Pepsinogen Assay Findings in Individuals With Gastric Atrophy and Intestinal Metaplasia

Serum pepsinogen (PG) testing is widely used as a non-invasive biomarker for gastric atrophy; however, its clinical interpretation varies depending on the severity and distribution of gastritis as well as on the assay methods. Autoimmune gastritis is characterized by markedly decreased PG I levels and PG I/II ratios, along with increased gastrin levels, reflecting profound corpus atrophy. In contrast, Helicobacter pylori–associated atrophy typically shows moderate reductions in PG I levels and PG I/II ratios, with variability according to the extent of antral and corpus involvement. Accumulating evidence indicates that PG testing is more effective at identifying severe atrophy and higher Operative Link on Gastritis Assessment stages than detecting mild atrophy. Notably, cutoff values differ substantially between assay systems, with higher PG I and PG I/II cutoff values observed in GastroPanel tests than in East Asian kits interpreted with the ABC method. Overall, PG testing is useful for detecting advanced corpus atrophy and stratifying gastric cancer risk when combined with gastrin measurement, but has limited sensitivity for early-stage disease. Monitoring low PG I/II ratios and high gastrin levels may improve risk assessment, particularly in patients with corpus atrophy or persistent intestinal metaplasia after H. pylori eradication.