Gastric intestinal metaplasia and gastric cancer prevention: Watchful waiting

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Figure 1
Endoscopic appearance of gastric intestinal metaplasia (GIM). (A) White-light endoscopy reveals macroscopic GIM, with an irregular, even surface. The arrow indicates an elongated, groove-type pit pattern. (B) Enhanced narrow-band imaging of the same surface shows multiple pale, elevated patches.
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Figure 2
The Correa cascade illustrates the progression from precancerous histologic changes in the gastric mucosa to the development of gastric intestinal metaplasia.
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Figure 3
An algorithmic approach to the management of gastric intestinal metaplasia (GIM).

TABLE 1

Autoimmune vs environmental metaplastic atrophic gastritis

	Autoimmune-mediated metaplastic atrophic gastritis	Helicobacter pylori-mediated metaplastic atrophic gastritis
Location	Primary involvement of the gastric body and fundus	All gastric epithelium including antrum
Acid production	Lost entirely	Decreased
Fasting gastrin level	Markedly elevated	Variable
Antibodies	Antibodies to intrinsic factor and parietal cells	Antibodies to H pylori
Vitamin B₁₂ deficiency	Present, often severe	May be present, usually mild
Association	Other autoimmune disorders	Peptic ulcer disease, adenocarcinoma, “MALToma”

TABLE 2

Risk factors for progression to malignancy in gastric intestinal metaplasia

	Relative risk	95% confidence interval
Incomplete gastric intestinal metaplasia¹	3.33	1.96–5.64
Extensive gastric intestinal metaplasia¹	2.07	0.97–4.42
Family history of a first-degree relative with gastric cancer¹	4.5	1.3–15.5
Smoking²⁶	1.57	1.24–1.98
Alcohol²⁶	1.29	1.12–1.50

TABLE 3

Variations in society recommendations for the management of gastric intestinal metaplasia

Geographic location	Society recommendations
East Asia	Endoscopic or radiographic screening of all men and women at age 50 or older²⁹ In patients with gastric intestinal metaplasia and high-risk features, endoscopy recommended in 1 to 3 years
Europe	Patients with extensive gastric intestinal metaplasia should undergo endoscopic surveillance every 3 years Consider endoscopic surveillance in patients with gastric intestinal metaplasia limited to the corpus or antrum of the stomach but with a family history of gastric cancer, persistent Helicobacter pylori infection, incomplete gastric intestinal metaplasia, or autoimmune gastritis³⁰
United States	AGA recommends against routine endoscopic surveillance after gastric intestinal metaplasia is detected in the general population, but if H pylori is detected, treatment is encouraged Patients with gastric intestinal metaplasia and risk factors associated with progression could be considered for endoscopic surveillance every 3 to 5 years if the patient favors surveillance (which has an unclear impact on mortality risk) vs endoscopic evaluation, which has a risk of complications³¹ ASGE recommends endoscopic surveillance exclusively in patients with risk factors, but not in the general cohort of patients in whom gastric intestinal metaplasia is detected³²