, as these deficiencies significantly impact quality of life and can cause irreversible neurological damage if untreated 1
• Do not assume gastritis is benign without histological confirmation—endoscopy with biopsy is essential to exclude dysplasia, early gastric cancer, or neuroendocrine tumors 1
• Be aware that gallbladder disease and gastritis can coexist; the absence of gallstones does not exclude biliary pathology as a contributing factor to symptoms, though bile reflux gastritis is uncommon without prior surgery 2, 5