Management of Gastric Intestinal Metaplasia
For patients with gastric intestinal metaplasia (GIM), testing for Helicobacter pylori followed by eradication is strongly recommended as the primary management approach, while routine endoscopic surveillance is not recommended for all patients but should be selectively offered to those with high-risk features. 1
Initial Management
- All patients diagnosed with GIM should be tested for H. pylori infection and treated if positive, as this is the only intervention with strong evidence for reducing gastric cancer risk (strong recommendation, moderate quality evidence) 1, 2
- H. pylori eradication is the cornerstone of management and the only universally recommended non-endoscopic intervention for gastric cancer prevention 1, 2
- Proper specimen collection during initial endoscopy is crucial, 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 into high-risk and low-risk categories based on the following factors:
High-Risk Features:
- Incomplete (colonic-type) versus complete (small intestinal-type) GIM (3-fold higher risk) 2
- Extensive GIM involving both antrum and corpus (2-fold higher risk) versus limited GIM confined to antrum/incisura 1, 2
- Family history of gastric cancer in first-degree relatives (4.5-fold increased risk) 1, 2
- Racial/ethnic minorities and immigrants from high gastric cancer incidence regions 1
- Persistent refractory H. pylori infection 1
- Advanced OLGIM stages (III/IV) 1
Low-Risk Features:
- Complete (small intestinal-type) GIM 2
- Limited GIM confined to antrum/incisura 1, 2
- No family history of gastric cancer 1
- Successful H. pylori eradication 1
Surveillance Recommendations
- Routine endoscopic surveillance is not recommended for all patients with GIM (conditional recommendation, very low quality evidence) 1
- For high-risk patients who elect surveillance after shared decision-making, most guidelines recommend a 3-year interval between endoscopies 1
- Short-interval repeat endoscopy (<1 year) for risk stratification is not routinely recommended (conditional recommendation, very low quality evidence) 1
- However, patients with high-risk features may reasonably elect for repeat endoscopy within 1 year for risk stratification based on shared decision-making 1
Special Considerations
- Despite the recommendation against routine surveillance, the cumulative risk of developing gastric cancer in patients with GIM is approximately 1.6% at 10 years 2
- High-quality endoscopy techniques are important when performing surveillance, including adequate examination time (at least 7 minutes) and systematic biopsy protocols 3
- Recent advances in image-enhanced endoscopy with artificial intelligence may improve the identification of GIM and neoplastic lesions 4
- For patients with visible dysplasia or early-stage gastric adenocarcinoma, endoscopic resection is appropriate if there are no high-risk features and H. pylori has been eradicated 3
Common Pitfalls and Caveats
- GIM is often underdiagnosed or inadequately assessed during routine endoscopy 5
- The prevalence of GIM varies significantly by geographic region and correlates with H. pylori prevalence 5, 6
- Only 16% of patients with GIM in the US receive recommendations for surveillance, highlighting inconsistent management practices 6
- Current guidelines are based on limited evidence, particularly regarding surveillance recommendations (very low quality evidence) 1
- The effect of H. pylori eradication on established GIM is limited, which is why risk stratification and potential surveillance remain important considerations 4