Gastric Atrophy Management

Pathogenesis and Natural History

The American Gastroenterological Association recommends that patients with gastric atrophy associated with H. pylori infection should be treated with combined antibiotic therapy to eradicate H. pylori, followed by confirmation of eradication and endoscopic surveillance every 3 years for patients with advanced atrophy 1
Gastric atrophy associated with H. pylori infection is characterized by progressive histopathological changes, including atrophic changes that begin initially in the incisura angularis and antral-corpus transitional mucosa as small foci with gland loss and intestinal metaplasia (IM) 2
The risk of progression from gastric atrophy to gastric adenocarcinoma varies between 0.1% and 0.3% per year, but can be higher depending on the severity of atrophy, its extension, and the presence of concomitant IM 3
The severity and topographic distribution of atrophic lesions are well-established determinants of the risk of gastric cancer 4

The diagnosis of gastric atrophy should be confirmed by histopathology, regardless of etiology, and topographic biopsies are recommended to determine the anatomical extension and histological severity for risk stratification 2
The updated Sydney protocol requires 5 gastric biopsies placed in separate labeled containers: 2 from the antrum, 2 from the corpus, and 1 from the incisura angularis 6
All patients with gastric atrophy should be tested for H. pylori using non-serological methods, and if positive, the infection should be eradicated, followed by non-serological testing to confirm successful eradication 1

Eradication of H. pylori is the cornerstone of treatment for H. pylori-positive gastric atrophy, with quadruple therapy with bismuth recommended as first-line treatment due to increasing resistance to clarithromycin 1
Successful eradication should be confirmed by non-serological testing, and endoscopic surveillance should be considered for patients with advanced gastric atrophy every 3 years 6

Endoscopic surveillance should be considered for patients with advanced gastric atrophy every 3 years, with the definition of advanced gastric atrophy based on anatomical extension and histological grade 6
The American Gastroenterological Association recommends that patients with gastric atrophy should be evaluated for anemia and micronutrient deficiencies, including iron and vitamin B12, regardless of anemia 5

Patients with chronic gastric atrophy are at increased risk of developing type I neuroendocrine tumors (NETs), with an estimated incidence rate of 0.4-0.7% per year, and should be evaluated and managed accordingly 3
The American Gastroenterological Association recommends that patients with gastric atrophy should be evaluated for calcium status, along with other micronutrient deficiencies, including vitamin D, iron studies, and vitamin B12 8