Guideline sources The following summarized guidelines for the evaluation and management of atrophic gastritis are prepared by our editorial team based on guidelines from the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the Italian Society of Digestive Endoscopy (SIDE/SIGE 2022), the American Gastroenterological Association (AGA 2021; 2020), the European Society of Gastrointestinal Endoscopy (ESGE/ESP/SPED/EHMSG 2019), the British Society of Gastroenterology (BSG 2019), and the American Society for Gastrointestinal Endoscopy (ASGE 2015). 1 2 3 4 5 6 7 8 Guidelines 1. 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. B https://web.pathway.md/diseases/rec75dvWQq2gKXK7H 1/6 6/23/23, 3:16 AM Atrophic gastritis Pathway Show 2 more As per ESGE 2019 guidelines, confirm intestinal metaplasia histologically as the most reliable marker of atrophy in gastric mucosa. A 2. Classification and risk stratification Risk of malignancy: recognize that patients with chronic atrophic gastritis or intestinal metaplasia are at risk for gastric adenocarcinoma, A 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. B 3. Diagnostic investigations Antibody testing: consider obtaining anti-parietal cell antibodies and anti-intrinsic factor antibodies to assist in the diagnosis of patients with histology compatible with autoimmune gastritis. C Serum pepsinogen levels: assess serum pepsinogen I level and serum pepsinogen I/II ratio to identify patients with advanced stages of atrophic gastritis. B Helicobacter pylori testing: As per AGA 2021 guidelines, obtain testing for H. pylori infection in all patients with atrophic gastritis. B As per AGA 2020 guidelines, obtain testing for H. pylori followed by eradication in patients with gastric intestinal metaplasia. B Evaluation of anemia: As per AGA 2021 guidelines, obtain evaluation for anemia due to vitamin B12 and iron deficiencies in patients with histology compatible with autoimmune gastritis. B As per AGA 2020 guidelines, obtain evaluation for iron and vitamin B12 deficiencies in patients with atrophic gastritis irrespective of etiology, especially if corpus-predominant. B Screening for autoimmune thyroid disease: obtain screening for autoimmune thyroid disease in patients with autoimmune gastritis. B 4. 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. C 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. D https://web.pathway.md/diseases/rec75dvWQq2gKXK7H 2/6 6/23/23, 3:16 AM Atrophic gastritis Pathway As per AGA 2021 guidelines: Providers should recognize typical endoscopic features of atrophic gastritis, which include pale appearance of gastric mucosa, increased visibility of vasculature due to thinning of the gastric mucosa, and loss of gastric folds, and, if with concomitant intestinal metaplasia, light blue crests and white opaque fields. Because these mucosal changes are often subtle, techniques to optimize evaluation of the gastric mucosa should be performed. B When endoscopic features of atrophic gastritis are present, providers should assess the extent endoscopically. Providers should obtain biopsies from the suspected atrophic/metaplastic areas for histopathological confirmation and risk stratification; at a minimum, biopsies from the body and antrum/incisura should be obtained and placed in separately labeled jars. Targeted biopsies should additionally be obtained from any other mucosal abnormalities. B As per BSG 2019 guidelines, perform a full systematic endoscopy (examination time of a minimum of 7 minutes) of the stomach with clear photographic documentation of gastric regions and pathology in patients at higher risk for gastric adenocarcinoma, including atrophic gastritis and gastric intestinal metaplasia. B Show 6 more As per ESGE 2019 guidelines, perform endoscopy in patients with advanced stages of atrophic gastritis, particularly if H. pylori serology is negative. B Show 2 more Biopsy, general indications: As per AGA 2021 guidelines, perform biopsies of the suspected atrophic/metaplastic areas for histopathological confirmation and risk stratification. Take biopsies from the body and antrum/incisura and place them in separately labeled jars. Perform additional targeted biopsies for any other mucosal abnormalities. B As per SPED/ESP/EHMSG/ESGE 2019 guidelines: Perform gastric biopsies both for H. pylori infection diagnosis and identification of advanced stages of atrophic gastritis during the first diagnostic upper gastrointestinal endoscopy, to adequately stage gastric precancerous conditions. B Take biopsies from at least 2 topographic sites (from both the antrum and the corpus, at the lesser and greater curvature of each) and label them clearly in 2 separate vials. Perform additional biopsies of visible neoplastic suspicious lesions. B Biopsy, patients with anemia: As per AGA 2020 guidelines, do not perform a routine gastric biopsy to diagnose atrophic gastritis in patients with iron deficiency anemia. D As per BSG 2019 guidelines, consider performing a baseline endoscopy with biopsies in 50 years old patients with laboratory evidence of pernicious anemia, defined by vitamin B12 deficiency and either positive anti-parietal cell or anti-intrinsic factor antibodies. Take biopsies from the greater and lesser curves since atrophic gastritis affects the corpus in pernicious anemia. C