Atrophic Gastritis Treatment & Management
- Author: Nafea Zayouna, MD; Chief Editor: BS Anand, MD more...
Once atrophic gastritis is diagnosed, treatment can be directed (1) to eliminate the causal agent, which is a possibility in cases of H pylori–associated atrophic gastritis; (2) to correct complications of the disease, especially in patients with autoimmune atrophic gastritis who develop pernicious anemia (in whom vitamin B-12 replacement therapy is indicated); or (3) to attempt to reverse the atrophic process.
No consensus from different studies exists regarding the reversibility of atrophic gastritis; however, removal of H pylori from the already atrophic stomach may block further progression of the disease. Until recently, specific recommendations for H pylori eradication were limited to peptic ulcer disease. At the Digestive Health Initiative International Update Conference on H pylori held in the United States, the recommendations for H pylori testing and treatment were broadened. H pylori testing and eradication of the infection also were recommended after resection of early gastric cancer and for low-grade mucosa-associated lymphoid tissue lymphoma.
If H pylori is identified as the underlying cause of gastritis, subsequent eradication now is almost generally an accepted practice. Protocols for H pylori eradication require a combination of antimicrobial agents and antisecretory agents, such as a proton pump inhibitors (PPIs), ranitidine bismuth citrate (RBC), or bismuth subsalicylate. Despite the combinatorial effect of drugs in regimens used to treat H pylori infection, cure rates remain, at best, 80-95%.
Lack of patient compliance and antimicrobial resistance are the most important factors influencing poor outcome. Currently, the most widely used and efficient therapies to eradicate H pylori are triple therapies (recommended as first-line treatments) and quadruple therapies (recommended as second-line treatment when triple therapies fail to eradicate H pylori). In both cases, the best results are achieved by administering therapy for 10-14 days, although some studies have recommended the duration of treatment of 7 days. The accepted definition of cure is no evidence of H pylori 4 or more weeks after ending the antimicrobial therapy.
Triple therapy, with indicated adult dose
Twice-a-day (bid) PPI or RBC triple therapies include lansoprazole (Prevacid), 30 mg PO bid; omeprazole (Prilosec), 20 mg PO bid; or RBC (Tritec), 400 mg bid. Antibiotic therapy includes clarithromycin (Biaxin), 500 mg PO bid; amoxicillin, 1000 mg PO bid; or metronidazole, 500 mg PO bid.
Pack kits containing combination triple therapies are available as combinations of lansoprazole, amoxicillin, and clarithromycin (PrevPac) and bismuth subsalicylate, tetracycline, and metronidazole (Helidac). PrevPac contains drug combinations in the dosage recommended as first-line treatment by the Maastricht 2-2000 Consensus report from Europe. Note the following:
PrevPac components include lansoprazole (Prevacid), 30 mg PO bid; clarithromycin (Biaxin), 500 mg PO bid; and amoxicillin, 1000 mg PO bid.
Helidac triple-therapy components include bismuth subsalicylate, 525 mg (two 262.4-mg chewable tabs) 4 times per day (qid); metronidazole, 250 mg qid; and tetracycline HCL, 500 mg qid.
Quadruple therapy, with indicated adult dose
Quadruple therapy, with indicated adult dose is a PPI bid, including lansoprazole (Prevacid), 30 mg PO bid or omeprazole (Prilosec), 20 mg PO bid, and antibiotics, including tetracycline HCl, 500 mg PO qid; bismuth subsalicylate, 120 mg PO qid; and metronidazole, 500 mg PO 3 times per day (tid).
Handle subsequent H pylori eradication failures on a case-by-case basis.
Epidemiologic studies of H pylori–associated chronic gastritis show that acquisition of the infection is associated with large crowded households and lower socioeconomic status.
Well-defined measures to prevent infection are not established.
Guidelines for follow-up care for cases of atrophic gastritis are not established.
If the patient was treated for H pylori infection, confirm eradication. Perform evaluation of eradication at least 4 weeks after the end of treatment. Eradication may be assessed by noninvasive methods, such as the urea breath test.
