What is the management of intestinal metaplasia in the stomach?

Management of Gastric Intestinal Metaplasia

All patients with gastric intestinal metaplasia (GIM) should be tested for H. pylori and treated if positive, but routine endoscopic surveillance is not recommended for most patients. 1

Immediate Management: H. pylori Testing and Eradication

• Test all patients with GIM for H. pylori and eradicate if positive (strong recommendation, moderate quality evidence). 1
• H. pylori eradication reduces the risk of progression to dysplasia and gastric cancer. 2, 3
• This is the single most important intervention to reduce gastric cancer mortality in patients with GIM. 4

Surveillance Strategy: Risk-Stratified Approach

For most patients with GIM, routine endoscopic surveillance is NOT recommended (conditional recommendation, very low quality evidence). 1

However, surveillance may be appropriate through shared decision-making for patients with high-risk features:

High-Risk GIM Features (Consider Surveillance):

Histologic high-risk features:

• Incomplete (colonic-type) intestinal metaplasia carries 3-fold higher gastric cancer risk compared to complete type. 2
• Extensive GIM involving both antrum and corpus has approximately 2-fold higher progression risk compared to limited GIM confined to antrum/incisura. 2, 4

Patient-specific high-risk factors:

• First-degree relative with gastric cancer increases gastric cancer risk 4.5-fold in patients with GIM. 2
• Racial/ethnic minorities (particularly Asian, Hispanic, African American populations). 1
• Immigrants from high gastric cancer incidence regions (East Asia, Eastern Europe, Central/South America). 1

Surveillance Intervals (When Elected):

• Avoid routine short-interval repeat endoscopy (<1 year) for risk stratification in most patients (conditional recommendation, very low quality evidence). 1
• Patients with high-risk stigmata, concerns about completeness of baseline endoscopy, or overall increased gastric cancer risk may reasonably elect for repeat endoscopy within 1 year for risk stratification through shared decision-making. 1

Proper Endoscopic Technique

When performing endoscopy in patients with known or suspected GIM:

• Obtain mapping biopsies from antrum (greater and lesser curvature), incisura angularis, and corpus (greater and lesser curvature). 5
• Place biopsies from antrum/incisura and corpus in separate labeled specimen jars to allow assessment of anatomic extent of GIM. 2
• This anatomic mapping is critical for risk stratification, as extensive GIM carries higher cancer risk. 2, 4

Key Clinical Considerations

Cumulative gastric cancer risk: Patients with GIM in the gastric antral region have approximately 1.6% cumulative risk of gastric cancer at 10 years. 2

The presence of GIM almost invariably implies underlying atrophic gastritis, as GIM represents replacement of normal gastric epithelium with intestinal-type epithelium. 2, 6

Common Pitfalls to Avoid

• Do not perform universal surveillance on all patients with GIM—this is not cost-effective given the low absolute cancer risk in most patients. 1, 4
• Do not skip H. pylori testing—this is the only strong recommendation and has moderate quality evidence supporting reduced cancer risk. 1, 4
• Do not fail to risk-stratify—incomplete vs. complete type and extent of GIM significantly impact cancer risk and should guide surveillance decisions. 2, 4
• Do not ignore family history—a first-degree relative with gastric cancer substantially increases risk and may warrant surveillance even with limited GIM. 2