In the Journals

AGA issues new guidelines on management of gastric intestinal metaplasia

Samir Gupta
Samir Gupta

The American Gastroenterological Association released new clinical practice guidelines for the management of gastric intestinal metaplasia.

Samir Gupta, MD, MSCS, AGAF, of Moores Cancer Center at University of California, San Diego, told Healio Gastroenterology and Liver Disease that the AGA’s technical review team found that approximately 5% of individuals who have a gastric biopsy in the United States will receive a diagnosis of gastric intestinal metaplasia (GIM). However, many questions persist about the management of this condition.

“The main concern is that we think it’s a risk factor for development of stomach cancer,” he said. “It’s one of the changes that occurs on the pathway to developing stomach cancer.”

Gupta said there is still a lot of variation in practice for how each individual gastroenterologist handles GIM, including different approaches to Helicobacter pylori eradication and endoscopic surveillance.

“That’s part of the void we are trying to fill and give some clarity on what people should be thinking about,” he said.

The guidelines included three recommendations:

Test for H. pylori followed by eradication over no testing and eradication

The most common population at risk for GIM is patients who have had H. pylori infection. Although research has shown that eradicating H. pylori reduces the risk for gastric cancer, Gupta said some studies have suggested that once a patient has developed GIM due to H. pylori, that eradicating it may not matter.

“That patient has gotten to a point of no return in terms of subsequent risk for stomach cancer,” Gupta said of this line of thinking. “However, on balance, when we looked at the literature, for patients with H. pylori overall and what was available for patients with GIM, the data suggest that eradicating H. pylori is favored over no testing and eradication. If someone finds GIM, we should make sure that were testing for H. Pylori, and if it is present, that we eradicate it.”

Suggest against routine use of endoscopic surveillance

The technical review team did not find much evidence in support for or against routine endoscopic surveillance. However, Gupta said the technical review team identified risk factors associated with higher risk for gastric cancer among patients with GIM who might benefit from surveillance, including those with family history of gastric cancer and specific histologic features of GIM — like extensive versus limited extent. Patients with overall increased risk for gastric cancer, such as racial or ethnic minorities, as well as immigrants from regions with high incidence could also be candidates for surveillance.

“We did identify some patients with GIM who appear to be at higher risk for gastric cancer,” Gupta said. “We think for patients with any of those characteristics there should be a shared decision making that goes on with the doctor and the patient that could lead to a recommendation for surveillance.”

Suggest against routine short-interval, repeat endoscopy

While some GIs routinely perform repeat endoscopy for risk stratification in patients with GIM, Gupta said that may not be necessary for all patients.

“Our conclusion was that if the patient already has a risk feature that might increase the risk for stomach cancer, you might not need to do a short-interval repeat endoscopy within 12 months,” he said. “You might already have the information you need to have that informed conversation with the patient about whether they want to do subsequent surveillance.” – by Alex Young

Disclosure: The authors report no relevant financial disclosures.

Samir Gupta
Samir Gupta

The American Gastroenterological Association released new clinical practice guidelines for the management of gastric intestinal metaplasia.

Samir Gupta, MD, MSCS, AGAF, of Moores Cancer Center at University of California, San Diego, told Healio Gastroenterology and Liver Disease that the AGA’s technical review team found that approximately 5% of individuals who have a gastric biopsy in the United States will receive a diagnosis of gastric intestinal metaplasia (GIM). However, many questions persist about the management of this condition.

“The main concern is that we think it’s a risk factor for development of stomach cancer,” he said. “It’s one of the changes that occurs on the pathway to developing stomach cancer.”

Gupta said there is still a lot of variation in practice for how each individual gastroenterologist handles GIM, including different approaches to Helicobacter pylori eradication and endoscopic surveillance.

“That’s part of the void we are trying to fill and give some clarity on what people should be thinking about,” he said.

The guidelines included three recommendations:

Test for H. pylori followed by eradication over no testing and eradication

The most common population at risk for GIM is patients who have had H. pylori infection. Although research has shown that eradicating H. pylori reduces the risk for gastric cancer, Gupta said some studies have suggested that once a patient has developed GIM due to H. pylori, that eradicating it may not matter.

“That patient has gotten to a point of no return in terms of subsequent risk for stomach cancer,” Gupta said of this line of thinking. “However, on balance, when we looked at the literature, for patients with H. pylori overall and what was available for patients with GIM, the data suggest that eradicating H. pylori is favored over no testing and eradication. If someone finds GIM, we should make sure that were testing for H. Pylori, and if it is present, that we eradicate it.”

Suggest against routine use of endoscopic surveillance

The technical review team did not find much evidence in support for or against routine endoscopic surveillance. However, Gupta said the technical review team identified risk factors associated with higher risk for gastric cancer among patients with GIM who might benefit from surveillance, including those with family history of gastric cancer and specific histologic features of GIM — like extensive versus limited extent. Patients with overall increased risk for gastric cancer, such as racial or ethnic minorities, as well as immigrants from regions with high incidence could also be candidates for surveillance.

“We did identify some patients with GIM who appear to be at higher risk for gastric cancer,” Gupta said. “We think for patients with any of those characteristics there should be a shared decision making that goes on with the doctor and the patient that could lead to a recommendation for surveillance.”

Suggest against routine short-interval, repeat endoscopy

While some GIs routinely perform repeat endoscopy for risk stratification in patients with GIM, Gupta said that may not be necessary for all patients.

“Our conclusion was that if the patient already has a risk feature that might increase the risk for stomach cancer, you might not need to do a short-interval repeat endoscopy within 12 months,” he said. “You might already have the information you need to have that informed conversation with the patient about whether they want to do subsequent surveillance.” – by Alex Young

Disclosure: The authors report no relevant financial disclosures.