What is the recommended management approach for patients with intestinal metaplasia in a gastric biopsy report?

Management of Gastric Intestinal Metaplasia

In patients with gastric intestinal metaplasia (GIM), testing for H. pylori followed by eradication therapy is strongly recommended, while routine endoscopic surveillance is not recommended for most patients unless they have specific high-risk features. 1

Initial Management Steps

1. H. pylori Testing and Eradication

   • All patients with GIM should be tested for H. pylori infection 1, 2
   • If positive, eradication therapy should be provided (strong recommendation, moderate quality evidence) 1
   • Use non-serological testing methods (urea breath test, stool antigen test, or histological examination with special stains) 2
   • Verify eradication after treatment to prevent underestimation of GIM extent and reduce gastric cancer risk 2

2. Risk Stratification

   • Assess for high-risk features that may warrant surveillance:
     • Incomplete vs. complete GIM 1, 2
     • Extensive vs. limited GIM 1, 2
     • Family history of gastric cancer 1, 2
     • Racial/ethnic minorities from high-incidence regions 1, 2
     • Immigrants from regions with high gastric cancer incidence 1, 2
     • OLGIM stages III/IV 2
     • Persistent refractory H. pylori infection 2
     • Corpus-extended GIM 2

Surveillance Recommendations

• Low-risk patients: Routine endoscopic surveillance is NOT recommended (conditional recommendation, very low quality evidence) 1, 2
• High-risk patients: Consider endoscopic surveillance every 3 years 2
  • Use high-definition endoscopy with chromoendoscopy
  • Obtain biopsies from at least two topographic locations (antrum and body) in separate containers

Biopsy Protocol

When performing endoscopy for GIM assessment:

• Follow a systematic gastric biopsy protocol 2
• Obtain samples from both antrum and corpus/body 2
• Avoid inadequate sampling which could miss areas of dysplasia

Additional Management Considerations

1. Against Short-Term Follow-Up Endoscopy

   • The AGA suggests against routine repeat short-interval endoscopy with biopsies solely for risk stratification (conditional recommendation, very low quality evidence) 1

2. Lifestyle Modifications

   • Reduce consumption of preserved, smoked, and salty foods 2
   • Increase intake of fresh fruits and vegetables 2
   • Limit alcohol consumption 2

3. Monitor for Complications

   • Check for micronutrient deficiencies, particularly vitamin B12 2, 3
   • Monitor complete blood count to detect anemia 2
   • Consider screening for autoimmune conditions in suspected autoimmune gastritis 2

Important Caveats

• The recommendations against routine surveillance are conditional, meaning shared decision-making is appropriate 1
• Patients at higher risk who place high value on potential reduction in gastric cancer mortality may reasonably elect for surveillance despite uncertain benefits 1
• Long-term proton pump inhibitor use may be associated with increased risk of GIM in H. pylori-positive patients in a dose-dependent manner 4
• Patients should be educated about warning symptoms that should prompt earlier evaluation 2

Approach to Dysplasia

• For visible dysplasia and early-stage gastric adenocarcinoma without high-risk features, endoscopic resection is appropriate 5
• Endoscopic ablation therapies may be considered for invisible or extensive dysplasia 5

Remember that while most patients with GIM do not progress to cancer 5, appropriate risk stratification and management can help identify those who would benefit most from surveillance.