Follow-Up Management in Patients with Chronic Atrophic Gastritis: An Evidence-Based Summary

Abstract

Objective

To summarize the best evidence for the follow-up management of patients with chronic atrophic gastritis and provide a reference for clinical follow-up management.

Methods

Following the “6S” evidence model, domestic and foreign databases, guideline websites and relevant association websites were systematically searched for evidence on the follow-up management of patients with chronic atrophic gastritis, including clinical decisions, guidelines, expert consensus, evidence summaries and systematic reviews, etc. The search time limit was from January 2015 to October 2025. Two researchers independently used corresponding tools to evaluate the quality of the included literature and extract the evidence.

Results

A total of 13 literatures were included, including 1 clinical decision, 7 guidelines, 4 expert consensus and 1 systematic review. Thirty‑two pieces of evidence were summarized from 8 aspects such as the necessity of follow-up, the mode of follow-up, the eradication treatment and management of Helicobacter pylori (H. pylori), lifestyle and health education, endoscopic surveillance strategies, evaluation and management of staging, drug use management, comorbidities and special population management.

Conclusion

The evidence summarized in this study can provide an evidence-based basis for the follow-up management of patients with chronic atrophic gastritis, which can help to optimize clinical practice and improve patient prognosis and quality of life.

Introduction

Chronic atrophic gastritis (CAG) is a well-established precancerous condition of the stomach,¹ with a global prevalence of approximately 25%.² It is characterized by the loss of normal gastric glandular structures, which are replaced either by fibrous connective tissue (non-metaplastic atrophy) or by non-native epithelial cell types (metaplastic atrophy) as a consequence of chronic inflammation.³ As a key precursor lesion in the Correa cascade, CAG is strongly associated with an increased risk of gastric cancer. Globally, an estimated 968,350 new cases of gastric cancer and 659,853 related deaths occurred in 2022.⁴ The standardized management and follow-up of CAG represent a critical intervention point for interrupting this cascade – the progressive sequence from chronic inflammation to atrophy, intestinal metaplasia, dysplasia, and ultimately gastric adenocarcinoma.⁵

Although several clinical guidelines have proposed recommendations for the follow-up and management of CAG, these recommendations are limited in scope and lack systematic integration. Furthermore, most relevant studies have not reported the level of evidence or strength of recommendations, which hinders the translation of research findings into clinical practice. In this context, there is an urgent need to systematically synthesize, evaluate, and classify the available evidence using rigorous scientific methods.

Therefore, this study aimed to systematically review the literature and summarize the best available evidence for the follow-up management of patients with CAG, using an evidence-based nursing approach. The findings are intended to provide an evidence-based foundation for healthcare professionals to develop standardized and effective follow-up protocols for this patient population.

Material and Methods

This study has been registered on the platform of the Evidence-Based Nursing Center at Fudan University (Registration Number: ES20259073). Based on the methodology of the JBI Evidence-Based Medicine Center in Australia, the Evidence-Based Nursing Center at Fudan University has developed guidelines for evidence summary reporting.⁶ These guidelines cover six aspects: problem formulation, literature search, literature selection, literature evaluation, evidence synthesis and classification, and the development of practice recommendations. This study follows the evidence summary reporting standards established by the Evidence-Based Nursing Center at Fudan University.⁶ This study is a secondary analysis of the existing literature and is considered exempt from ethical review.

Problem Establishment

The evidence-based practice question is constructed based on the PIPOST model.⁷ With the specific content as follows: P (target population for evidence application): Patients diagnosed with chronic atrophic gastritis (CAG); I (intervention): Evidence-based follow-up management strategies, encompassing surveillance and monitoring, treatment optimization, lifestyle and risk factor modification, and targeted patient education on disease management; P (professionals applying the evidence): Clinical healthcare professionals; O (outcome): Improvement in patient adherence to treatment and follow-up protocols; enhancement of quality of life and mitigation of dyspeptic symptoms; delay or reversal of gastric mucosal atrophy/intestinal metaplasia; reduction of gastric cancer risk; and increase in the early detection rate of gastric cancer; S (place of applying the evidence): Hospitals, community healthcare facilities, and home settings; T (type of evidence): guidelines, expert consensus, clinical decision-making, evidence summaries, systematic reviews, and randomized controlled trials.

Retrieval Strategy

Following the “6S Evidence Model” evidence pyramid,⁸ we searched the following databases from the top down: UpToDate, BMJ Best Practice, Web of Science, PubMed, Cochrane Library, China Knowledge Resource Integrated Database (CNKI), Wanfang Database, VIP Database, SinoMed, CINAHL, JBI Evidence-Based Healthcare Database, Campbell Collaboration, Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Health and Care Excellence (NICE), Registered Nurses’ Association of Ontario (RNAO), National Guideline Clearinghouse (NGC), Guidelines International Network (GIN), Medlive; American Society for Gastrointestinal Endoscopy (ASGE), European Society of Gastrointestinal Endoscopy (ESGE), Chinese Society of Gastroenterology. The search used keywords like “Chronic Atrophic Gastritis*/Atrophic Gastritis/Atrophic Gastritide*/Chronic Gastric Atrophy*/Autoimmune Gastritis*“,”follow-up/follow-up care/return visit/management/health management/transitional care/continuity of care”, combining free-text terms and MeSH terms, tailored to each database. The search period was from January 2015 to October 2025. An example of the PubMed search strategy is provided in Table 1.

