From the Guidelines
For patients with gastric intestinal metaplasia who have a first-degree relative diagnosed with gastric cancer at age 50, endoscopic surveillance should be performed every 3 years. This recommendation is based on the increased risk of gastric cancer development in individuals with both intestinal metaplasia and a family history of early-onset gastric cancer, as highlighted in the British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma 1. The surveillance should include systematic biopsies from multiple areas of the stomach (antrum, incisura, and corpus) using high-definition white light endoscopy with narrow-band imaging if available, as recommended by the AGA clinical practice update on screening and surveillance in individuals at increased risk for gastric cancer in the United States 1. During each surveillance procedure, at least 2-3 biopsies should be taken from each anatomic region to adequately assess for dysplastic changes. If high-grade dysplasia is found, more frequent surveillance (every 6-12 months) or endoscopic resection may be necessary. This surveillance strategy allows for early detection of progression to dysplasia or cancer, which significantly improves treatment outcomes. The presence of both intestinal metaplasia and a first-degree relative with gastric cancer diagnosed before age 55 represents a higher risk scenario that justifies this surveillance interval, as supported by the AGA clinical practice guidelines on management of gastric intestinal metaplasia 1.
Key points to consider:
- The British Society of Gastroenterology guidelines recommend endoscopic surveillance every 3 years for patients with extensive gastric atrophy and/or extensive gastric intestinal metaplasia 1.
- The AGA clinical practice update on screening and surveillance in individuals at increased risk for gastric cancer in the United States recommends endoscopy as the best test for screening or surveillance in individuals at increased risk for gastric cancer 1.
- The AGA clinical practice guidelines on management of gastric intestinal metaplasia suggest that patients with GIM who have a first-degree relative with gastric cancer may benefit from endoscopic surveillance 1.
- A recent review of current guidelines on the management of patients with gastric intestinal metaplasia highlights the importance of a risk-stratified approach to endoscopic surveillance and H. pylori eradication when present 1.
Overall, the recommendation for 3-year endoscopic surveillance in patients with gastric intestinal metaplasia and a first-degree relative with gastric cancer diagnosed at age 50 is supported by the most recent and highest quality evidence, including guidelines from the British Society of Gastroenterology 1 and the AGA clinical practice update on screening and surveillance in individuals at increased risk for gastric cancer in the United States 1.
From the Research
Endoscopic Surveillance Intervals for Gastric Intestinal Metaplasia
- The European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), and European Society of Pathology (ESP) suggest that patients with extensive endoscopic changes or advanced histological stages of atrophic gastritis should be followed up with high-quality endoscopy every 3 years 2.
- For patients with a family history of gastric cancer, the ESGE/EHMSG/ESP recommend individual gastric risk assessment and stratification of precancerous conditions for first-time gastroscopy 2.
- A study on the cost-effectiveness of endoscopic surveillance for gastric intestinal metaplasia found that endoscopic surveillance every year for a 10-year period was cost-effective in preventing gastric cancer-related deaths 3.
- However, the optimal surveillance interval for patients with gastric intestinal metaplasia and a first-degree relative diagnosed with gastric cancer at the age of 50 is not explicitly stated in the provided studies.
- The ESGE/EHMSG/ESP guideline update 2025 recommends that biopsies should be taken from at least two topographic sites in two separate, clearly labeled vials, and that patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum may not require surveillance in the absence of endoscopic signs of extensive lesions or other risk factors 2.
Risk Factors and Surveillance
- Family history of gastric cancer is a known risk factor for gastric cancer development and is associated with increased risk of progression to gastric cancer among patients with gastric intestinal metaplasia (GIM) 4, 5.
- The presence of intestinal metaplasia is a precancerous condition that increases the risk of gastric cancer 4, 5, 2, 3.
- Endoscopic surveillance is recommended for patients with a high risk of gastric cancer, including those with a family history of gastric cancer or precancerous conditions such as atrophic gastritis or intestinal metaplasia 2, 3, 6.