Management of Gastric Intestinal Metaplasia
In patients with gastric intestinal metaplasia (GIM), H. pylori testing followed by eradication therapy is strongly recommended as the primary treatment approach, while routine endoscopic surveillance is not recommended for most patients unless they have specific high-risk features. 1, 2
Diagnostic Approach and Risk Stratification
GIM represents replacement of normal gastric mucosa by intestinal-type epithelium and is a precancerous condition along the pathway to gastric cancer. Patients with GIM should be stratified into risk categories:
High-risk features include:
- Incomplete vs complete GIM
- Extensive vs limited GIM
- Family history of gastric cancer
- Racial/ethnic minorities from high-incidence regions
- Immigrants from high-incidence regions
- Corpus-extended GIM
- OLGIM stages III/IV
- Persistent H. pylori infection
Low-risk features include:
- Limited GIM
- Complete GIM subtype
- No family history of gastric cancer
Treatment Algorithm
Step 1: H. pylori Testing and Eradication
- All patients with GIM should be tested for H. pylori infection using non-serological methods (urea breath test, stool antigen test, or histological examination) 1, 2
- If positive, provide appropriate eradication therapy (strong recommendation, moderate quality evidence)
- Verify successful eradication after treatment to reduce gastric cancer risk 2
Step 2: Risk Assessment and Surveillance Decisions
- For low-risk patients: Routine endoscopic surveillance is not recommended (conditional recommendation, very low quality evidence) 1, 2
- For 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
- Follow a systematic gastric biopsy protocol to avoid inadequate sampling
Special Considerations
Endoscopic Management of Dysplasia
- For visible dysplasia and early-stage gastric adenocarcinoma without high-risk features, endoscopic resection is appropriate 3
- Endoscopic ablation therapies may be considered for invisible or extensive dysplasia 3
Patient Education and Lifestyle Modifications
- Educate patients about warning symptoms requiring earlier evaluation
- Recommend dietary modifications:
- Reduce consumption of preserved, smoked, and salty foods
- Increase intake of fresh fruits and vegetables
- Limit alcohol consumption 2
Monitoring
- Monitor for micronutrient deficiencies, particularly vitamin B12 and iron
- Consider screening for autoimmune conditions in patients with suspected autoimmune gastritis 2
Pitfalls and Caveats
Inadequate biopsy sampling: Follow systematic protocols with samples from both antrum and corpus/body to properly assess GIM extent 2
Failure to verify H. pylori eradication: This can lead to underestimation of GIM extent and increased cancer risk 2
Overuse of proton pump inhibitors: Higher cumulative doses of PPIs have been associated with increased likelihood of GIM, particularly in H. pylori-positive patients 4
Missed surveillance in high-risk patients: While routine surveillance is not recommended for all GIM patients, those with high-risk features may benefit from periodic endoscopic evaluation 1, 2
Inadequate endoscopic examination: Light examination for at least 7 minutes with mapping biopsies may increase yield for detecting dysplasia and early gastric cancer 3
The AGA recognizes that new evidence may emerge that might more strongly support short-interval repeat endoscopy with biopsies for risk stratification and/or endoscopic surveillance for gastric cancer risk reduction in the future 1.