Table 1.

Literature Search Strategy of PubMed

Steps	Search Strategies
#1	(“Gastritis, Atrophic”[MeSH]) OR (Chronic atrophic gastritis*[Title/Abstract] OR Atrophic gastrit*[Title/Abstract] OR Autoimmune Gastritis*[Title/Abstract] OR Chronic gastric atrophy*[Title/Abstract])
#2	(“Follow-Up Studies”[MeSH]) OR (Follow-up[Title/Abstract] OR “Follow-up care”[Title/Abstract] OR “Return visit”[Title/Abstract] OR Management[title/Abstract] OR “Health management”[Title/Abstract] OR “Transitional care”[Title/Abstract] OR “Continuity of care”[Title/Abstract])
#3	#1 AND #2

Literature Inclusion and Exclusion Criteria

Inclusion criteria: (1) The research subjects were patients with chronic atrophic gastritis; (2) Involving follow-up, continuous nursing, and management of patients with chronic atrophic gastritis, etc; (3) The language was English or Chinese; (4) The types of literature were clinical decisions, guidelines, systematic reviews, evidence summaries, expert consensus, and high-quality randomized controlled trials.

Exclusion criteria: (1) The literature type was a proposal, case report, draft, or abstract; (2) unavailability of full text; (3) studies that failed in the literature quality evaluation; (4) literature repeatedly included by multiple institutions.

Literature Screening

Duplicates were removed after the literature obtained from the search was imported into Zotero. The literature was screened independently by two individuals with a background in evidence-based nursing research. Pre-screening was performed using the title, abstract, and keywords of the literature, and then re-screening was performed by reading the full text. The quality of the final included literature was evaluated. In the process of literature evaluation, if there was any disagreement, the evidence-based panel would adjudicate, following the principle of prioritizing evidence-based sources, high-quality studies, and recently published literature.

Quality Evaluation of the Literature

The quality of the guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II).⁷ The scale consists of 6 dimensions and 23 items with 2 additional overall evaluation items. Each item was rated on a scale of 1–7 (1 = strongly disagree, 7 = strongly agree), and the standardized percentage of each domain = (actual score-minimum possible score)/(maximum possible score-minimum possible score) × 100%. Quality grade: Grade A for guidelines with all domains scoring ≥60%, Grade B for those with ≥3 domains scoring ≥30% but some <60%, and Grade C for those with ≥3 domains scoring <30%. The systematic review was evaluated using the systematic review tool by AMSTAR 2,⁹ which consists of 16 items, each of which contains three options, “Yes”, “No”, and “Partial Yes”. Overall confidence was determined according to weaknesses in critical and non-critical domains. The expert consensus was evaluated using the Expert Consensus Evaluation Tool by the Australian JBI Centre for Evidence-Based Health Care (2016 version),¹⁰ with six evaluation items, each with four options, “Yes”, “No”, “Unclear”, and “Not Applicable”. If there were more than 2 items with the result “No”, the literature is judged to be of low quality. UpToDate from authoritative databases was directly considered high-quality evidence.

The quality assessment was independently performed by researchers with expertise in evidence-based knowledge. Four evaluators (Shuqi Li, Lixin Zhao, Xinru Zhang, Yiyi Yao) were involved in the assessment of guidelines, while two evaluators (Shuqi Li, Lixin Zhao) assessed other types of literature. In case of disagreements, a clinical nursing expert (Yu Guo) was added to discuss and decide whether to include or exclude the literature.

Evidence Summary and Grading

Two researchers (Shuqi Li and Lixin Zhao) trained in evidence-based nursing independently extracted information such as the type of literature, title, and the original evidence content. In case of disagreements, consensus was reached through discussion or by consulting a third researcher (Xinru Zhang). The evidence extraction process followed these principles: (1) When the content is consistent, evidence is selected to represent the concentrated expertise; (2) When different evidence sources are similar or complementary, they are combined into a unified evidence; (3) When there are significant differences among multiple pieces of evidence, the highest quality or most recently published data from authoritative, evidence-based journals is chosen.

For included clinical practice guidelines, expert consensus statements, and clinical decision resources with explicit evidence levels or recommendation grades, the original grading was retained. For the systematic review without explicit JBI evidence levels and recommendation grades, the JBI Evidence Pre-Grading and Evidence Recommendation Level System (2014 version) was used to classify the evidence level and determine the recommendation grade.¹¹ The final recommendation grade was determined by two clinical experts and two researchers with reference to the original evidence grading and the JBI 2014 Evidence Recommendation Level System. During this process, the feasibility, appropriateness, meaningfulness, and effectiveness (FAME) of evidence implementation were comprehensively considered,¹¹ and the final recommendation grade was established after discussion and consensus.

