Gastric antrum erythema evaluation and management
Erythema in the gastric antrum is evaluated as an endoscopic correlate of gastritis and premalignant risk where histology confirms atrophy or intestinal metaplasia. (esge.com)
Management is based on (1) symptom risk stratification for malignancy, (2) endoscopic sampling strategy, and (3) Helicobacter pylori status with subsequent eradication when indicated. (pubmed.ncbi.nlm.nih.gov)
Initial clinical risk stratification
Upper gastrointestinal endoscopy is recommended for dyspepsia at age ≥60 years to exclude organic pathology (including upper GI neoplasia). (pubmed.ncbi.nlm.nih.gov)
Alarm features should not automatically prompt endoscopy for dyspepsia in younger patients, because alarm features have limited predictive value for malignancy. (pubmed.ncbi.nlm.nih.gov)
Endoscopic re-evaluation and escalation of sampling are required when erythema is accompanied by visible abnormalities that suggest focal neoplasia rather than diffuse gastritis. (esge.com)
Endoscopic assessment and tissue sampling strategy
Endoscopic sampling should target suspected H. pylori–associated gastritis with biopsies from the antrum and corpus. (esge.com)
When H. pylori is suspected, ESGE recommends two biopsies from the antrum and two biopsies from the corpus. (esge.com)
Separate specimen containers should be used for antrum and corpus biopsies. (esge.com)
Biopsy of the incisura angularis (the “angle”) should be performed when histologic staging systems for atrophy or intestinal metaplasia are intended (e.g., OLGA and OLGIM). (esge.com)
When erythema is not a diffuse background finding and instead represents an endoscopically visible lesion suspicious for early neoplasia, targeted biopsy should document dysplasia or neoplasia. (esge.com)
Helicobacter pylori testing and eradication indications
H. pylori infection is a curable cause of gastritis and is associated with peptic ulcer disease and gastric cancer risk. (esge.com)
Testing and treatment strategies should align with North American guideline recommendations and global consensus guidance for indications and regimen selection. (pubmed.ncbi.nlm.nih.gov)
Erythema with histologic or endoscopic suspicion for H. pylori–associated gastritis supports biopsy-based evaluation and subsequent eradication when infection is confirmed. (esge.com)
Treatment regimen selection and sequencing
Bismuth quadruple therapy for 14 days is the preferred regimen when antibiotic susceptibility is unknown for treatment-naïve H. pylori infection. (pubmed.ncbi.nlm.nih.gov)
Proof of H. pylori eradication is required after treatment by stool antigen testing, urea breath testing, or biopsy-based testing. (gi.org)
Test-of-cure timing requires completion of antibiotics and discontinuation of PPI/PCAB therapy before testing, using a minimum 4-week interval after antibiotics and at least 2 weeks off PPI/PCABs. (gi.org)
During the PPI/PCAB washout period before test-of-cure, bridging with H2 receptor antagonists and antacids can be used. (gi.org)
Histology-driven risk stratification and follow-up
Chronic atrophic gastritis and gastric intestinal metaplasia increase gastric adenocarcinoma risk, which supports histology-guided management after biopsy sampling. (esge.com)
A staging approach using OLGA and OLGIM supports identification of patients with higher progression risk based on the extent of atrophy or intestinal metaplasia. (pmc.ncbi.nlm.nih.gov)
ESGE MAPS guidance defines advanced atrophic gastritis warranting surveillance using histologic extent or OLGA/OLGIM stage III/IV criteria. (esge.com)
Common pitfalls to avoid
Failure to sample both antrum and corpus when H. pylori is suspected can miss the diagnosis due to patchy gastric distribution of infection. (esge.com)
Failure to use an incisura (angle) biopsy when OLGA/OLGIM staging is intended prevents appropriate risk stratification for premalignant follow-up. (esge.com)
Relying on endoscopic erythema alone without histologic confirmation can miss focal dysplasia or early neoplasia when endoscopic findings extend beyond diffuse inflammation. (esge.com)
Performing test-of-cure while on PPI/PCAB therapy or too soon after antibiotics can reduce diagnostic accuracy and delay confirmation of eradication. (gi.org)
Treatment goals
The treatment goal for erythema consistent with H. pylori–associated gastritis is eradication with confirmed negative test-of-cure after the recommended washout period. (gi.org)
The treatment goal for histology demonstrating atrophy and/or intestinal metaplasia is risk-based surveillance planning based on OLGA/OLGIM staging and defined advanced-stage criteria. (esge.com)