Your pathology report for reactive gastropathy

by Jason Wasserman MD PhD FRCPC
July 27, 2025

Reactive gastropathy, also known as chemical gastropathy, is a condition in which the stomach’s lining becomes damaged after exposure to substances not normally present in the stomach. These substances may include bile, alcohol, or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin. The damage causes changes in the cells that normally protect the stomach, leading to pain, irritation, and—in some cases—more serious problems like ulcers.

What causes reactive gastropathy?

The inside of the stomach is lined by foveolar cells, which produce a thick substance called mucus. This mucus forms a protective barrier that shields the stomach lining from stomach acid and digestive enzymes. In reactive gastropathy, the protective foveolar cells become damaged and may stop producing enough mucus. Without this mucus, the stomach lining is more vulnerable to injury.

Common causes of reactive gastropathy include:

  • Bile reflux – The most frequent cause. Bile and other digestive fluids from the small intestine flow backward (reflux) into the stomach, irritating the lining.

  • NSAIDs – Medications like aspirin, ibuprofen, or naproxen can damage the stomach lining when taken regularly or in high doses.

  • Alcohol – Alcohol can irritate and weaken the stomach lining over time.

  • Smoking – Tobacco products increase the risk of stomach damage.

  • Pancreatic secretions – These enzymes can also reach the stomach through reflux and contribute to the damage.

What are the symptoms of reactive gastropathy?

Some people with reactive gastropathy have no symptoms. When symptoms do occur, they may include:

  • Upper abdominal pain or discomfort, especially after eating.

  • Nausea.

  • Bloating.

  • Loss of appetite.

These symptoms are similar to other causes of gastritis and may come and go depending on diet, medication use, or other triggers.

What are the possible long-term complications?

If reactive gastropathy is not treated, the ongoing damage to the stomach lining may lead to:

  • Erosions – Loss of surface cells, which can be painful and may bleed.

  • Ulcers – Deeper injuries that can cause more significant bleeding or scarring.

  • Intestinal metaplasia – A change where the normal stomach lining is replaced by cells more like those found in the intestines. This change is a sign of long-standing damage and is considered a risk factor for stomach cancer in some cases.

How is the diagnosis made?

The diagnosis of reactive gastropathy is made by examining a biopsy, a small tissue sample taken from the inside of the stomach. This is usually done during a gastroscopy or upper endoscopy, a procedure where a thin, flexible camera is inserted through the mouth to view the esophagus, stomach, and the first part of the small intestine. If your doctor sees an area that looks abnormal, they will take one or more biopsies to send to a pathologist.

The pathologist examines the tissue under a microscope to look for features that support the diagnosis of reactive gastropathy.

What does reactive gastropathy look like under the microscope?

When a pathologist examines a biopsy from a patient with reactive gastropathy, they typically see the following features:

  • Foveolar hyperplasia: Foveolar metaplasia means there are more foveolar cells than normal, and the glands they form appear elongated, twisted, or corkscrew-shaped. This change happens as the stomach tries to repair itself.
  • Mucin depletion: Foveolar cells normally contain a thick substance called mucin, which is used to make protective mucus. In reactive gastropathy, these cells often have less mucin, which makes the stomach lining more vulnerable to acid and injury.
  • Erosion: Erosion refers to the loss of surface cells from the lining of the stomach. This is a sign that the tissue has been damaged, and in severe cases, it can lead to bleeding or ulcer formation.
  • Intestinal metaplasia: Sometimes, in response to ongoing injury, the stomach lining changes into a type of lining more like the small intestine. This process is called intestinal metaplasia. While it is not cancer, it is considered a warning sign that the stomach lining has been exposed to injury for a long time.

What can I do to reduce the risk or treat reactive gastropathy?

Treatment focuses on removing or reducing exposure to the substances causing damage. This may include:

  • Stopping or limiting NSAIDs (under the guidance of your doctor).

  • Reducing or avoiding alcohol and smoking.

  • Using medications to reduce stomach acid (such as proton pump inhibitors).

  • Treating underlying conditions that cause bile reflux.

  • Eating smaller meals and avoiding lying down after eating.

If intestinal metaplasia is found, your doctor may recommend regular follow-up endoscopies to monitor for further changes.

Questions to ask your doctor

  • What caused the reactive gastropathy in my case?

  • Should I stop or change any medications I’m currently taking?

  • Do I need treatment for bile reflux?

  • Was any intestinal metaplasia seen in my biopsy?

  • Will I need follow-up endoscopies or additional tests?

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