Results

Literature Search Results

A total of 3,316 articles were initially retrieved from the databases. After removing duplicates, 2,236 articles remained. Following the exclusion of articles that did not meet the inclusion criteria, 66 articles were retained. After reading the full texts and conducting quality evaluations, a total of 13 articles were ultimately included.^12–24 These comprised 7 guidelines,^12–18 4 expert consensus statements,^19–22 1 clinical decision,²³ and 1 systematic review.²⁴ The literature screening process is illustrated in Figure 1, and the general characteristics of the included studies are presented in Table 2. Although high-quality randomized controlled trials were predefined as eligible evidence sources, no individual RCT was separately included in the final synthesis. Relevant trial-level evidence on H. pylori eradication, gastric cancer prevention, or management of gastric precancerous lesions had largely been incorporated into the included higher-level evidence sources, including guidelines, expert consensus statements and clinical decision resources.

Figure 1.

Flowchart of Literature Screening.

Abbreviations: CNKI, China Knowledge Resource Integrated Database; SIGN, Scottish Intercollegiate Guidelines Network; NICE, The National Institute for Health and Care Excellence; RNAO, Registered Nurses’ Association of Ontario; NGC, National Guideline Clearinghouse; GIN, Guidelines International Network; ASGE, American Society for Gastrointestinal Endoscopy, ESGE, European Society of Gastrointestinal Endoscopy.

Table 2.

Characteristics of Included Studies (n = 13)

Included Literature	Publication Year	Literature Source	Literature Type	Literature Topic
Zhou L et al12	2022	CNKI	Guideline	2022 Chinese National Clinical Practice Guideline on Helicobacter pylori Eradication Treatment
Chinese Society of Gastroenterology, et al13	2022	CNKI	Guideline	Guidelines for diagnosis and treatment of chronic gastritis in China
Dinis-Ribeiro M et al14	2025	PubMed	Guideline	Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025
Lahner E et al15	2019	PubMed	Guideline	Chronic atrophic gastritis: natural history, diagnosis and therapeutic management. A position paper by the italian society of hospital gastroenterologists and digestive endoscopists [AIGO], the italian society of digestive endoscopy [SIED], the italian society of gastroenterology [SIGE], and the italian society of internal medicine [SIMI]
Banks M et al16	2019	PubMed	Guideline	British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma
Morgan DR et al17	2025	PubMed	Guideline	ACG clinical guideline: Diagnosis and management of gastric premalignant conditions
Wang P et al18	2022	CNKI	Guideline	Chinese integrated guideline on the management of gastric precancerous conditions and lesions
Leung WK et al19	2026	PubMed	Expert consensus	Asian Pacific Association of Gastroenterology task force recommendations on surveillance for Helicobacter pylori associated gastric premalignant conditions
Digestive System Diseases Professional Committee of Chinese Association of Integrative Medicine et al20	2025	Medlive	Expert consensus	Expert Consensus on Integrated Traditional Chinese and Western Medicine Diagnosis and Treatment of Chronic Atrophic Gastritis (2025)
Ding SZ et al21	2021	PubMed	Expert consensus	Chinese Consensus Report on Family-Based Helicobacter pylori Infection Control and Management (2021 Edition)
National Clinical Research Center for Digestive Disease (Shanghai) et al22	2020	Sinomed	Expert consensus	Chinese consensus on management of gastric epithelial precancerous conditions and lesions (2020)
Pamela J Jensen et al23	2025	UpToDate	Clinical decision	Chronic (atrophic) gastritis: approach to diagnosis and management of subtypes
Yang F et al24	2021	CNKI	Systematic review	Effect of continuous nursing on compliance behavior and quality of life in patients with chronic gastritis: a systematic review

Quality Evaluation Results of the Guidelines

There were 7 guidelines included in this study. One guideline has ≥60% percentage of standardisation in six fields, with a recommendation level of A. The rest of the guidelines have a recommendation level of B. The results of the standardised scores for each domain and the overall quality evaluation of the guidelines are shown in Table 3.

Table 3.

Quality Evaluation Results of Clinical Guidelines (N = 7)

Guideline	Standardized Scores in Various Domains (%)						≥60%	≥30%	ICC	Quality Evaluation
	Scope and Purpose	Stakeholder Involvement	Rigour of Development	Clarity of Presentation	Applicability	Editorial Independence
Zhou L et al12	87.50%	72.22%	85.41%	88.88%	54.16%	70.83%	5	6	0.926	B
Chinese Society of Gastroenterology et al13	91.66%	55.55%	66.66%	93.05%	35.41%	89.58%	3	6	0.906	B
Dinis-Ribeiro M et al14	100.00%	59.72%	92.70%	94.44%	64.58%	75.00%	5	6	0.984	B
Lahner E et al15	86.11%	58.33%	72.39%	81.94%	39.58%	85.41%	4	6	0.968	B
Banks M et al16	100.00%	72.22%	90.62%	97.22%	65.62%	95.83%	6	6	0.982	A
Morgan DR et al17	93.05%	68.05%	78.12%	94.44%	42.70%	83.33%	5	6	0.963	B
Wang P et al18	97.22%	69.44%	57.29%	94.44%	41.67%	85.42%	4	6	0.951	B

Notes: Quality evaluation: Grade A = all six AGREE II domains scored ≥60%; Grade B = at least three domains scored ≥30%, with one or more domains scoring <60%.

