What is Atrophic Gastritis?
Gastric Atrophy (GA) and Intestinal Metaplasia (GIM) are conditions that fall under the umbrella of Chronic Atrophic Gastritis (CAG). Both of these are early stage conditions that can potentially lead to a type of stomach cancer known as gastric adenocarcinoma. In this article, we will explore the latest information and guidance on how to diagnose, manage, and monitor Chronic Atrophic Gastritis in an effort to identify those who may be at risk of progressing to gastric adenocarcinoma.
Chronic Atrophic Gastritis is considered an early warning sign for stomach cancer, which is the fifth most common type of cancer worldwide and has the third highest rate of cancer-related deaths. This aggressive form of cancer usually gets diagnosed at a late stage, especially in countries that lack systematic screening programs. The late diagnosis often leads to a high number of deaths.
The common causes of this pre-cancerous condition are a bacteria called Helicobacter pylori and autoimmune gastritis. Persistent inflammation results in the loss of gastric mucosa, resulting in an environment with reduced acid. This is thought to be an early stage of distal gastric cancer.
Helicobacter pylori is a type of bacteria that prefers environments with low oxygen. It plays a role in causing not only atrophic gastritis, but also peptic ulcers, gastric adenocarcinoma, and a type of lymphoma called MALT. Identifying and eliminating this bacteria significantly reduces the risk of developing Chronic Atrophic Gastritis.
It is extremely important to identify early stage, pre-cancerous conditions by identifying those who are at risk. Regular check-ups including endoscopy (a procedure to examine the digestive tract) are also crucial. If necessary, minimally invasive interventions can help avoid major surgical procedures in advanced stage stomach cancer.
The popular Correa Cascade model suggests a linear progression from Chronic Atrophic Gastritis with changes in the intestinal lining to low-grade and high-grade dysplasia, and ultimately, gastric adenocarcinoma.
What Causes Atrophic Gastritis?
Atrophic gastritis is a condition involving the stomach that’s still not fully understood. However, bacteria called H. pylori are known to be a main cause of a chronic form of this disease. Over the course of time, these bacteria can gradually destroy the stomach’s glands, a condition known as multifocal atrophic gastritis. About half of the world’s population has this bacteria present in their bodies. H. pylori were first found to cause stomach and duodenal ulcers in the early 1980s. The real challenge is managing people infected with the bacteria because it can impact the treatment of diseases of the esophagus.
Autoimmune gastritis, on the other hand, happens when the body’s immune system mistakenly attacks the cells of the stomach lining. This is caused by antibodies, part of the body’s immune system, that target a protein in the stomach called H+/K+ ATPase antigen, resulting in the wasting away of the stomach lining. This attack primarily affects the upper parts of the stomach, where these cells live, and tends to leave the lower part of the stomach, known as the antrum, unaffected.
Risk Factors and Frequency for Atrophic Gastritis
Chronic atrophic gastritis is usually more common in older people, but the exact rates vary from place to place. This medical condition often doesn’t present any symptoms, making it difficult to diagnose. In a study conducted in Germany, the occurrence of this condition increased from 4.8% in people aged 50 to 54 to 8.7% in those aged 70 to 74. Similar trends were seen in Japan as well, but the increase was from 2.7% to 9.1%.
Autoimmune atrophic gastritis, on the other hand, is typically found in older women from Northern European and Scandinavian regions. However, recent studies have shown that it can occur in any ethnicity, region, and age.
Individuals who are older and infected with H. pylori bacteria have a higher chance of developing chronic atrophic gastritis. This condition is slightly more prevalent in men. It’s worth noting that in areas of high incidence like Japan and China, the rate can range between 33 and 84%.
A diagnosis of chronic atrophic gastritis comes with an increased risk of gastric adenocarcinoma, a type of stomach cancer. However, the annual risk remains less than 1% regardless of whether an individual is considered low-risk or high-risk. Gastric adenocarcinoma is commonly linked to H. pylori infection, but there’s also a chance of developing a neuroendocrine gastrin-dependent tumor, caused by an abnormal increase of certain cells in the stomach.
Finally, studies show that people with H.pylori-derived acute gastritis undergoing endoscopy surveillance face varying risks of gastric cancer, depending on the severity of their medical condition. These risks can range from 0.7% for mild or no acute gastritis, to as high as 10% for severe acute gastritis.
Signs and Symptoms of Atrophic Gastritis
Atrophic gastritis is a condition that typically doesn’t show many signs or symptoms. When symptoms do occur, they can include a stomach ache in the upper part of the abdomen, a feeling of sickness, or occasional vomiting. However, these symptoms are quite rare. Instead, the most frequent sign of atrophic gastritis is anemia, which can cause general weakness, fatigue, headaches, and a rapid heartbeat.
- Stomach ache in the upper abdomen
- Feeling of sickness
- Occasional vomiting
- General weakness
- Fatigue
- Headaches
- Rapid heartbeat
Specific types of atrophic gastritis may present differently. For example, H. pylori-induced atrophic gastritis often doesn’t show any symptoms. If symptoms do appear, they usually take the form of short-term, recurrent feelings of nausea and vomiting. Autoimmune metaplastic atrophic gastritis commonly shows vague signs and symptoms, particularly in women over 60 years of age.
