Atrophic gastritis diagnosis confirmation
Atrophic gastritis is defined as loss of gastric glands, with or without metaplasia, in the setting of chronic inflammation mainly due to Helicobacter pylori infection or autoimmunity. [1] The diagnosis of atrophic gastritis should be confirmed by histopathology. [1]
Etiologic assessment and H pylori eradication
All individuals with atrophic gastritis should be assessed for H pylori infection. [1] If H pylori is positive, treatment should be administered. [1] Successful eradication should be confirmed using nonserological testing modalities. [1]
Endoscopic evaluation and biopsy strategy
Typical endoscopic features include pale gastric mucosa, increased visibility of vasculature due to mucosal thinning, and loss of gastric folds. [1] When concomitant intestinal metaplasia is present, light blue crests and white opaque fields may be seen. [1] When endoscopic features suggest atrophic gastritis, the extent should be assessed endoscopically. [1] Biopsies should be obtained from suspected atrophic/metaplastic areas for histopathological confirmation and risk stratification. [1] At minimum, biopsies from the body and antrum/incisura should be obtained and placed in separately labeled jars. [1] Targeted biopsies should also be obtained from any other mucosal abnormalities. [1]
Autoimmune gastritis evaluation
In patients with histology compatible with autoimmune gastritis, antiparietal cell antibodies and anti–intrinsic factor antibodies should be considered to assist with diagnosis. [1] Anemia due to vitamin B-12 and iron deficiencies should be evaluated. [1]
Nutritional deficiency assessment and treatment targets
Iron and vitamin B-12 deficiencies should be evaluated in patients with atrophic gastritis irrespective of etiology, especially when disease is corpus-predominant. [1] In patients with unexplained iron or vitamin B-12 deficiency, atrophic gastritis should be included in the differential diagnosis and appropriate diagnostic evaluation pursued. [1]
Pernicious anemia management pathway
Pernicious anemia should be recognized as a late-stage manifestation of autoimmune gastritis characterized by vitamin B-12 deficiency and macrocytic anemia. [1] Patients with a new diagnosis of pernicious anemia who have not had a recent endoscopy should undergo endoscopy with topographical biopsies. [1] This endoscopy should be performed to confirm corpus-predominant atrophic gastritis and to rule out prevalent gastric neoplasia, including neuroendocrine tumors. [1]
Gastric neuroendocrine tumor screening and follow-up
Individuals with autoimmune gastritis should be screened for type 1 gastric neuroendocrine tumors with upper endoscopy. [1] Small neuroendocrine tumors should be removed endoscopically. [1] After endoscopic removal, surveillance endoscopy every 1–2 years should be performed depending on neuroendocrine tumor burden. [1]
Endoscopic surveillance interval
The optimal surveillance interval for atrophic gastritis is not well-defined and should be individualized with shared decision-making. [1] A surveillance endoscopy every 3 years should be considered in individuals with advanced atrophic gastritis. [1] Advanced atrophic gastritis should be defined based on anatomic extent and histologic grade. [1] For autoimmune gastritis, interval endoscopic surveillance should be considered based on individualized assessment and shared decision-making. [1]
Common management triggers and decision points
Histology demonstrating intestinal metaplasia on gastric biopsy almost invariably implies atrophic gastritis. [1] Coordinated documentation between gastroenterology and pathology should support consistent recording of extent and severity, particularly when atrophy is marked. [1] Autoimmune thyroid disease is commonly concomitant with autoimmune gastritis, and screening should be performed. [1]