Abbreviation: ICC, intraclass correlation coefficient.

Quality Evaluation Results of Expert Consensus

Four expert consensus articles were included,^19–22 and the evaluation results are shown in Table 4. Among them, the evaluation results of all 6 items in 1 expert consensus were “Yes”;¹⁹ the other 3 expert consensuses had an evaluation result of “Unclear” for item 6,^20–22 while the evaluation results of the remaining items were all “Yes”. Therefore, these four expert consensuses are of high overall quality and can be included.

Table 4.

Results of Expert Consensus Quality Evaluation (N = 4)

Items	Leung WK et al19	Digestive System Diseases Professional Committee of Chinese Association of Integrative Medicine et al20	Ding SZ et al21	National Clinical Research Center for Digestive Disease (Shanghai) et al22
Is the source of the opinion clearly identified?	Yes	Yes	Yes	Yes
2Does the source of opinion have standing in the field of expertise?	Yes	Yes	Yes	Yes
3Are the interests of the relevant population the central focus of the opinion?	Yes	Yes	Yes	Yes
4Is the stated position the result of an analytical process, and is there logic in the opinion expressed?	Yes	Yes	Yes	Yes
5Is there reference to the extant literature?	Yes	Yes	Yes	Yes
6Is any incongruence with the literature/sources logically defended?	Yes	Unclear	Unclear	Unclear

Quality Evaluation Results of Systematic Reviews

A total of one systematic review was included in this study, with the detailed quality assessment results presented in Table 5.²⁴ The evaluation result for item 9 was “No”, while the evaluation results for all other items were “Yes”. This literature evaluates multiple clinical randomized controlled trials, with a relatively complete design and high quality, so it was included.

Table 5.

Quality Evaluation Results of Systematic Review (N = 1)

Items	Yang F et al24
1. Did the research questions and inclusion criteria for the review include the components of PICO?	Yes
2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?	Yes
3. Did the review authors explain their selection of the study designs for inclusion in the review?	Yes
4. Did the review authors use a comprehensive literature search strategy?	Yes
5. Did the review authors perform study selection in duplicate?	Yes
6. Did the review authors perform data extraction in duplicate?	Yes
7. Did the review authors provide a list of excluded studies and justify the exclusions?	Yes
8. Did the review authors describe the included studies in adequate detail?	Yes
9. Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?	No
10. Did the review authors report on the sources of funding for the studies included in the review?	Yes
11. If meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results?	Yes
12. If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?	Yes
13. Did the review authors account for RoB in primary studies when interpreting/discussing the results of the review?	Yes
14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?	Yes
15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?	Yes
16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?	Yes

Evidence Synthesis

By extracting and summarizing the evidence from follow-up studies on chronic atrophic gastritis, a total of 32 pieces of evidence were finally formed from 8 aspects: the necessity of follow-up, methods of follow-up, eradication treatment and management of Helicobacter pylori (H. pylori), lifestyle and health education, endoscopic monitoring and follow-up strategies, assessment and staging, management of drug use, and management of comorbidities and special populations, as shown in Table 6.

Table 6.

Summary of Evidence for Follow-Up Management of Chronic Atrophic Gastritis (N = 32)

