Atrophic gastritis (AG) is a chronic condition characterized by long-term inflammation of the stomach lining. This sustained inflammation leads to the progressive loss of specialized cells, particularly those that produce gastric acid and intrinsic factor. Over time, the stomach lining thins and is replaced by tissue resembling the intestinal lining, a change called intestinal metaplasia. This gradual process impairs the stomach’s ability to perform its normal digestive and absorptive functions. Managing AG requires a long-term strategy focused on addressing the root cause, correcting nutritional imbalances, and maintaining regular medical surveillance.
Targeting the Underlying Cause
Treatment for atrophic gastritis begins with identifying and eliminating the primary trigger of the inflammation, which is often a bacterial infection or an autoimmune response. The most frequent cause is chronic infection with the bacterium Helicobacter pylori (\(H. pylori\)), which must be eradicated to halt the progression of mucosal damage. Eradication typically involves a combination therapy, such as a proton pump inhibitor (PPI) along with two or three different antibiotics, administered for 10 to 14 days. These regimens, often called triple or quadruple therapy, aim for a high cure rate, confirmed with a follow-up test (urea breath test or stool antigen test) at least four weeks after treatment completion.
Eradicating H. pylori may not completely reverse the atrophy or intestinal metaplasia that has already occurred, but it is necessary to prevent further damage to the stomach lining. In cases of Autoimmune Gastritis (AIG), the body’s own immune system mistakenly attacks the parietal cells. Management for AIG therefore shifts focus to correcting complications that arise from the lack of stomach acid and intrinsic factor. While the autoimmune trigger cannot be eliminated, controlling the inflammation helps manage the condition and slow its potential long-term effects.
Management of Nutritional Deficiencies
A major consequence of atrophic gastritis is the impairment of nutrient absorption due to hypochlorhydria (low stomach acid) and the lack of intrinsic factor. Vitamin B12 deficiency is a concern. This occurs because destroyed parietal cells produce intrinsic factor, a protein required for B12 absorption in the small intestine. Without sufficient B12, patients can develop megaloblastic anemia and neurological dysfunction, including nerve damage.
For patients with established B12 deficiency, supplementation is mandatory, often administered through intramuscular injections to bypass the need for intrinsic factor and the stomach. High-dose oral supplementation (500 to 1000 micrograms daily) may be adequate for individuals with mild deficiency or those who retain some residual ability to absorb the vitamin. Regular monitoring of serum B12 levels is necessary regardless of the supplementation method.
Iron deficiency anemia (IDA) is also commonly seen, often presenting earlier than B12 deficiency, particularly in women. Stomach acid is needed to convert dietary iron from its insoluble ferric form to the more absorbable ferrous form. The low acid environment created by AG prevents this conversion, leading to poor iron uptake.
Iron status is monitored through blood tests that measure ferritin (iron stores) and transferrin saturation. Treatment involves oral iron supplements, though in cases of severe deficiency or intolerance, iron infusions may be required to restore body stores. Additionally, the reduced acid environment can impair the absorption of other micronutrients, including calcium and Vitamin D, necessitating their monitoring and possible supplementation to mitigate the risk of bone health issues.
Essential Long-Term Monitoring
Atrophic gastritis, particularly when associated with intestinal metaplasia, is recognized as a pre-neoplastic condition, meaning it carries an elevated risk of progression to gastric cancer. This necessitates structured long-term medical surveillance to detect cancerous changes early. Medical societies recommend regular endoscopic examinations with biopsies to monitor the stomach lining.
The frequency of these procedures is determined by the extent and severity of the atrophy and metaplasia, often categorized using staging systems like OLGA (Operative Link on Gastritis Assessment) or OLGIM. Patients with advanced atrophic gastritis, classified as stage III or IV, are advised to undergo surveillance endoscopy every three years. During the endoscopy, the physician takes targeted biopsies from specific stomach regions, such as the antrum and the body, to assess the tissue’s cellular health.
Patients with Autoimmune Gastritis also require surveillance every three to five years, and they need to be screened for Type 1 gastric neuroendocrine tumors (NETs). Regular blood tests are necessary to ensure that nutritional deficiencies, such as low B12 and iron, remain adequately managed through ongoing supplementation. This proactive, lifelong monitoring is key to treating atrophic gastritis, separate from the initial intervention or daily nutrient replacement.
Supportive Dietary and Lifestyle Changes
While medical treatment focuses on the underlying cause and correcting deficiencies, supportive changes to diet and lifestyle can help manage symptoms and reduce irritation of the remaining stomach lining. Patients are advised to avoid irritants such as alcohol, tobacco, and nonsteroidal anti-inflammatory drugs (NSAIDs). Reducing the intake of spicy or acidic foods can also help minimize discomfort.
Adjusting eating habits can improve the digestive process and lessen the workload on the compromised stomach. Eating smaller portions more frequently throughout the day, rather than three large meals, can aid digestion and reduce the feeling of fullness or bloating. Chewing food thoroughly is helpful, as mechanical breakdown of food in the mouth supports the subsequent digestive steps.
Acid supplementation, such as betaine hydrochloride, is sometimes discussed as a way to replace the lost stomach acid and aid digestion. However, using any form of acid supplement should only be done under strict medical supervision, as its effect and safety in the context of advanced atrophic gastritis are not fully established. Patients should always consult their physician before incorporating any new supplement or making significant dietary changes.