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    Home > Active Ingredient News > Digestive System Information > How is atrophic gastritis diagnosed and treated?

    How is atrophic gastritis diagnosed and treated?

    • Last Update: 2021-10-10
    • Source: Internet
    • Author: User
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    *It is only for medical professionals to read for reference.
    What are the similarities and differences between Chinese guidelines and Chinese guidelines? The editor has sorted it out for you~ Atrophic gastritis is a precancerous lesion that often manifests as dull pain, fullness, belching, loss of appetite or weight loss, anemia, etc.
    in the upper abdomen
    .

    At present, there is no direct drug to prevent cancer, but it can eliminate the cause of atrophic gastritis and correct its pathological state to achieve the purpose of preventing cancer.
    This mainly depends on two major methods-timely eradication of Helicobacter pylori (Hp) and endoscopic resection High-risk precancerous lesions
    .

    A few days ago, in order to provide clinicians with further guidance on the diagnosis and management of atrophic gastritis, AGA has updated the guidelines for the diagnosis and treatment of atrophic gastritis.
    What are the recommendations? See it soon! Recommendation 1: The definition of atrophic gastritis is mainly in the case of chronic inflammation caused by Hp infection or autoimmunity, the proper glands of the gastric mucosa atrophy, with or without metaplasia
    .

    Regardless of the cause, the diagnosis of atrophic gastritis should be confirmed by histopathology
    .

    Figure 1 Histopathological characteristics of normal gastric mucosa, chronic atrophic gastritis, and gastric neuroendocrine tumors (A) The mucosa of the normal gastric oxyntic zone is characterized by closely arranged pits and flat glands, the upper third of the glands The second is mainly composed of (pink) parietal cells, and the base (purple) is mainly composed of main cells
    .

    (B) Normal gastric antrum mucosa, with wide pits and loosely packed glands, mainly showing the arrangement of mucus secreting cells
    .

    (C, D) Hp-related atrophic gastritis
    .

    (C) Chronic inflammation of the gastric body mucosa, moderate loss of oxyntic glands, pseudopyloric metaplasia (asterisk) and intestinal metaplasia (thick arrow), and the remaining parietal cells (thin arrow) are forming short and disordered glands
    .

    If the oxyntic glands are significantly atrophied (not shown), there may be no parietal cells and principal cells at all, which is indistinguishable from antral atrophy histologically
    .

    (D) The gastric antrum mucosa is atrophy, the glands disappear (thin arrow), and the intestinal metaplasia (thick arrow) is surrounded by fibromuscular tissue in the lamina propria
    .

    (E, F) The mucosa of the gastric oxyntic glands showed autoimmune gastritis
    .

    (E) Chronic inflammation of the mucosa, complete loss of parietal cells and principal cells, metaplasia replaced by pseudopyloric cells (asterisks) and intestinal cells (arrows), and proliferation of ECL cells (F)
    .

    (G, H) Type I gastric neuroendocrine tumor
    .

    (G) The tumor is composed of well-differentiated cells with a single round nucleus.
    These cells are arranged in small nests (arrows) to infiltrate the lamina propria
    .

    Using chromogranin A staining (H), neuroendocrine differentiation can be confirmed
    .

    Recommendation 2: The endoscopist should be aware that if the presence of intestinal metaplasia is found on a gastric histological biopsy, it almost represents the presence of atrophic gastritis
    .

    Gastroenterologists and pathologists should work together to improve the accuracy and consistency of the diagnosis of atrophic gastritis, especially when there is significant atrophy
    .

    Our guidelines also recognize that "intestinal metaplasia represents atrophic gastritis", and the tone is more positive
    .

    Our guidelines believe that intestinal metaplasia is a later change of atrophic gastritis
    .

    Therefore, pathologically confirmed metaplastic atrophy is a reliable indicator for judging gastric mucosal atrophy
    .

    Recommendation 3: The endoscopist should recognize the typical endoscopic features of atrophic gastritis, including pale gastric mucosa, increased visibility of blood vessels due to thinning of the mucosa, disappearance of gastric folds, and light blue if accompanied by intestinal metaplasia Protrusions and white opaque areas
    .

    Since these mucosal changes are usually very subtle, techniques that optimize gastric mucosal evaluation should be used
    .

    The Chinese guidelines describe gastric mucosal atrophy under endoscopy as red and white mucosa, mainly white, folds flatten or disappear, and some mucosal blood vessels are exposed; it may be accompanied by mucosal granules or nodules
    .

    "Bright blue ridge", which represents intestinal metaplasia, refers to the methylene blue staining under white light endoscopy, or narrow band imaging magnifying endoscopy (NBI ME) with electronic staining during gastroscopy, which can be found on the surface of gastric mucosal epithelial cells The gyrus-like structure is a slender light blue thread-like structure in the crest
    .

    It should be noted that the "bright blue ridge" only occurs in the non-cancerous area, and does not exist in the cancerous area
    .

    If the "bright blue ridge" is found during the endoscopy, intestinal metaplasia can be considered here.
    At the same time, a more detailed examination of the whole stomach should be performed, and the surrounding area of ​​the "bright blue ridge" should be observed, especially the middle area around it.

    .

    Paying attention to the disappearance of the "bright blue ridge" in the area of ​​intestinal metaplasia may help prevent the occurrence of early cancer
    .

    Figure 2 Narrowband imaging magnifying endoscopy shows the "bright blue ridge" (yellow arrow) of intestinal metaplasia.
    As for "techniques that can optimize gastric mucosal evaluation", China's guidelines mention that high-definition staining endoscopy is used in the diagnosis of gastric mucosal precancerous lesions and early stages.
    Gastric cancer is better than ordinary white light endoscopy
    .

