Mistakes in... 2022 - 20

ueg education
Mistakes in... 2022
Mistakes in the management of chronic gastritis and how to
avoid them
Pierluigi Fracasso and Mário Dinis-Ribeiro
Chronic gastritis is a common condition that occurs when an inflammatory infiltrate is
present in the gastric mucosa. Diverse factors can cause such inflammation to develop,
including food, common bacteria (particularly Helicobacter pylori) and even some
viruses. Although the inflammatory infiltrate itself may not cause a disease per se, in
some cases gastritis will evolve into atrophic gastritis, ulcers or gastric cancer. Clinicians
therefore need to be aware of when gastritis is a harmless condition that can be left alone
and when further action is required. In addition, many patients and some clinicians use
the term 'chronic gastritis' to describe symptoms, mostly those of dyspepsia. This
misuse of the terminology can lead to the erroneous conclusion that a diagnosis is being
discussed and not a symptom. Here we address these mistakes and some of the others
that are frequently made when managing patients with chronic gastritis. We discuss
how to avoid making the mistakes to ensure that patients are managed adequately while
reducing over treatment.
Mistake 1 Managing dyspepsia without
testing for H. pylori infection
Dyspepsia is a symptom that affects a large part
of the general population, and it can be caused
by numerous diverse conditions, including
chronic gastritis. As most patients who have
dyspepsia do not have a serious disease their
symptoms can be managed conservatively, which
avoids unnecessary and over treatment.
Two strategies that are based on H. pylori
being a cause of dyspepsia and upper
gastrointestinal disease have been proposed
and assessed-'test and treat' and 'test and
scope'.1
The first step for both strategies is to
perform a non-invasive test for H. pylori infection
(for example, the 13
C-urea breath test, the
faecal antigen test, or measurement of
circulating antibodies [IgG]). For the 'test and
treat' strategy, all patients found to have an
H. pylori infection immediately receive therapy.
By contrast, the 'test and scope' strategy directs
patients to undergo gastroscopy to evaluate
H.-pylori-related diseases, namely for older
patients or those with alarm symptoms.
There are many studies demonstrating that
'test and treat' is a safe and cost-effective strategy
and that it may reduce the burden on endoscopy
services.1
Regardless of the strategy chosen, all
patients with dyspepsia should first have the
presence of H. pylori infection confirmed before
additional management strategies are put in place.
© UEG 2022 Fracasso and Dinis-Ribeiro.
Cite this article as: Fracasso P and Dinis-Ribeiro M. Mistakes in
the management of chronic gastritis and how to avoid them.
UEG Education 2022; 22: 8-10.
Pierluigi Fracasso is Chief of Gastroenterology and Digestive
Endoscopy at Local Health Agency Roma 2, Rome, Italy.
8
Mistake 2 Thinking that it is too late to
treat H. pylori infection
Several trials have shown a reduction in the
incidence of gastric cancer after eradication of
H. pylori.2
Clearly, the sooner the H. pylori
infection is detected and eradicated the better, but
if H. pylori infection and chronic gastritis are not
detected until after endoscopy has been
performed and biopsy samples taken it is still
worthwhile treating the infection. Indeed,
although therapy for H. pylori infection has the
most significant impact before atrophy and
intestinal metaplasia occur, even after
precancerous conditions have developed
H. pylori eradication may stop progression.3
There
is also evidence that after endoscopic therapy for
early gastric cancer, H. pylori eradication reduces
the risk of metachronous cancers.3
message is that it is never too late to eradicate
H. pylori,2
opportunity for primary prevention of gastric
cancer and also of peptic ulcer disease.
Mistake 3 Overlooking the gastric cancer
risk at endoscopy
An upper gastrointestinal endoscopy can be
scheduled according to diverse indications and it
is crucial for the detection of gastric cancer and its
precursors. Regardless of the indication, the
possibility that early gastric cancer might be
Mário Dinis-Ribeiro is the Head of Department of
Gastroenterology and Research Group coordinator at RISE@
CI-IPO (Health Research Network), Portuguese Oncology Institute
of Porto (IPO Porto) / Porto Comprehensive Cancer Center (Porto.
CCC), Porto, Portugal.
Introduction figure: courtesy of L. Coppola and F. Borrini.
The take-home
and eradication may represent a unique
present should always be kept in mind. In the
Western world, there are indirect signs that
increasing attention is being paid to early
detection of gastric cancer when performing
endoscopy,4
but it is still a challenge and one that
should not be overlooked.
The estimated miss rate for gastric cancer is
approximately 10%.5,6 Therefore, it is of paramount
importance that the quality of any gastroscopy
is optimised, including fasting prior to the
procedure, adequate observation time,
photographic documentation and ensuring that
any biopsy samples are taken according to the
guidelines (figure 1).7
gastric cancer must also be kept in mind (for
example, in other pathologies such as Barrett
oesophagus in patients with reflux, or coeliac
disease in patients with anaemia).
Of course, the a priori risk of
Figure 1 | Early neoplastic lesions in the upper corpus,
seen only in retroversion. Image provided courtesy of
M. Dinis-Ribeiro.
Illustration: J. Shadwell.
Correspondence to: mdinisribeiro@gmail.com and
pierlu@hotmail.com
Conflicts of interest: PF has no conflicts of interest in relation to this
article. MDR has provided consultancy for Medtronic and Roche.
Published online: April 7, 2022.

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