Category	Content of Evidence	Evidence Level	Recommendation Level
Necessity of Follow-up	1. Follow-up management can improve patient compliance, enhance the long-term efficacy of treatment for chronic atrophic gastritis, and improve patients’ quality of life.24	2b	A
	2. CAG is a significant precancerous disease of the stomach. Patients with CAG are a population at risk for gastric cancer, and regular follow-up monitoring can significantly improve the early detection rate of gastric cancer.20	3b	A
	3. Standardized follow-up monitoring has good health economic benefits for individuals at high risk of gastric cancer.20	3c	A
Methods of Follow-up	4. Professional guidance for patients with chronic atrophic gastritis can be provided through various methods such as SMS reminders, telephone follow-up, home visits, and mobile applications (eg WeChat).24	2b	A
Helicobacter pylori (H. pylori) Eradication Treatment and Management	5. It is recommended that patients with chronic atrophic gastritis and gastric mucosal intestinal metaplasia receive H. pylori testing and eradication therapy to reduce the risk of histopathological progression and the occurrence of gastric cancer.19	1a	A
	6. In clinical diagnosis and treatment, for patients with initial and recurrent H. pylori infections, it is recommended to adopt a bismuth-containing quadruple therapy (proton pump inhibitor + bismuth + 2 antimicrobial agents) or a high-dose dual therapy for eradication treatment.12,13	1b	A
	7. The recommended duration for empirical bismuth-containing quadruple therapy is 14 days, unless local studies confirm that a 10-day regimen is effective (eradication rate > 90%).13	1a	A
	8. All patients should routinely undergo H. pylori testing after eradication treatment to assess the effectiveness of the therapy; the preferred non-invasive assessment method is the 13C or 14C urea breath test; the assessment should be conducted at least 4 weeks after treatment completion.13	1a	A
	9. When treating H. pylori infection empirically, it is recommended to adjust the initial and re-treatment regimens for H. pylori eradication based on the patient’s history of antibiotic use. 12	1b	A
	10. For patients with unstable intestinal microbiota, the use of probiotics in conjunction with a bismuth-containing quadruple regimen is recommended during initial and repeat H. pylori eradication therapy.12	1b	A
	11. Family-based H. pylori infection control is an important strategy for interrupting H. pylori infection and transmission. It is recommended that family members living with patients suffering from chronic atrophic gastritis undergo screening for Helicobacter pylori (H. pylori) and receive treatment if infected.21	1a	A
	12. Household transmission prevention measures, including separate meals, serving chopsticks or spoons, and safe food and water, should be included in family-based H. pylori health education to reduce intrafamilial transmission and reinfection risk.21	5a	A
Lifestyle and Health Education	13. Guide patients to maintain regular eating habits, consume plenty of fresh vegetables, fruits, and high-quality protein, adhere to a light, low-salt diet, and strictly limit or avoid pickled, smoked, fried, and moldy foods.20	1a	A
	14. Maintain physical and mental health: maintain a positive and optimistic mental state, live a regular life, and ensure adequate sleep. 13	5a	A
	15. Long-term smoking significantly increases the risk of occurrence and progression of gastric precancerous lesions; patients should be educated and encouraged to quit smoking. 13,19,22	1b	A
	16. Alcohol can damage the gastric mucosal barrier, exacerbating atrophy and intestinal metaplasia, and can affect the acid-suppressive effect of PPIs in bismuth-containing quadruple therapy; patients should be advised against excessive alcohol consumption.19	3b	A
	17. Through effective doctor-patient communication and public health education, help patients develop an optimistic mindset and understand their disease risks, thereby improving their adherence to long-term monitoring and follow-up.20	5b	A
Assessment and Staging	18. Strongly recommend using the operative link on gastritis assessment (OLGA) or the operative link on gastritis assessment based on intestinal metaplasia (OLGIM) staging systems for histopathological staging of the extent and severity of gastric atrophy in patients with atrophic gastritis. This provides a reliable basis for gastric cancer risk stratification and the development of individualized endoscopic surveillance plans.14,15	3a	A
	19. It is recommended to use the Kimura-Takemoto classification or the endoscopic grading of gastric intestinal metaplasia (EGGIM) system for graded assessment of the extent of lesions during endoscopic follow-up.19,23	3a	A
	20. It is recommended to use changes in dyspepsia symptom scores (Likert scale) as the primary evaluation for the efficacy of treatment on clinical symptoms in CAG.20	3a	A
Endoscopic Surveillance Follow-up Strategy	21. During follow-up, a reasonable endoscopic monitoring plan should be formulated based on risk stratification, also considering cost-effectiveness.22	3b	B
	22. Endoscopic follow-up examination is recommended for patients with autoimmune gastritis (AIG) at least every 3 years.13,15	3a	A
	23. For the low-risk group with complete intestinal metaplasia (IM) limited to the antrum and mild atrophic gastritis (biopsy indicating limited involvement), endoscopic surveillance every 3 years is recommended if other risk factors are present. These risk factors include family history of gastric cancer, immigration from a region with a high incidence of gastric cancer, persistent H. pylori infection, or belonging to East Asian, Latin American, Black, Native American (including Alaska Native) populations. Endoscopic surveillance is not recommended for individuals without the aforementioned risk factors.14,15	3a	A
	24. For patients with moderate-stage chronic atrophic gastritis and gastric intestinal metaplasia (OLGA/OLGIM II), endoscopic surveillance every 3 years is recommended. Different surveillance intervals may be considered based on population risk and available resources.19	3b	A
	25. Patients with advanced atrophic gastritis present with extensive endoscopic changes (Kimura-Takemoto classification ≥ C3 or EGGIM score ≥ 5), severe atrophic changes or severe IM, and/or significant involvement of both antrum and corpus, classified as OLGA/OLGIM III/IV. The endoscopic surveillance strategy for these patients depends on family history: - For those without a family history of gastric cancer, endoscopic surveillance every 3 years is recommended. - For those with a family history of gastric cancer, surveillance frequency may be increased (every 1–2 years). 14,23	3a	A
	26. For asymptomatic individuals over 80 years of age, gastric cancer screening and precancerous lesion surveillance should be stopped or not initiated.14,23	5a	B
Medication Use Standards	27. Routine use of medications such as antioxidants, NSAIDs, COX-2 inhibitors, or aspirin for chemoprevention to reduce gastric cancer risk is not recommended for CAG patients. For patients already taking such medications for other definitive indications, a comprehensive assessment of the benefits and risks of continued use is necessary to decide whether to adjust the medication.13,16–18	1a	A
	28. Patients with appropriate indications for using proton pump inhibitors (PPIs) or histamine H2 receptor antagonists (H2RAs) should not discontinue these necessary medications simply because they have CAG.14,15	1a	A
	29. For patients with significant active inflammation, acid suppressants and mucosal protectants may be used for a short term.18	3b	A
Management of Comorbidities and Special Populations	30. Patients with atrophic gastritis should also be screened for other treatable conditions, such as vitamin B12 and iron deficiency.23	4a	B
	31. Patients with autoimmune gastritis are advised to be tested for concomitant autoimmune diseases, such as type 1 diabetes and autoimmune thyroid disease.23	4a	B
	32. If patients present with symptoms such as anxiety or depression, follow-up counseling should be provided and/or appropriate mental health resources should be offered for specialized psychological treatment, referencing clinical indications.20	3a	A

