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Atrophic gastritis

What's new

The American College of Gastroenterology (ACG) has published a new guideline on gastric premalignant conditions, including autoimmune gastritis (AIG). H. pylori testing with a nonserological test is recommended in patients with AIG, followed by eradication if positive, and post-treatment testing to confirm eradication. While evidence on endoscopic surveillance is insufficient, individualized surveillance is suggested due to the increased risk of type 1 neuroendocrine tumors and possible gastric cancer. Endoscopic surveillance at 3-year intervals is suggested for atrophic gastritis (AG) in antrum or corpus biopsies. .

Background

Overview

Definition
Atrophic gastritis is defined as a chronic inflammation leading to the loss of gastric glands, which can occur with or without metaplasia.
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Pathophysiology
The pathophysiology of atrophic gastritis involves an immune response directed towards the parietal cells and intrinsic factor of the gastric body and fundus. This leads to hypochlorhydria, hypergastrinemia, and inadequate production of the intrinsic factor, which in turn results in the reduction of essential substances like hydrochloric acid and intrinsic factor.
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Epidemiology
The prevalence of atrophic gastritis worldwide is estimated at 25%, and the risk is 2.4 times higher in H. pylori-positive individuals.
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Risk factors
Risk factors for atrophic gastritis include H. pylori infection, autoimmune disorders, and long-term use of PPIs. It is also frequently found in association with other autoimmune diseases, such as Hashimoto's thyroiditis and T1DM.
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Disease course
Clinically, atrophic gastritis can be asymptomatic or present with vague gastrointestinal symptoms. Complications such as pernicious anemia or gastric cancer can occur due to the condition's impact on the stomach's secretion of essential substances.
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Prognosis and risk of recurrence
The prognosis of atrophic gastritis is influenced by the extent and severity of gland loss and the underlying cause. It can progress to gastric cancer, especially in patients with advanced stages of gastritis.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of atrophic gastritis are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2025), the American Gastroenterological Association (AGA 2025,2021,2020), the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the Italian Society of Digestive Endoscopy (SIDE/SIGE 2022), the British Society of Gastroenterology (BSG ...
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Screening and diagnosis

Diagnosis: as per AGA 2021 guidelines, recognize that atrophic gastritis is defined as the loss of gastric glands, with or without metaplasia, in the setting of chronic inflammation mainly due to H. pylori infection or autoimmunity.
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Classification and risk stratification

Risk of malignancy: as per EHMSG/ESGE/ESP/SPED 2019 guidelines, recognize that patients with chronic atrophic gastritis or intestinal metaplasia are at risk for gastric adenocarcinoma,
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and patients with advanced stages of gastritis with atrophy and/or intestinal metaplasia affecting both antral and corpus mucosa are at higher risk for gastric adenocarcinoma.
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Diagnostic investigations

Antibody testing: as per AGA 2021 guidelines, consider obtaining anti-parietal cell antibodies and anti-intrinsic factor antibodies to assist in the diagnosis of patients with histology compatible with autoimmune gastritis.
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More topics in this section

  • Serum pepsinogen levels

  • H. pylori testing

  • Evaluation of anemia

  • Screening for autoimmune thyroid disease

Diagnostic procedures

Diagnostic endoscopy
As per KCHUGR 2023 guidelines:
Consider performing image-enhanced endoscopy in addition to white light endoscopy to increase the diagnostic accuracy of intestinal metaplasia.
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Do not rely on white light endoscopy findings to determine whether to perform a biopsy when considering a biopsy to confirm atrophic gastritis or intestinal metaplasia.
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  • Biopsy (general indications)

  • Biopsy (patients with anemia)

  • Biopsy (patients with polyps)

  • Histopathology

Medical management

H. pylori eradication: as per KCHUGR 2023 guidelines, consider initiating H. pylori eradication therapy to improve atrophic gastritis in patients with Helicobacter-positive atrophic gastritis.
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Specific circumstances

Patients with pernicious anemia
As per AGA 2021 guidelines:
Obtain an appropriate diagnostic evaluation for atrophic gastritis in patients with unexplained iron or vitamin B12 deficiency.
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Perform endoscopy with topographical biopsies to confirm corpus-predominant atrophic gastritis for risk stratification and to rule out prevalent gastric neoplasia (including neuroendocrine tumors) in patients with a new diagnosis of pernicious anemia.
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Preventative measures

Prevention of progression
As per BSG 2019 guidelines:
Do not use NSAIDs or COX-2 inhibitors to reduce the risk of progression of premalignant lesions of the stomach.
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Do not use antioxidants to reduce the prevalence of premalignant gastric lesions.
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Follow-up and surveillance

Endoscopic surveillance: as per ACG 2025 guidelines, consider obtaining individualized endoscopic surveillance in patients with autoimmune gastritis due to the increased risk of type 1 neuroendocrine tumors and the possible increased risk of gastric cancer.
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