Follow-up care may be individualized depending on findings during endoscopy. For example, if dysplasia is found at endoscopy, increased surveillance is necessary.
Yanaoka K, Oka M, Ohata H, et al. Eradication of Helicobacter pylori prevents cancer development in subjects with mild gastric atrophy identified by serum pepsinogen levels. Int J Cancer. 2009 Dec 1. 125(11):2697-703. [Medline].
Vannella L, Lahner E, Annibale B. Risk for gastric neoplasias in patients with chronic atrophic gastritis: a critical reappraisal. World J Gastroenterol. 2012 Mar 28. 18(12):1279-85. [Medline]. [Full Text].
Weck MN, Gao L, Brenner H. Helicobacter pylori infection and chronic atrophic gastritis: associations according to severity of disease. Epidemiology. 2009 Jul. 20(4):569-74. [Medline].
Tahara T, Shibata T, Wang FY, et al. Mannan-binding lectin B allele is associated with a risk of developing more severe gastric mucosal atrophy in Helicobacter pylori-infected Japanese patients. Eur J Gastroenterol Hepatol. 2009 Jul. 21(7):781-6. [Medline].
Gao L, Weck MN, Nieters A, Brenner H. Inverse association between a pro-inflammatory genetic profile and Helicobacter pylori seropositivity among patients with chronic atrophic gastritis: enhanced elimination of the infection during disease progression?. Eur J Cancer. 2009 Nov. 45(16):2860-6. [Medline].
Gao L, Weck MN, Stegmaier C, Rothenbacher D, Brenner H. Alcohol consumption and chronic atrophic gastritis: Population-based study among 9,444 older adults from Germany. Int J Cancer. 2009 Jun 2. 125(12):2918-22. [Medline]. [Full Text].
Palladino M, Chiusolo P, Reddiconto G, et al. MTHFR polymorphisms involved in vitamin B12 deficiency associated with atrophic gastritis. Biochem Genet. 2009 Oct. 47(9-10):645-50. [Medline].
Lahner E, Norman GL, Severi C, et al. Reassessment of intrinsic factor and parietal cell autoantibodies in atrophic gastritis with respect to cobalamin deficiency. Am J Gastroenterol. 2009 Aug. 104(8):2071-9. [Medline].
Stummvoll GH, DiPaolo RJ, Huter EN, et al. Th1, Th2, and Th17 effector T cell-induced autoimmune gastritis differs in pathological pattern and in susceptibility to suppression by regulatory T cells. J Immunol. 2008 Aug 1. 181(3):1908-16. [Medline]. [Full Text].
Huter EN, Stummvoll GH, DiPaolo RJ, Glass DD, Shevach EM. Pre-differentiated Th1 and Th17 effector T cells in autoimmune gastritis: Ag-specific regulatory T cells are more potent suppressors than polyclonal regulatory T cells. Int Immunopharmacol. 2009 May. 9(5):540-5. [Medline].
Massironi S, Cavalcoli F, Rossi RE, et al. Chronic autoimmune atrophic gastritis associated with primary hyperparathyroidism: a transversal prospective study. Eur J Endocrinol. 2013 May. 168(5):755-61. [Medline].
Yagi K, Nakamura A, Sekine A, Graham D. Features of the atrophic corpus mucosa in three cases of autoimmune gastritis revealed by magnifying endoscopy. Case Report Med. 2012. 2012:368160. [Medline]. [Full Text].
Zhang Y, Weck MN, Schottker B, et al. Gastric parietal cell antibodies, Helicobacter pylori infection, and chronic atrophic gastritis: evidence from a large population-based study in Germany. Cancer Epidemiol Biomarkers Prev. 2013 May. 22(5):821-6. [Medline].
Capella C, Fiocca R, Cornaggia M. Autoimmune gastritis. Graham DY, Genta RM, Dixon MF, eds. Gastritis. Philadelphia, Pa: Lippincott Williams; 1999. 79-96.
Correa P. Human gastric carcinogenesis: a multistep and multifactorial process-- First American Cancer Society Award Lecture on Cancer Epidemiology and Prevention. Cancer Res. 1992 Dec 15. 52(24):6735-40. [Medline].
