Management of Gastric Intestinal Metaplasia
In patients with gastric intestinal metaplasia (GIM), testing for Helicobacter pylori followed by eradication is strongly recommended as the primary intervention, while routine endoscopic surveillance is not recommended for all patients but should be considered for those with high-risk features. 1
Initial Management
- All patients diagnosed with GIM should be tested for H. pylori infection and receive eradication therapy if positive (strong recommendation, moderate quality evidence) 1
- H. pylori eradication is the only non-endoscopic intervention with proven efficacy for gastric cancer prevention in patients with GIM 1
- Proper specimen collection is crucial for diagnosis, with biopsies from antrum/incisura and corpus placed in separate labeled specimen jars to allow assessment of the anatomic extent of GIM 2
Risk Stratification
GIM patients should be stratified based on risk factors for progression to gastric cancer:
High-Risk Features:
- Incomplete (colonic-type) intestinal metaplasia (3-fold higher risk compared to complete type) 2
- Extensive GIM involving both antrum and gastric body (2-fold higher risk compared to limited GIM) 2
- Family history of gastric cancer in a first-degree relative (4.5-fold increased risk) 2
- Persistent refractory H. pylori infection 1
- Racial/ethnic minorities and immigrants from regions with high gastric cancer incidence 1
- OLGIM (Operative Link on Gastritis Assessment based on Intestinal Metaplasia) stages III/IV 1
Surveillance Recommendations
- Routine endoscopic surveillance is not recommended for all patients with GIM (conditional recommendation, very low quality evidence) 1
- For patients with high-risk features who value potential cancer mortality reduction over the risks of endoscopy, endoscopic surveillance may be reasonable based on shared decision-making 1
- If surveillance is indicated, most guidelines recommend a 3-year interval between endoscopies 1
- Routine short-interval repeat endoscopy (within 1 year) for risk stratification is not recommended for all GIM patients 1
Special Considerations
- Patients with high-risk stigmata, concerns about completeness of baseline endoscopy, or overall increased risk for gastric cancer may reasonably elect for repeat endoscopy within 1 year for risk stratification 1
- The presence of GIM on gastric histology almost invariably implies the diagnosis of atrophic gastritis 2
- Current guidelines acknowledge significant evidence gaps regarding the optimal management of GIM, particularly regarding which populations merit index endoscopic screening and objective metrics for high-quality endoscopy 1
Pitfalls and Caveats
- The effect of H. pylori eradication on established GIM is limited, with conflicting evidence on whether GIM can improve or reverse after treatment 1, 3
- Not all guidelines are aligned on histological staging systems, creating potential inconsistencies in risk assessment 1
- The yield of systematically repeating baseline endoscopy to characterize the anatomic extent and histologic subtype of GIM requires further study 1
- Guidelines recognize 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 1