Figure 1: Click on image to enlarge



This picture (Figure 1) shows gastric mucosal atrophy with the submucosal vessels clearly visible (indicated by arrows in the other pictures (Figures 2)). In the presence of inflammation which is usually diagnosed on histology, this referred to as atrophic gastritis.


Histologically, atrophic gastritis is characterised by chronic inflammation (with loss of gastric glandular cells and replacement by intestinal-type epithelium, pyloric-type glands, and fibrous tissue as a response to chronic injury. Gastric mucosa atrophy is essentially the endpoint of chronic gastric inflammation. The most common cause of gastritis and atrophic gastritis is Helicobacter pylori (H. pylori) infection (Figure 3 - top panel), autoimmune processes (autoimmune gastritis) directed against gastric glandular cells and other environmental factors (Figure 3 - bottom panel).


H. pylori is by far the most common cause of atrophic gastritis. H. pylori infection is usually acquired during childhood from family members (hence family clustering of infections) and untreated, progresses over the lifespan of the individual. Most are asymptomatic or mildly symptomatic. In infected stomach, the gastric mucosal is infiltrated by chronic inflammatory cells (mononuclear lymphoplasmacytic and polymorphonuclear cells). Chronic infection and inflammation result in significant damage that is associated with the release of bacterial and inflammatory toxic products resulting in increasing cell loss or gastric atrophy over time. This will result in intestinal metaplasia and over time, dysplasia occurs and can progress to carcinoma (adenocarcinoma). It has been shown that once inflammation has progress to atrophy (point of no return), eradication of H. pylori may not reverse the process.


Among the two most common cause of atrophic gastritis (H. pylori and autoimmune gastritis- which may lead to pernicious anaemia), distinct topographic types of gastritis can be distinguished endoscopically and histologically. H. pylori associated atrophic gastritis is usually a multi-focal process that involves both the antrum and oxyntic mucosa of the gastric corpus and fundus (Figure 3 - top panel). However, the atrophy can be variable (different areas affected differently). In autoimmune gastritis, the inflammation is restricted to the gastric corpus and fundus (Figure 3 - bottom panel).


Figure 2a: Moderate degree of atrophy with significant endoscopic features of gastritis

Figure 2b: Gastric atrophy with slightly less endoscopic gastritis

Figure 2c: Gastric atrophy with slightly very minimal endoscopic gastritis




Figure 3: Distribution of atrophic gastritis between the two common causes.



Image and text contributed and prepared by

Dr Vui Hengi Chong, Gastroenterology & Hepatology Unit, Department of Internal Medicine, RIPAS Hospital, Brunei Darussalam.

All images are copyrighted and property of RIPAS Hospital.