Dixon MF, Genta RM, Yardley JH. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol. 1996 Oct. 20(10):1161-81. [Medline].
Dore MP, Leandro G, Realdi G, Sepulveda AR, Graham DY. Effect of pretreatment antibiotic resistance to metronidazole and clarithromycin on outcome of Helicobacter pylori therapy: a meta-analytical approach. Dig Dis Sci. 2000 Jan. 45(1):68-76. [Medline].
Franceschi F, Genta RM, Sepulveda AR. Gastric mucosa: long-term outcome after cure of Helicobacter pylori infection. J Gastroenterol. 2002. 37 Suppl 13:17-23. [Medline].
Gao L, Weck MN, Raum E, et al. Sibship size, Helicobacter pylori infection and chronic atrophic gastritis: a population-based study among 9444 older adults from Germany. Int J Epidemiol. 2010 Feb. 39(1):129-34. [Medline].
Graham DY. Therapy of Helicobacter pylori: current status and issues. Gastroenterology. 2000 Feb. 118(2 Suppl 1):S2-8. [Medline].
Graham DY, Belson G, Abudayyeh S, et al. Twice daily (mid-day and evening) quadruple therapy for H. pylori infection in the United States. Dig Liver Dis. 2004 Jun. 36(6):384-7. [Medline].
Hershko C, Hoffbrand AV, Keret D, et al. Role of autoimmune gastritis, Helicobacter pylori and celiac disease in refractory or unexplained iron deficiency anemia. Haematologica. 2005 May. 90(5):585-95. [Medline].
Inoue T, Uedo N, Ishihara R, et al. Autofluorescence imaging videoendoscopy in the diagnosis of chronic atrophic fundal gastritis. J Gastroenterol. 2010 Jan. 45(1):45-51. [Medline].
Konturek PC, Konturek SJ, Brzozowski T. Helicobacter pylori infection in gastric cancerogenesis. J Physiol Pharmacol. 2009 Sep. 60(3):3-21. [Medline].
Krasinskas AM, Abraham SC, Metz DC, et al. Oxyntic mucosa pseudopolyps: a presentation of atrophic autoimmune gastritis. Am J Surg Pathol. 2003 Feb. 27(2):236-41. [Medline].
Laiyemo AO, Kamangar F, Marcus PM, et al. Atrophic gastritis and the risk of incident colorectal cancer. Cancer Causes Control. 2010 Jan. 21(1):163-70. [Medline].
Leung WK, Kim JJ, Kim JG. Microsatellite instability in gastric intestinal metaplasia in patients with and without gastric cancer. Am J Pathol. 2000 Feb. 156(2):537-43. [Medline].
Malfertheiner P, Megraud F, O'Morain C, et al. Current concepts in the management of Helicobacter pylori infection--the Maastricht 2-2000 Consensus Report. Aliment Pharmacol Ther. 2002 Feb. 16(2):167-80. [Medline].
Rugge M, Genta RM. Staging and grading of chronic gastritis. Hum Pathol. 2005 Mar. 36(3):228-33. [Medline].
Shin CM, Kim N, Lee HS, et al. Validation of diagnostic tests for Helicobacter pylori with regard to grade of atrophic gastritis and/or intestinal metaplasia. Helicobacter. 2009 Dec. 14(6):512-9. [Medline].
Sipponen P, Harkonen M, Alanko A, et al. Diagnosis of atrophic gastritis from a serum sample. Clin Lab. 2002. 48(9-10):505-15. [Medline].
Vaananen H, Vauhkonen M, Helske T, et al. Non-endoscopic diagnosis of atrophic gastritis with a blood test. Correlation between gastric histology and serum levels of gastrin-17 and pepsinogen I: a multicentre study. Eur J Gastroenterol Hepatol. 2003 Aug. 15(8):885-91. [Medline].
Whittingham S, Mackay IR. Autoimmune gastritis: historical antecedents, outstanding discoveries, and unresolved problems. Int Rev Immunol. 2005 Jan-Apr. 24(1-2):1-29. [Medline].