Gastric intestinal metaplasia (GIM), which is linked to non-cardia gastric cancer, is often detected during routine endoscopy, leading to questions about how patient care should be managed. A new clinical guideline from the American Gastroenterological Association, published in Gastroenterology, the official journal of the AGA Institute, provides recommendations for the management of patients with GIM detected as part of routine upper endoscopy for reasons including work up of endoscopically identified gastropathy/presumed gastritis, dyspepsia or exclusion of Helicobacter pylori (H. pylori).
There is wide variation in practice patterns for the management of gastric intestinal metaplasia among endoscopists in the U.S., even those caring for populations at increased risk based on their race, ethnicity or immigration status. AGA developed this evidence-based guideline, the first supported by a comprehensive literature review in the U.S., for the management of patients with GIM incidentally detected on gastric biopsies in to help standardize clinical practice."
Samir Gupta, MD, MSCS, AGAF, lead author of the guideline, and associate professor of clinical medicine and staff physician at the University of San Diego, CA, and Veterans Affairs San Diego Healthcare System
Screening for gastric cancer (either population-wide or in select populations), management of patients with dysplasia of the gastric mucosa, gastric adenocarcinoma, and/or autoimmune gastritis are beyond the scope of this guideline.
The guideline recommends:
1.In patients with GIM, AGA recommends testing for H. pylori followed by eradication over no testing and eradication. (strong recommendation: moderate quality evidence)
2.In patients with GIM, AGA suggests against routine use of endoscopic surveillance. (conditional recommendation: very low-quality evidence)
* Comments: Patients with GIM at higher risk for gastric cancer who put a high value on potential but uncertain reduction in gastric cancer mortality, and who put a low value on potential risks of surveillance endoscopies, may reasonably elect for surveillance.
3.In patients with GIM, AGA suggests against routine repeat short interval endoscopy with biopsies for the purpose of risk stratification (conditional recommendation: very low-quality evidence)
* Comments: Based on shared decision making, patients with GIM and high risk stigmata, concerns about completeness of baseline endoscopy, and/or who are at overall increased risk for gastric cancer (racial/ethnic minorities, immigrants from regions with high gastric cancer incidence, or individuals with family history of first-degree relative with gastric cancer) may reasonably elect for repeat endoscopy within 1 year for risk stratification.
AGA recognizes that new evidence may emerge in the future that may more strongly support short-interval repeat endoscopy with biopsies for risk stratification, and/or endoscopic surveillance for gastric cancer risk reduction.
Read the AGA Institute guidelines for management of gastric intestinal metaplasia to review the complete recommendations.
What is gastric intestinal metaplasia?
Gastric cancer is the third-leading cause of cancer death worldwide. Each year, 1,033,701 incident cases are diagnosed globally, including 26,240 in the U.S. The majority of gastric cancers in the U.S. are non-cardia gastric cancers, arising from the antrum, incisura, body and/or fundus. Chronic infection with H. pylori is the primary risk factor for (intestinal-type) non-cardia gastric cancer, with at least 80% of the global gastric cancer burden attributable to this pathogen. Gastric intestinal metaplasia (GIM) may represent the histologic step just prior to development of dysplasia. GIM has been considered as one specific marker to identify patients who might benefit from surveillance because it has been associated with increased risk for gastric cancer and is routinely encountered in clinical practice.
Gupta, S., et al. (2019) AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia. Gastroenterology. doi.org/10.1053/j.gastro.2019.12.003.