Sometimes, this condition can lead to the development of pernicious anemia, which is a condition characterized by vitamin B12 deficiency that occurs in about 0.1% of cases. Symptoms can include fatigue, dizziness, irritability, depression, problems with sleep, and mood swings. However, sometimes, the vitamin B12 levels can appear normal.
Many people with these conditions get treated for their iron, folate, or vitamin B12 deficiencies without getting a diagnosis for the underlying condition. Symptoms can vary greatly depending on other health conditions the person might have, like hypothyroidism, myelodysplastic syndromes, sideroblastic anemia, iron deficiency anemia, or thalassemia, which can make diagnosing the condition a little tricky.
On a physical examination, a doctor might not notice many specific signs. Some may exhibit paleness, anemia, and weight loss due to lack of appetite, but these signs are rare. People with autoimmune metaplastic atrophic gastritis might show signs of associated autoimmune illness such as yellowing of the skin, a rapid heartbeat, or a heart murmur on one side.
Testing for Atrophic Gastritis
Worldwide guidelines highlight that people with chronic atrophic gastritis or intestinal metaplasia are at risk of developing a type of stomach cancer known as gastric adenocarcinoma. The goal is to identify early signs of advanced gastritis in the stomach, preventing the onset of severe dysplasia (abnormal tissue development) and cancer.
Pepsinogen, a type of digestive enzyme, is an important marker in this process. Low levels of pepsinogen 1 and a low ratio of pepsinogen 1 to pepsinogen 2 can point towards advanced atrophic gastritis. Following these indications, doctors will likely recommend an endoscope test to get a clearer picture. Combining the examination of pepsinogen levels, H. pylori bacteria status, and gastrin-17 levels has been found effective in diagnosing atrophic gastritis in individuals at high risk of stomach cancer.
Most endoscopy guidelines emphasize the importance of diagnosing, treating, and monitoring atrophic gastritis, intestinal metaplasia, and dysplasia. Regarding the actual endoscopy process, the first round of biopsies should be carried out from at least two different areas of the stomach, since gastritis can spread unevenly. Any visually abnormal areas, like ulcers, should also be biopsied for a closer examination.
Standard chromoendoscopy, a technique that applies special dyes to highlight different tissues is very accurate in detecting pre-cancerous gastric lesions. A high-definition version of this process is even better for diagnosing and mapping gastric precancerous lesions. Narrowband imaging, a type of specialized lighting, has shown promise for detecting advanced gastritis and early-stage cancers, often used in combination with high-definition white light endoscopy for better results.
If results show dark-staining cells (low-grade or high-grade dysplasia), experts recommend high-quality chromoendoscopy for a more intense surveillance or referral for potential surgical removal of the lesion. Notably, two systems (OLGA and OLGIM) underline the importance of testing for and treating H. pylori in patients with gastric precancerous lesions. Both recognize that extensive intestinal metaplasia (or with a family history of stomach cancer) is considered high-risk, and both don’t necessarily require to subtype intestinal metaplasia but find it interesting for monitoring purposes.
While the exact frequency and follow-up method for endoscopy in atrophic gastritis patients are influenced by different guidelines, it’s generally accepted that the patient’s specific risk factors and overall health should be considered. The focus is mainly on minimizing the risk of progressing to stomach cancer.
Treatment Options for Atrophic Gastritis
There has been substantial research on the impact of eradication therapy on chronic gastric conditions related to atrophy, inflammation, and even stomach cancer. One in-depth study concluded that eradication therapy significantly improved certain types of atrophy and intestinal changes in the stomach.
Further research suggests that eradicating Helicobacter pylori, a bacteria often found in the stomach, could notably decrease the chances of developing intestinal stomach cancer. This eradication therapy is particularly recommended for individuals who have been medically treated for a type of stomach growth known as superficial gastric neoplasia. This form of treatment can reduce the likelihood of cancer returning by almost fifty percent.
In summary, the eradication of Helicobacter pylori plays a key role in improving certain conditions like atrophy and may contribute to reducing the progression to stomach cancer.
Despite evidence suggesting that cyclo-oxygenase inhibitors (substances referred to as “COX-1” or “COX-2”) can slow the progression of risky gastric conditions and potentially decrease the chances of developing stomach cancer, there is not enough statistical evidence to advocate their use for prevention.
There is some indication that non-steroidal anti-inflammatory drugs and aspirin can slow the progression of pre-cancerous stomach conditions after Helicobacter pylori eradication. However, more research is needed, and any potential benefits need to be weighed against potential side effects, specifically in the stomach.
Certain substances like traditional Chinese herbal medicine, moluodan, and vitamin supplements A, C, and E have also shown potential benefits in reducing the risk of stomach cancer, but more research is needed.
Regarding treatment, monitoring chronic atrophic gastritis and intestinal metaplasia can help minimize their progression to more serious conditions. The best approach for treating certain growths in the stomach depends on their size. Gastrointestinal endoscopic resection, which involves removing tissue using a specific type of scope, is often recommended. Techniques used could include endoscopic mucosal resection for smaller growths and endoscopic submucosal dissection for larger growths. More advanced cases should be managed according to established stomach cancer protocols.
