A current clinical overview of atrophic gastritis

ABSTRACT

Introduction: Atrophic gastritis (AG) is a complex syndrome which arises as a consequence of H. pylori infection or in the context of gastric autoimmunity. It often deserves a benign course but may lead to potentially life-threatening complications: cancer and anemia. This review aims to address traditional and innovative knowledge on this often under-diagnosed disorder.

Areas covered: This review covers clinical presentation, risk factors, diagnosis, and management of AG and provides an updated resource for clinicians to get insight into this challenging disorder. Updated literature was searched in PubMed. Manual search from reference lists of publications was performed.

Expert opinion: A case-finding strategy may be beneficial in individuals with anemia, dyspepsia, autoimmune thyropaties and type 1 diabetes, and family history of gastric cancer. AG is linked to gastric cancer risk and endoscopic surveillance is indicated according to topography of gastric atrophy and risk factors. The direction for future research in AG is summarized.

KEYWORDS:

• Atrophic gastritis
• iron deficiency anemia
• vitamin B₁₂ deficiency
• dyspepsia
• Helicobacter pylori
• chromoendoscopy
• narrow-band imaging
• gastric cancer

Article Highlight

• AG is a relatively prevalent illness, common in older adults but often present also in younger adults, which may arise as long-term consequence of H. pylori infection or as or in the context of gastric autoimmunity.

• The gold standard for the diagnosis of AG is represented by the histopathological assessment of the biopsies of antrum and corpus mucosa of the stomach (two biopsies of the antrum, one from incisura and two of the corpus should be obtained and sent in separate vials), to achieve a correct staging of AG and/or intestinal metaplasia (IM)

• The histopathological evaluation of gastric biopsies should be performed according to the updated Sydney system and staging should be expressed according to OLGA/OLGIM classification systems.

• Electronic chromoendoscopy (narrow-band imaging or blue light imaging) allows to recognize metaplastic AG permitting to perform ‘target biopsies’ in areas with a high suspicion for IM increasing the diagnostic accuracy.

• A validated classification for the endoscopic grading of gastric intestinal metaplasia (EGGIM) shows a high accuracy in the staging of IM compared to histological exam as gold standard.

• AG involving the corpus mucosa may be associated with iron and/or vitamin B₁₂ deficiency anemia, sometimes with more unspecific hematological alterations as macro- or microcytosis or anisocytosis; the timely diagnosis and treatment of these alterations is critical, especially in the elderly.

• A case-finding strategy (serological testing or gastroscopy with biopsies) may be beneficial in individuals with unexplained iron deficiency anemia, macrocytosis, or macrocytic anemia, persistent dyspepsia, autoimmune thyropaties and type 1 diabetes mellitus, positive family history of gastric cancer/precancerous lesions, and on continuous PPI treatment.

• Serological tests like pepsinogens and gastrin are useful to screen patients with a high suspicion of AG to identify those who need to perform gastroscopy; anti-H. pylori antibody is helpful to identify patients with previous or current H. pylori infection; anti-parietal cell antibodies seem to be a promising tool in autoimmune and H. pylori-related AG but validation is awaited.

• AG is linked to an increased risk of gastric cancer and therefore endoscopic surveillance is indicated according to intragastric distribution of gastric atrophy and risk factors.

• Patients with AG involving the corpus mucosa should undergo endoscopic surveillance every 3 years or every 1–2 years if first-degree family history of gastric cancer is present; patients with AG only in the antrum without IM do not need surveillance, patients with metaplastic AG only in the antrum should be followed-up every 3 years only in the presence of risk factors (first-degree family history of gastric cancer, incomplete IM, autoimmune gastritis or persistent H. pylori infection).

• In patients with a corpus-involving AG, the use of antisecretory drugs like proton pump inhibitors may not be indicated because of the presence of the impaired gastric acid secretion due to the atrophic damage of the corpus oxyntic glands.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.