    Ordinary white light endoscopy is not obvious to the microscopic morphology of the mucosa, while the use of high-definition staining endoscopy can observe the subtle morphological changes of the mucosal surface, which helps to identify the lesion and improve the positive rate of biopsy
    .

    High-definition dyeing endoscopy includes chemical dyeing endoscopy (CE), electronic dyeing endoscopy [narrow band imaging technology (NBI), endoscopic electronic spectroscopic image processing (FICE), magnifying endoscopy, blue light imaging] and so on
    .

    Recommendation 4: When the endoscopic features of atrophic gastritis appear, the endoscopist should evaluate its degree through endoscopy
    .

    The endoscopist should take tissue biopsies from the suspected atrophy/metaplasia area to confirm histopathological changes and carry out risk stratification; at least the tissue biopsies should be taken from the gastric corpus and gastric antrum/gastric notch and placed in a separately labeled Biopsy specimen collection bottle
    .

    In addition, biopsy should be taken from other abnormal parts of the mucosa
    .

    Our guidelines also emphasize that in order to accurately determine the scope and extent of atrophic gastritis, it is recommended that at least one piece of gastric mucosal tissue be taken from the antrum, gastric corpus, and gastric horn during endoscopy, and marked in separate bottles.
    If there are other suspicious lesions, separate them.
    Biopsy
    .

    Because the degree and scope of gastric mucosal atrophy are closely related to the evolution of the disease
    .

    The wider the atrophy of the gastric mucosa, the higher the risk of gastric cancer
    .

    Recommendation 5: For patients whose histology is consistent with autoimmune gastritis, the provider should consider checking anti-parietal cell antibodies and anti-intrinsic factor antibodies to assist in the diagnosis
    .

    The provider should also assess whether the patient is suffering from anemia due to vitamin B12 and iron deficiency
    .

    Recommendation 6: All patients with atrophic gastritis should be assessed for the presence of Hp infection
    .

    If it exists, Hp treatment should be performed, and non-serological methods should be used after treatment to confirm successful eradication
    .

    China’s guidelines recognize the routine detection of Hp infection for chronic atrophic gastritis, and point out that eradication of Hp is the primary measure for the treatment of chronic atrophic gastritis, which can partially reverse gastric mucosal atrophy, thereby reducing the risk of gastric precancerous state progressing to gastric cancer
    .

    Although Hp eradication is difficult to reverse intestinal metaplasia in the short term, it has an intervention effect on the atrophy of coexisting intestinal metaplasia
    .

    In addition, eradication of Hp helps to block the progression of low-grade intraepithelial neoplasia of gastric mucosa into high-grade intraepithelial neoplasia or gastric cancer
    .

    Recommendation 7: The optimal endoscopic monitoring interval for patients with atrophic gastritis should be based on individual risk assessment and determined by joint decision-making
    .

    If the patient’s atrophic gastritis is at an advanced stage (based on the area of ​​atrophy and histological grade), then endoscopy should be considered every 3 years
    .

    China’s guidelines have a higher density of recommendations for endoscopic monitoring: for severe chronic atrophic gastritis involving the entire stomach (the OLGA system and OLGIM system are staged as Ⅲ and Ⅳ), high-definition endoscopy should be reviewed every 1 to 2 years; mild to moderate, For chronic atrophic gastritis confined to the antrum, it is recommended to review the gastroscope every 3 years
    .

    Recommendation 8: The optimal endoscopic monitoring interval for patients with autoimmune gastritis is unclear, and should be considered on the basis of individualized evaluation and joint decision-making
    .

    Recommendation 9: The provider should recognize that pernicious anemia is a late manifestation of autoimmune gastritis, manifested as vitamin B12 deficiency anemia, that is, macrocytic anemia
    .

    Patients newly diagnosed with pernicious anemia and who have not recently undergone endoscopy should undergo endoscopy and local biopsy to identify atrophic gastritis, and for risk stratification.
    Common gastric tumors, including neuroendocrine tumors, should also be excluded
    .

    Recommendation 10: Patients with autoimmune gastritis should be screened for type 1 gastric neuroendocrine tumors through gastroscopy
    .

    Small neuroendocrine tumors should be removed under endoscopy, and then, depending on the condition of the neuroendocrine tumor, endoscopy should be performed every 1 to 2 years
    .

    Recommendation 11: Regardless of the cause, doctors should assess whether there is iron and vitamin B12 deficiency in patients with atrophic gastritis, especially for atrophic gastritis that is dominated by the stomach
    .

    Similarly, for patients with unexplained iron or vitamin B12 deficiency, atrophic gastritis should be considered in the diagnosis and differential diagnosis
    .

    Recommendation 12: Doctors should be aware that patients with autoimmune gastritis are likely to be accompanied by other autoimmune diseases, especially autoimmune thyroid diseases, and should be screened for autoimmune thyroid diseases
    .

    References: [1] 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 Aug 25.
    DOI: 10.
    1053/j .
    gastro.
    2021.
    06.
    078.
    [2] National Research Center for Gastrointestinal Diseases Clinical Medicine (Shanghai), National Alliance of Gastrointestinal Early Cancer Prevention and Treatment Centers, Chinese Medical Association Gastroenterology Branch, etc.
    Precancerous status and precancerous status of gastric mucosa in China Expert consensus on disease management strategies (2020).
    Chinese Journal of Digestion.
    2020.
    40(11):731-741.
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