What is the appropriate management of atrophic gastritis?

Management of Atrophic Gastritis

All patients with atrophic gastritis must be tested and treated for H. pylori infection if positive, undergo endoscopic surveillance every 3 years if advanced disease is present, and receive screening for vitamin B12 and iron deficiencies regardless of etiology. 1

Initial Diagnostic Confirmation and Risk Stratification

Obtain topographical gastric biopsies from at minimum the body and antrum/incisura in separately labeled containers to confirm histopathology and assess the anatomic extent and severity of atrophy. 1, 2 Target any additional mucosal abnormalities seen endoscopically. 1

• Recognize that intestinal metaplasia on histology almost invariably indicates underlying atrophic gastritis, even when atrophy is not explicitly documented by the pathologist. 1
• Coordinate with pathology to ensure consistent documentation of the extent and severity of atrophic changes, particularly when marked atrophy is present. 1
• Avoid diagnosing "atrophic gastritis" unless moderate or severe unequivocal loss of gastric glands and/or metaplasia is found in at least 50% of the evaluated mucosa; otherwise use "chronic gastritis with focal atrophy" and obtain more extensive sampling. 3

Mandatory H. pylori Assessment and Eradication

Test every patient with atrophic gastritis for H. pylori infection using non-serological methods (urea breath test, stool antigen test, or histology from biopsies). 1, 4, 2

• If positive, administer appropriate eradication therapy for 10-14 days. 2
• Confirm successful eradication using non-serological testing modalities after treatment completion. 1, 2, 5
• This is critical because H. pylori eradication reduces gastric cancer risk, though it does not completely eliminate it once advanced atrophy has developed. 6, 7

Autoimmune Gastritis-Specific Evaluation

When histology shows corpus-predominant atrophy, check antiparietal cell antibodies and anti-intrinsic factor antibodies to confirm autoimmune etiology. 1, 2

Screen for nutritional deficiencies:

• Measure vitamin B12 levels and complete blood count to detect macrocytic anemia. 1, 2
• Assess iron status, as hypochlorhydria impairs iron absorption leading to iron-deficiency anemia. 1, 2
• Provide lifelong vitamin B12 replacement (oral high-dose or intramuscular) and iron supplementation (oral or intravenous as needed). 5

Screen for type 1 gastric neuroendocrine tumors (NETs) with upper endoscopy, as autoimmune gastritis causes hypergastrinemia that drives NET development. 1, 2, 5

• Remove small NETs endoscopically and follow with surveillance endoscopy every 1-2 years depending on tumor burden. 1, 2, 5

Endoscopic Surveillance Strategy

For advanced atrophic gastritis (defined by extensive anatomic distribution and/or severe histologic grade), perform surveillance endoscopy every 3 years. 1, 2, 5

• Advanced atrophic gastritis carries a gastric cancer incidence of 0.31%-0.87% per year, making surveillance essential for early cancer detection. 6
• High-risk features include endoscopically severe atrophy or extensive intestinal metaplasia. 6
• Use enhanced imaging techniques (electronic chromoendoscopy) to identify subtle mucosal changes and guide targeted biopsies. 1, 7

For autoimmune gastritis, surveillance intervals should be individualized through shared decision-making, though the same 3-year interval is reasonable for advanced disease. 1, 5

For patients with new pernicious anemia who have not had recent endoscopy, perform endoscopy with topographical biopsies to confirm corpus-predominant atrophy, stratify cancer risk, and exclude prevalent gastric neoplasia including NETs. 1, 2, 5

Special Consideration: Previous H. pylori Infection

Patients with atrophic gastritis who test negative for active H. pylori but have no documented eradication history likely experienced spontaneous clearance or unintentional eradication from antibiotics given for other infections. 6

• These patients still require the same surveillance as those with documented eradication, as the cancer risk persists based on the degree of atrophy already present. 6
• The gastric cancer incidence in this population ranges from 0.31%-0.87% per year depending on atrophy severity. 6

Common Pitfalls to Avoid

• Do not rely on endoscopic appearance alone—histopathologic confirmation is mandatory, as normal-appearing mucosa can harbor atrophy. 1, 5
• Do not use serologic H. pylori testing for diagnosis or post-treatment confirmation in atrophic gastritis, as advanced atrophy reduces antibody titers leading to false negatives. 1, 4
• Do not delay vitamin B12 replacement in corpus-predominant atrophy, as untreated deficiency causes irreversible neurologic damage. 5
• Do not assume inflammation precludes atrophy diagnosis—when moderate-to-severe inflammation is present, use "indefinite for atrophy" and re-evaluate after H. pylori eradication. 3