Notes: Recommendation level: Grade A = strong recommendation according to the JBI FAME framework; Grade B = weak recommendation according to the JBI FAME framework.

Abbreviations: CAG, chronic atrophic gastritis; H. pylori, Helicobacter pylori; OLGA, Operative Link on Gastritis Assessment; OLGIM, Operative Link on Gastric Intestinal Metaplasia Assessment; EGGIM, Endoscopic Grading of Gastric Intestinal Metaplasia; PPI, proton pump inhibitor; H2RA, histamine-2 receptor antagonist.

Discussion

Standardized Follow-Up of Chronic Atrophic Gastritis is Key to Secondary Prevention of Gastric Cancer

Evidence 1 to 3 highlight the necessity of follow-up for CAG. CAG is closely associated with the development of gastric cancer. Early identification and standardized management of patients with CAG play a crucial role in the secondary prevention of gastric cancer.²⁵ Standardized follow-up can not only significantly improve patient compliance and quality of life but also delay the progression of gastric mucosal atrophy and intestinal metaplasia through early intervention, thereby increasing the early detection rate of gastric cancer. Furthermore, implementing standardized follow-up monitoring for individuals at high risk of gastric cancer can optimize the allocation of medical resources and reduce overall diagnosis and treatment costs.

Follow-Up Modalities Should Be Tailored to Patient Characteristics and Integrated into Clinical Workflows and Electronic Management Systems

Evidence 4 indicates that follow-up for patients with chronic atrophic gastritis can be conducted through various modalities, including online reminders, telephone communication, in-person follow-up when necessary, and mobile platform-based management. These approaches not only help maintain communication between patients and healthcare providers, but can also be used for follow-up reminders, health education, symptom feedback, and medication guidance, thereby improving the continuity of follow-up management. In clinical practice, the choice of follow-up modality should be tailored to patients’ age, health literacy, ability to use digital tools, disease risk level, and available healthcare resources.²⁴ For patients with higher acceptance of digital tools, WeChat-based platforms, mobile applications, or text message notifications may be used more frequently. For older adults, patients with difficulties using digital tools, or those with poor follow-up adherence, telephone follow-up, printed health education materials, family-assisted follow-up, or home visits when necessary may be more appropriate.

On this basis, follow-up modalities should be further embedded into clinical workflows and electronic management systems. Medical institutions may rely on electronic health records or follow-up management platforms to integrate information on patients’ infection treatment, pathological and endoscopic assessment, individual risks, and medication use.^13,22 These systems can support follow-up reminders, H. pylori retesting, endoscopic surveillance scheduling, and health education delivery, thereby transforming follow-up management for chronic atrophic gastritis from fragmented reminders into a continuous, standardized, and traceable management process.

Helicobacter pylori Eradication in Chronic Atrophic Gastritis Should Balance Standardized Treatment and Household Prevention

Evidence 5 to 12 summarize the main strategies for H. pylori management in patients with chronic atrophic gastritis. H. pylori eradication is a key intervention for reducing gastric mucosal inflammation and the risk of histological progression.^3,12,13,19 It may also partially improve gastric mucosal atrophy in some patients, thereby reducing the risk of progression from gastric precancerous conditions to gastric cancer.^5,12,19 Therefore, H. pylori management should not be limited to the selection of eradication regimens, but should follow an integrated pathway of testing, standardized eradication therapy, post-treatment confirmation, adjunctive management, and family-based prevention.²¹

In clinical practice, the selection of eradication regimens should consider guideline recommendations, previous antibiotic exposure, local antimicrobial resistance, patient tolerance, and adherence. Post-treatment confirmation of eradication should also be emphasized to avoid persistent infection affecting subsequent risk assessment and management. For patients with unstable intestinal microbiota or marked gastrointestinal reactions during eradication therapy, probiotic use may be considered according to symptoms, tolerance, and clinical indications, but should not be applied routinely to all patients undergoing H. pylori eradication therapy.^12,13

In addition, H. pylori-related follow-up should consider household factors when appropriate.^26,27 Because H. pylori infection can cluster within families, cohabiting family members who are infected but remain untreated may contribute to repeated exposure or reinfection after eradication.^26,27 Therefore, clinicians should provide family-oriented guidance, including H. pylori screening for cohabiting family members when appropriate, eradication treatment for those with confirmed infection, and household prevention measures such as separate meals, serving chopsticks or spoons, and safe food and water.²¹