What else can Atrophic Gastritis be?
Here is a list of conditions that could cause symptoms in the upper part of your digestive system. Doctors use invasive procedures like endoscopy to diagnose these conditions:
Esophagus Conditions:
Inflammatory:
- Reflux esophagitis
- Eosinophilic esophagitis
- Esophageal constriction
Infections:
- Various types of esophagitis (caused by bacteria, fungi, or viruses)
- Chagas disease
- Yeast infection or candidiasis
Movement Disorders:
- Achalasia of the esophagus
- Uncoordinated esophageal spasms
- Nutcracker esophagus
Cancers:
- Adenocarcinoma
- Squamous cell carcinoma
- Out of ordinary tumors like lymphoma, gastrointestinal stromal tumor, or neuroendocrine tumor
Stomach Conditions:
Inflammatory:
- Stomach ulcers (caused by H. pylori, steroids, stress, anastomotic ulcers)
- Sudden inflammation (caused by pain relievers, aspirin)
- Due to cancer treatment toxins
- Crohn’s disease
- Biliary reflux gastritis
- Menetrier gastritis
- After radiation exposure
- Foreign objects
Infections:
- Bacterial, viral or fungal gastritis
Cancers:
- Stomach cancer or gastric adenocarcinoma
- Lymphoma, Non-Hodgkin
- Gastrointestinal stromal tumor
- Neuroendocrine tumor
Duodenum Conditions:
Inflammatory:
- Duodenitis
- Duodenal ulcers
Infections:
- Bacterial, viral, or fungal gastroenteritis
Cancers:
- Different types of neoplasms
- Gastrointestinal stromal tumor
- Neuroendocrine tumor
Pancreas Condition:
- Pancreatitis
Gallbladder Condition:
- Gallstones or cholelithiasis
What to expect with Atrophic Gastritis
Gastric adenocarcinoma, a type of stomach cancer, ranks as the fifth most common cancer worldwide.
Often individuals with chronic atrophic gastritis, a condition that can lead to stomach cancer, do not have symptoms for many years and it’s discovered by accident when seeking medical help for other conditions. Those over the age of 50 who start experiencing stomach issues, those with pernicious anemia, or those with a family history of the disease are at risk and should have screenings.
A large review of global studies found stomach cancer varies widely across regions and ethnicities. The rate of stomach cancer in people with gastric atrophy ranges from 0.53 percent to 15.24 per 1000 people each year, with the highest numbers seen in Asian countries. In individuals with intestinal changes, rates ranged from 0.38 to 17.08 per 1000 people each year, again with the highest numbers seen in Asia and the United States.
In terms of how the disease progresses over time, a Japanese study found that the five-year incidence of gastric adenocarcinoma increases from 0.7% in mild cases to 10% in severe cases, specifically in people suffering from H. pylori-related gastritis.
It’s vital to look out for high-risk individuals, particularly from certain ethnic minorities, and provide appropriate screenings. One study found a high presence of H. pylori, a bacteria that can lead to stomach cancer, and precancerous stomach conditions in Americans of Hispanic and Asian descent. Therefore, a person’s ethnicity should be considered a potential risk when searching for early signs of stomach cancer.
Possible Complications When Diagnosed with Atrophic Gastritis
Complications that can happen due to the thinning of the stomach lining, also known as gastric mucosal atrophy, include:
- Loss of acid production leading to an excess of a hormone called gastrin (Achlorhydria)
- Anemia due to larger than normal red blood cells (Macrocytic anemia) in cases of autoimmune gastritis
- Consistent lack of iron leading to anemia (Chronic iron deficiency anemia), because of less iron absorption
- Ulcer in the duodenum or stomach (Duodenal/gastric ulcer)
- Non-cancerous narrowing of the lower part of the stomach (Benign strictures of the pylorus)
- Bleeding inflammation of the stomach lining (Hemorrhagic gastritis)
- Stomach cancer (Gastric adenocarcinoma)
- Change in the tissue lining the stomach (Mucosa-associated lymphoid tissue or MALT)
- Growth of abnormal cells in the stomach leading to a type of tumor (Gastric carcinoid tumor, due to enterochromaffin cell hyperplasia)
Preventing Atrophic Gastritis
It’s very important to identify people who are at risk of gastric adenocarcinoma (a type of stomach cancer) and monitor them regularly. This will prevent the disease from getting worse.
While there’s disagreement about how to manage long-term conditions like atrophic gastritis (stomach inflammation) and intestinal metaplasia (abnormal tissue growth), having a detailed examination using a tube-like device called an endoscope can provide clear results. This can help doctors and patients agree on a plan for ongoing monitoring.
If a patient is unexpectedly found to have anemia (a shortage of iron or vitamin B12 in the blood), it’s important to look into this and provide treatment at the same time to avoid delaying the discovery of any other health issues.
Getting rid of a bacteria called helicobacter pylori and removing precancerous lesions in the stomach can cut down the risk of getting stomach cancer and prevent the occurrence of new cancers.