https://web.pathway.md/diseases/rec75dvWQq2gKXK7H 3/6 6/23/23, 3:16 AM Atrophic gastritis Pathway Biopsy (patients with polyps): consider performing systematic sampling of the surrounding non- polypoid gastric mucosa in the setting of multiple hyperplastic or adenomatous polyps, to assess for H. pylori and metaplastic atrophic gastritis. C Histopathology: As per SIGE 2022 guidelines, obtain immunohistochemical analysis in patients with chronic/atrophic gastritis. B As per ESGE 2019 guidelines, consider using systems for histopathological staging (such as the OLGA and the OLGIM assessment) to identify patients with advanced stages of atrophic gastritis. Consider performing an additional biopsy of the incisura if these systems are used to stratify patients. C 5. Medical management Helicobacter pylori eradication: As per KCHUGR 2023 guidelines, consider initiating H. pylori eradication therapy to improve atrophic gastritis in patients with Helicobacter-positive atrophic gastritis. C As per AGA 2021 guidelines, initiate H. pylori eradication therapy in patients with atrophic gastritis with H. pylori infection and confirm eradication with non-serological testing modalities. B As per BSG 2019 guidelines, initiate H. pylori eradication therapy to reduce the risk of gastric adenocarcinoma development in patients with atrophic gastritis. A As per ESGE 2019 guidelines: Initiate H. pylori eradication therapy to regress atrophic gastritis and to reduce the risk of gastric cancer in patients with atrophic gastritis. A Consider initiating H. pylori eradication therapy to reduce inflammation and atrophy in patients with established intestinal metaplasia. C 6. Specific circumstances Patients with pernicious anemia: Obtain an appropriate diagnostic evaluation for atrophic gastritis in patients with unexplained iron or vitamin B12 deficiency. B Perform endoscopy with topographical biopsies to confirm corpus-predominant atrophic gastritis for risk stratification and to rule out prevalent gastric neoplasia (including NETs) in patients with a new diagnosis of pernicious anemia. B 7. Preventative measures Prevention of progression: https://web.pathway.md/diseases/rec75dvWQq2gKXK7H 4/6 6/23/23, 3:16 AM Atrophic gastritis Pathway Do not use NSAIDs or COX-2 inhibitors to reduce the risk of progression of premalignant lesions of the stomach. D Do not use antioxidants to reduce the prevalence of premalignant gastric lesions. D 8. Follow-up and surveillance Endoscopic surveillance: As per AGA 2021 guidelines, decide on the optimal endoscopic surveillance interval in patients with atrophic gastritis or autoimmune gastritis based on individual risk assessment and shared decision-making. B Show 2 more As per AGA 2020 guidelines: Avoid obtaining routine endoscopic surveillance in patients with gastric intestinal metaplasia. D Avoid performing a routine short-interval repeat endoscopy for risk stratification of patients with gastric intestinal metaplasia. D As per BSG 2019 guidelines: Obtain endoscopic surveillance every 3 years in patients with extensive atrophic gastritis or gastric intestinal metaplasia, defined as affecting the antrum and body. B Do not obtain surveillance in patients with atrophic gastritis or gastric intestinal metaplasia limited to the gastric antrum unless there are additional risk factors, such as a strong family history of gastric cancer or persistent H. pylori infection. Consider obtaining 3-yearly surveillance in these patients. D As per ESGE 2019 guidelines, insufficient evidence to recommend surveillance in patients with mild-to-moderate atrophy restricted to the antrum. I Show 5 more References 1. Pedro Pimentel-Nunes, Diogo Lib nio, Ricardo Marcos-Pinto et al. Management of epithelial precancerous conditions and lesions in the stomach MAPS II European Society of Gastrointestinal Endoscopy ESGE , European Helicobacter and Microbiota Study Group EHMSG , European Society of Pathology ESP , and Sociedade Portuguesa de Endoscopia Digestiva SPED guideline update 2019. Endoscopy. 2019 Apr;51 4 365 388. Open 2. Shailja C Shah, M Blanca Piazuelo, Ernst J Kuipers et al. AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology. 2021 Oct;161 4 1325 1332.e7. Open 3. Seung Joo Kang, Jae Gyu Kim, Hee Seok Moon et al. Clinical Practice Guideline for Gastritis in Korea. J Korean Med Sci. 2023 Apr 3;38 13):e115. Open https://web.pathway.md/diseases/rec75dvWQq2gKXK7H 5/6 6/23/23, 3:16 AM Atrophic gastritis Pathway 4. Banks M, Graham D, Jansen M et al. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut. 2019 Sep;68 9 1545 1575. Open 5. Samir Gupta, Dan Li, Hashem B El Serag et al. AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia. Gastroenterology. 2020 Feb;158 3 693 702. Open 6. ASGE Standards of Practice Committee, John A Evans, Vinay Chandrasekhara et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015 Jul;82 1 1 8. Open 7. Marco Romano, Antonietta Gerarda Gravina, Leonardo Henry Eusebi et al. Management of Helicobacter pylori infection: Guidelines of the Italian Society of Gastroenterology SIGE and the Italian Society of Digestive Endoscopy SIED . Dig Liver Dis. 2022 Sep;54 9 1153 1161. Open 8. Cynthia W Ko, Shazia M Siddique, Amit Patel et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020 Sep;159 3 1085 1094. Open https://web.pathway.md/diseases/rec75dvWQq2gKXK7H 6/6