Management of Intestinal Metaplasia in Gastric Ulcer Biopsy
Patients with gastric intestinal metaplasia (GIM) should be tested for H. pylori infection with subsequent eradication if positive, and undergo risk stratification to determine the need for surveillance, with high-risk patients requiring endoscopic follow-up every 3 years. 1, 2
Risk Stratification Algorithm
Step 1: Test for H. pylori
- All patients with GIM should be tested for H. pylori infection using non-serological methods (urea breath test, stool antigen test, or histological examination with special stains) 2
- Eradicate H. pylori if positive (strong recommendation, moderate quality evidence) 1, 2
- Verify eradication after treatment 2
Step 2: Assess Risk Factors
Classify patients into high-risk or low-risk categories:
High-Risk Features:
- Extensive GIM (corpus-extended)
- OLGIM stages III/IV
- Incomplete GIM subtype
- Persistent refractory H. pylori infection
- First-degree family history of gastric cancer
- Racial/ethnic minorities from high-incidence regions
- Immigrants from high-incidence regions 1, 2
Low-Risk Features:
- Limited GIM
- Complete GIM subtype
- No family history of gastric cancer 2
Management Based on Risk
For High-Risk Patients:
- Endoscopic surveillance every 3 years 1, 2
- Use high-definition endoscopy with chromoendoscopy 2
- Obtain biopsies from at least two topographic locations (antrum and corpus) in separate containers 2
- Focus on the angulus (40%), antrum (35%), and lesser curvature of the corpus (33%) which show the highest prevalence of pre-malignant conditions 3
- Both targeted biopsies from visible lesions and non-targeted biopsies are necessary for optimal detection 3
For Low-Risk Patients:
- Routine endoscopic surveillance is not recommended 1, 2
- Educate patients about warning symptoms that should prompt earlier evaluation 2
Additional Management Considerations
Biopsy Techniques:
- Follow a systematic gastric biopsy protocol with samples from both antrum and corpus/body 2, 3
- Non-targeted biopsies should be obtained particularly from the antrum, angulus, and lesser curvature of the corpus 3
- Consider methylene blue staining for targeted biopsies, which has shown superior sensitivity (95%) compared to random biopsies 4
Monitoring:
- Check for micronutrient deficiencies, including vitamin B12 levels, iron status, and complete blood count to detect anemia 2
- Screen for other autoimmune conditions in patients with suspected autoimmune gastritis 2
Lifestyle Modifications:
- Reduce consumption of preserved, smoked, and salt-cured foods
- Increase intake of fresh fruits and vegetables
- Limit alcohol consumption 2
Management of Dysplasia or Cancer
- If dysplasia is detected, endoscopic resection is appropriate for visible dysplasia and early-stage gastric adenocarcinoma without high-risk features 5
- Endoscopic ablation therapies may be considered for invisible or extensive dysplasia 5
Important Caveats
- The presence of GIM at the cardia in patients with extensive intragastric GIM indicates a higher risk of concurrent dysplasia or gastric cancer 3
- High-grade dysplasia is often detected only in targeted biopsies, emphasizing the importance of careful endoscopic examination 3
- GIM is not directly connected with carcinogenesis but serves as a biomarker for prior gastric injury and repair 6
- The risk of gastric cancer is best assessed in relation to the severity, extent, and cause of atrophic changes 6