AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia

Abstract

This guideline focuses on recommendations for management of patients with GIM detected as part of routine upper endoscopy for reasons including workup of endoscopically identified gastropathy/presumed gastritis, dyspepsia, or exclusion of H pylori. Screening for gastric cancer (either population-wide or in select populations) and management of patients with dysplasia of the gastric mucosa, gastric adenocarcinoma, and/or autoimmune gastritis are beyond the scope of the current guideline. This guideline is intended to aid decision-making for patients who are undergoing upper endoscopy in North America. GIM is See editorial on page 473.

Screening for Upper Gastrointestinal Malignancies in the United States—Which Immigrant Groups Should Be Considered High-Risk?

“…The recently proposed guidelines from the American Gastroenterological Association recommend against routine use of endoscopic surveillance in patients with gastric intestinal metaplasia, instead advocating surveillance only in high-risk groups, including individuals with a family history of cancer, extensive mucosal involvement (spanning both the gastric body and antrum rather than being limited to the antrum alone), and racial/ethnic minorities or immigrants from high risk regions. 4 This is in line with prior American Society for Gastrointestinal Endoscopy recommendations, which suggested surveillance may only be indicated in the setting of risk factors, such as family history and Asian heritage. 5 These guidelines stop short of commenting on whether certain subsets of the US population would benefit from screening.…”

“…32 The American Gastroenterological Association guideline review highlights the significant knowledge gaps that remain in our understanding of which populations are truly at increased risk of gastric cancer and warrant intervention. 4 Many conclusions are extrapolated from data in Asia and other high-risk regions, and it is unclear how these data truly apply in the United States. Therefore, we propose the following roadmap to help guide future recommendations in an evidence-based way:…”

Gastric Cancer: Where Are We Heading?

“…Gastric precancerous lesions, that is, atrophic gastritis and IM, are associated with an increased risk of GC [47] and their surveillance appears as a logical strategy to prevent advanced GC. Indeed, several international guidelines on the management of these lesions have been recently published [48][49][50][51]. Most of these guidelines, except for AGA guidelines, recommend systematic surveillance of severe and extensive, pangastric, atrophy or IM, as evaluated by the operative link on gastritis assessment or operative link on gastric IM) scores, but the indication of surveillance of antrum-limited lesions appears less clear, depending on patient's characteristics and specific characteristics of the lesions (like the type of IM, complete or incomplete, etc.)…”

The Vexing Problem of Incidental Gastric Intestinal Metaplasia: Do the AGA Guidelines Help?

“…In this issue of Gastroenterology, the American Gastroenterological Association (AGA) published a new guideline (and 2 supporting technical reviews) that address the evidence-based management of incidental GIM targeting the US population. [6][7][8] In accordance with the AGA Clinical Guideline Development Process, this guideline was informed by a methodologically rigorous review of the relevant evidence published in 2 technical reviews. The technical review panel systematically reviewed the evidence related to H pylori testing and treatment, surveillance based on risk assessment, and the role of a repeat short-term endoscopy in patients incidentally found to have GIM on routine upper endoscopy.…”

“…Despite the relatively high prevalence of GIM in the United States, the overall incidence of gastric cancer in the United States is much lower when compared with regions such as Latin America and Asia, and the cumulative incidence of gastric cancer, among patients with diagnosed GIM at 3, 5, and 10 years was 0.4%, 1.1%, and1.6%, respectively. 8 The panel based this decision on the limited evidence for any benefit in light of the potential harms and burden of repeat endoscopy and ongoing surveillance. The pooled prevalence of GIM identified from pathology specimens in the United States is estimated to be about 5%.…”