Atrophic Gastritis and Gastric Polyps:
Patient presented with history of recent weight loss, fatigue and dyspepsia. Lab work showed a history of vitamin B12 deficiency requiring supplementation and most recently a normocytic anemia. Serologies were positive for anti-parietal cell and anti-Intrinsic factor antibodies. EGD was preformed and showed semi pedunculated polyp seen in image below approx 7mm-10mm in size, no dysplasia or malignancy. Random biopsies were positive for autoimmune metaplastic atrophic gastritis with linear neuroendocrine cell hyperplasia.
Are we done?
Atrophic gastritis is a condition that is characterized by the replacement of gastric glandular cells with fibrosis due to inflammation. It has been associated with H pylori infection, PPI use and autoimmune disease. It is an important finding as patients can have significant malabsorption and places them at higher risk for gastric cancers.
Prevalence 1-2% Female to Male 3:1
Patient Presentation: Patients with atrophic gastritis can present with an array of both GI and non-GI symptoms
Symptoms: Fatigue, dyspepsia, hair loss, brittle nails, psychiatric symptoms, impaired wound healing, nausea, psychiatric symptoms
Laboratory findings: Iron deficiency, Vitamin B12 deficiency(Pernicious anemia), Anemia (microcytic or macrocytic), elevated gastrin and achlorhydria
Causes:
Autoimmune Metaplastic Gastric Atrophy (AMAG):
-Inherited or due to prolonged H. pylori infection resulting in auto antibodies to parietal cells and intrinsic factors resulting in pernicious anemia.
-Confined to body and fundus of the stomach (Type A)
-Labs show elevated gastrin, auto-antibodies to parietal cells and intrinsic factor, low iron, low B12, either microcytic or macrocytic anemia can be present.
-Diagnosis entails serology for auto antibodies as well as classic histological findings
-Predisposes to Gastric Neuroendocrine Tumors type 1 as well as gastric adenocarcinoma
-Treatment includes supplementation and monitoring for development of gastric metaplasia and neuroendocrine tumors
Environmental Metaplastic Gastric Atrophy (EMAG):
-Associated with environmental toxins most notably H. pylori. Other possible causes include high salt intake, alcohol, tobacco use and chronic bile salt reflux.
-Confined to body and in some subtypes the antrum (Type B)
-Labs show NO auto-antibodies, normal gastrin levels,
-Diagnosis is based on pathology findings and exposure to known environmental triggers such as H. pylori
-Increased risk for gastric cancer and intestinal metaplasia
-Treatment includes testing and treating for H pylori as well as eliminating other environmental risk factors. Surveillance endoscopy should also be preformed at time of diagnosis and based on findings
Role of Endoscopy in Atrophic Gastritis: A premalignant condition
Endoscopy plays a key role in diagnosing and following patients with Atrophic Gastritis. Endoscopy should be preformed for all patients in which atrophic gastritis is a suspicion. Both forms EMAG and AMAG carry increased risks for malignant conditions like intestinal metaplasia, gastric adenocarcinoma and gastric neuro endocrine tumors. Both the ASGE and ESGE have guidelines for surveillance and management of polyps in atrophic gastritis. We will highlight some of the important recommendations below and the recent changes between ASGE 2015 guidelines and the updated 2020 ESGE guidelines
ESGE 2020 guidelines (updates or changes):
-For diagnosis of IM, AG, and early neoplastic lesions, use high-definition endoscopy with chromoendoscopy (CE).
-Use virtual CE, with or without magnification, to guide biopsy for staging AG and IM and to target neoplastic lesions.
-Take biopsy samples from the antrum and the corpus, at the lesser and greater curvature of each and additional samples of visible neoplastic suspicious lesions.
-In patients with dysplasia but no endoscopically defined lesion, conduct immediate high-quality endoscopic reassessment with CE (virtual or dye-based). If no lesion is detected, conduct biopsy for staging of gastritis (if not previously done) and perform endoscopic surveillance within 6 months for high-grade dysplasia or 12 months for low-grade dysplasia.
-In patients with IM at a single location and a family history of gastric cancer; incomplete IM; or persistent Helicobacter pylori gastritis, consider endoscopic surveillance with CE and guided biopsies in 3 years.
-Advanced AG (severe atrophic changes or IM in both antrum and corpus) warrants a high-quality endoscopy every 3 years.
-Advanced AG and a family history of gastric cancer may warrant more-intensive surveillance (e.g., every 1–2 years after diagnosis).
- No surveillance is necessary for mild-to-moderate atrophy restricted to the antrum.
- For autoimmune gastritis, consider endoscopic follow-up every 3–5 years.
ASGE 2015 Guidelines on management of gastric polyps
-In the setting of multiple hyperplastic or adenomatous polyps, we suggest systematic sampling of the surrounding nonpolypoid gastric mucosa to assess for H pylori and metaplastic atrophic gastritis
-We suggest endoscopy within 6 months of the diagnosis of pernicious anemia or the development of upper GI symptoms in patients with pernicious anemia
-We suggest endoscopic resection of small (<1 cm) type 1 and type 2 gastric carcinoids that do not demonstrate aggressive features such as angioinvasion, muscular wall invasion, high proliferative index, and/ or metastatic disease and endoscopic surveillance thereafter every 1 to 2 years. We suggest endoscopic removal for type 3 and 4 gastric carcinoids (isolated and <1 cm in diameter)
-We suggest surveillance endoscopy for patients with GIM who are at increased risk of gastric cancer due to ethnic background or family history. Optimal surveillance intervals have not been extensively studied and should be individualized
-We recommend solitary gastric polyps undergo biopsy or be resected when possible
-We suggest polypectomy of fundic gland polyps 1 cm or larger, hyperplastic polyps 0.5 cm or larger, and adenomatous polyps of any size when possible.
-We suggest surveillance endoscopy 1 year after removing adenomatous gastric polyps
Resources used for this post:
Evans et al: The role of endoscopy in the management of premalignant and malignant conditions of the stomach (ASGE 2015 Guidelines)
Pimentel-Nunes P et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II) (ESGE 2020 Guidelines)
Stefanie Kulnigg-Dabsch (2016). "Autoimmune gastritis". Wien Med Wochenschr. 166