Lifestyle and Health Education Should Strengthen Patients’ Long-Term Engagement in Follow-Up

Lifestyle and health education in the follow-up of chronic atrophic gastritis should not be limited to routine counseling, but should focus on improving patients’ long-term adherence. Given the slow progression of the disease and the inconsistency between symptom severity and pathological risk, patients may neglect follow-up examinations when symptoms improve or are absent.¹³ Therefore, doctor–patient communication should shift from general reminders to specific risk explanations, helping patients understand their individual risk, the purpose of follow-up, and the necessity of long-term management, thereby promoting active participation in follow-up.^19,20

Lifestyle interventions should also be translated into actionable management measures. During follow-up, continuous guidance on diet, smoking cessation, alcohol restriction, daily routines, and psychological status should be provided, taking into account patient age, health literacy, family support, and prior habits.¹⁴ In particular, long-term risk behaviors such as smoking and alcohol consumption are unlikely to change with a single intervention and require repeated reinforcement during follow-up.¹⁹ Therefore, the value of lifestyle and health education lies not only in symptom improvement, but also in reducing modifiable risk factors and enhancing the continuity of follow-up management.

Standardized Assessment Supports Stratified and Individualized Follow-Up Management in Chronic Atrophic Gastritis

Evidence 18–20 provide assessment tools for CAG from histopathological, endoscopic, and symptomatic dimensions. Standardized assessment is essential for translating follow-up management from general recommendations into risk-stratified decision-making. OLGA/OLGIM staging can evaluate the extent and severity of gastric atrophy and intestinal metaplasia from a histopathological perspective,^14,15 while the Kimura-Takemoto classification and EGGIM system help characterize the endoscopic extent of lesions.¹⁹ These tools provide complementary information for identifying patients who may require closer surveillance. In contrast, the Likert scale is mainly useful for monitoring dyspeptic symptoms and treatment response, but symptom improvement should not be interpreted as equivalent to a reduced pathological risk.²⁰

Therefore, follow-up decisions for CAG should not rely solely on clinical symptoms or a single endoscopic impression. Instead, OLGA/OLGIM staging, Kimura-Takemoto classification or EGGIM assessment, symptom scores, H. pylori infection and eradication status, family history of gastric cancer, lesion extent, age, and comorbidities should be considered together.¹⁴ This integrated assessment can help clinicians determine appropriate follow-up intensity and surveillance intervals, thereby improving the consistency and clinical relevance of individualized follow-up management.²⁸

Endoscopic Surveillance Strategies Should Balance Risk Stratification and Regional Applicability

Evidence 21 to 26 summarize risk-stratified endoscopic surveillance strategies for CAG. There is general agreement across guidelines that high-risk patients require endoscopic surveillance, with emphasis on tailoring strategies based on the extent of atrophy or intestinal metaplasia, histological staging, endoscopic findings, H. pylori status, and family history of gastric cancer. However, differences remain regarding specific target populations and surveillance intervals.^14,17,18,28

For low-risk patients, such as those with lesions confined to the antrum, mild atrophy or intestinal metaplasia, and no additional risk factors, European and North American guidelines tend to favor selective surveillance to avoid unnecessary endoscopic procedures. In contrast, in regions with a high incidence of gastric cancer or in the presence of additional risk factors, periodic follow-up may be considered, such as endoscopic surveillance every three years.^14,15

For patients with OLGA/OLGIM stage II (intermediate risk), current evidence generally supports a surveillance interval of three years, while also emphasizing that this interval should be adjusted according to population risk, regional gastric cancer burden, and healthcare resource availability.¹⁹

For high-risk patients, including those with OLGA/OLGIM stage III/IV, extensive atrophy or intestinal metaplasia, involvement of the gastric body, or a family history of gastric cancer, all guidelines support endoscopic surveillance, although recommended intervals vary.^18,22 Chinese guidelines generally favor shorter surveillance intervals, such as every 1–2 years, whereas European guidelines typically recommend surveillance every three years, with shorter intervals of 1–2 years in the presence of additional high-risk factors such as a family history of gastric cancer.¹⁴

Overall, guidelines and consensus statements from China and the Asia-Pacific region place greater emphasis on proactive surveillance in the context of a high gastric cancer burden, whereas European and North American guidelines prioritize selective surveillance, resource utilization, and shared decision-making.¹⁷ These differences may be related to variations in regional gastric cancer incidence, H. pylori prevalence, endoscopic resources, cost-effectiveness considerations, and healthcare system accessibility.²⁸

Therefore, the evidence summarized in this study should be applied in clinical practice with consideration of regional gastric cancer burden, endoscopic resource availability, patient risk factors, and individual preferences, rather than being uniformly applied to all populations.¹⁵

For asymptomatic individuals aged over 80 years, decisions regarding whether to initiate or continue gastric cancer screening and surveillance of precancerous lesions should take into account life expectancy, comorbidities, tolerance to endoscopy, prior lesion risk, and patient preferences.^14,17,28 For those with poor baseline health status and limited expected benefit, reducing or discontinuing surveillance may be appropriate; however, for individuals in good health, with prior high-risk lesions or a strong willingness for follow-up, continued surveillance may still be considered through shared decision-making.

