Bethesda, Maryland (Dec. 10, 2019) — 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 guideline1 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,” according to 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. “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.”
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.
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)
Comment: 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.
Patients with GIM specifically at higher risk of gastric cancer include those with:
- Incomplete vs. complete GIM
- Extensive vs. limited GIM
- Family history of gastric cancer
Patients at overall increased risk for gastric cancer include:
- Racial/ethnic minorities
- Immigrants from high incidence regions
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)
Comment: 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 one 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.2 Each year, 1,033,701 incident cases are diagnosed globally,2 including 26,240 in the U.S.3 The majority of gastric cancers in the U.S. are non-cardia gastric cancers, arising from the antrum, incisura, body and/or fundus.4 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 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.5
Resources for health care providers
1. Gupta, S., Li, D., El Serag, H.B., et al. American Gastroenterological Association Institute Guidelines for Management of Gastric Intestinal Metaplasia. Gastro. https://doi.org/10.1053/j.gastro.2019.12.003.
2. Bray, F., Ferlay, J., Soerjomataram, I., et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.32.
3. Siegel, R.L., Miller, K.D., Jemal, A. Cancer statistics, 2018. CA Cancer J Clin 2018;68:7-30.
4. Gupta, S., Tao, L., Murphy, J.D., et al. Race/Ethnicity-, Socioeconomic Status-, and Anatomic Subsite-Specific Risks for Gastric Cancer. Gastroenterology 2019;156:59-62.e4.
5. Plummer, M., Franceschi, S., Vignat, J., et al. Global burden of gastric cancer attributable to Helicobacter pylori. Int J Cancer 2014;136:487-90.
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About the AGA Institute
The American Gastroenterological Association is the trusted voice of the GI community. Founded in 1897, the AGA has grown to more than 16,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology. The AGA Institute administers the practice, research and educational programs of the organization. www.gastro.org.
Gastroenterology, the official journal of the AGA Institute, is the most prominent scientific journal in the specialty and is in the top 1 percent of indexed medical journals internationally. The journal publishes clinical and basic science studies of all aspects of the digestive system, including the liver and pancreas, as well as nutrition. The journal is abstracted and indexed in Biological Abstracts, Current Awareness in Biological Sciences, Chemical Abstracts, Current Contents, Excerpta Medica, Index Medicus, Nutrition Abstracts and Science Citation Index. For more information, visit www.gastrojournal.org.