Pharmacological Management in Patients with Chronic Atrophic Gastritis Should Be Based on Clear Clinical Indications

Evidence 27 to 29 address the need for precise evaluation of therapeutic indications and potential risks when administering medications to patients with CAG. Routine use of aspirin, NSAIDs, or similar agents for gastric cancer chemoprevention is not recommended in patients with CAG. Although some meta-analyses and retrospective studies have suggested an association between NSAID use and reduced gastric cancer incidence, the current evidence is insufficient to support their routine use for gastric cancer prevention.¹⁷ Moreover, these agents carry potential risks such as gastrointestinal mucosal injury and bleeding. For patients already receiving such medications for other compelling indications (eg, cardiovascular disease), decisions should be made collaboratively with cardiovascular specialists, with comprehensive assessment of cardiovascular benefits and gastrointestinal risks, alongside the development of appropriate gastric mucosal protection strategies. Furthermore, patients with clear indications for proton pump inhibitors (PPIs) or histamine H2 receptor antagonists (H2RAs) should not discontinue these essential medications solely due to the presence of CAG.^14,15 Premature withdrawal of effective therapy due to excessive concern over medication risks may lead to suboptimal control of the underlying condition, ultimately compromising overall patient health. Medication decisions should therefore be individualized, and multidisciplinary consultation may be needed in complex cases.

Follow-Up for Chronic Atrophic Gastritis Should Focus on Comprehensive Patient Health Management

Evidence 30 to 32 emphasize the importance of actively identifying and managing common comorbidities. As gastric mucosal atrophy progresses, patients with autoimmune gastritis (AIG) may develop malabsorption of essential micronutrients such as iron, vitamin B12, and folate, which can clinically manifest as pernicious anemia, iron deficiency anemia (IDA), and peripheral neuropathy.²⁹ Furthermore, patients with AIG have a significantly increased risk of concomitant autoimmune diseases, especially autoimmune thyroiditis and type 1 diabetes mellitus, with incidence rates approximately three to five times higher than those in the general population.¹³ Therefore, during follow-up management, regular testing for hemoglobin, serum iron, vitamin B12 levels, thyroid function, and relevant autoantibodies is recommended to enable comprehensive assessment and systematic management of patients’ nutritional status and immune-related comorbidities.¹³ Evidence 32 integrates mental health into the follow-up framework. Studies have shown that psychosocial factors are closely associated with dyspeptic symptoms, especially anxiety and depression.³⁰ It is recommended to proactively assess patients’ psychological status during follow-up and provide timely health education, psychological support, or referral to mental health specialists as needed, thereby promoting holistic improvement in patients’ physical and mental well-being.

Limitations

This evidence summary has several limitations. First, the included evidence was mainly derived from clinical guidelines, expert consensus statements, clinical decision resources, systematic reviews, and other higher-level evidence sources, while direct primary research evidence was limited. Although high-quality randomized controlled trials were predefined as eligible evidence sources, relevant trial-level evidence on H. pylori eradication, gastric cancer prevention, or the management of gastric precancerous lesions had largely been incorporated into higher-level evidence sources, such as guidelines, expert consensus statements and clinical decision resources. Therefore, individual RCTs were not separately included in the final evidence synthesis to avoid duplicate extraction and repeated weighting of the same evidence. Nevertheless, the lack of original studies directly focusing on the full process of follow-up management for chronic atrophic gastritis remains a limitation.

Second, the literature search was restricted to Chinese- and English-language publications, which may have led to the omission of relevant evidence published in other languages or regions. Third, a substantial proportion of the included evidence originated from Chinese guidelines and consensus documents. Although these sources are highly relevant to regions with a high burden of gastric cancer and H. pylori infection, the applicability of some recommendations to low-incidence regions, resource-limited settings, or healthcare systems with different endoscopic surveillance practices should be interpreted with caution.

Future studies should further validate risk-stratified follow-up strategies for chronic atrophic gastritis in diverse populations and healthcare settings, and evaluate their clinical effectiveness, patient acceptability, feasibility, and cost-effectiveness.

Conclusion

This study systematically synthesizes available evidence on follow-up management for chronic atrophic gastritis across eight dimensions: necessity of follow-up, follow-up modalities, Helicobacter pylori eradication therapy and management, lifestyle and health education, endoscopic surveillance strategies, assessment and staging, medication use, and management of comorbidities and special populations. This evidence supports the critical role of standardized follow-up management in enhancing treatment adherence, improving quality of life, and delaying progression of gastric mucosal lesions. Further high-quality research is warranted to validate and optimize risk stratification tools applicable to diverse populations, evaluate the cost-effectiveness of follow-up protocols, and establish multidisciplinary collaborative systems for follow-up implementation.

Data Sharing Statement

Data is available on request from the corresponding author.

Disclosure

The authors report no conflicts of interest in this work.