British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Abstract

Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include Helicobacter pylori infection, family history of gastric cancer—in particular, hereditary diffuse gastric cancer and pernicious anaemia. The stages in the progression to cancer include chronic gastritis, gastric atrophy (GA), gastric intestinal metaplasia (GIM) and dysplasia. The key to early detection of cancer and improved survival is to non-invasively identify those at risk before endoscopy. However, although biomarkers may help in the detection of patients with chronic atrophic gastritis, there is insufficient evidence to support their use for population screening. High-quality endoscopy with full mucosal visualisation is an important part of improving early detection. Image-enhanced endoscopy combined with biopsy sampling for histopathology is the best approach to detect and accurately risk-stratify GA and GIM. Biopsies following the Sydney protocol from the antrum, incisura, lesser and greater curvature allow both diagnostic confirmation and risk stratification for progression to cancer. Ideally biopsies should be directed to areas of GA or GIM visualised by high-quality endoscopy. There is insufficient evidence to support screening in a low-risk population (undergoing routine diagnostic oesophagogastroduodenoscopy) such as the UK, but endoscopic surveillance every 3 years should be offered to patients with extensive GA or GIM. Endoscopic mucosal resection or endoscopic submucosal dissection of visible gastric dysplasia and early cancer has been shown to be efficacious with a high success rate and low rate of recurrence, providing that specific quality criteria are met.

Magnifying i-scan Imaging for Endoscopic Diagnosis of Helicobacter pylori Infection: A Prospective Study

“…With progression of mucosal atrophy, irregular CVs become visible. 24 The field of IEE continues to progress rapidly. i-scan with optical enhancement applies digital image processing algorithms, by an optical filter which provides peak luminescence at the peaks of the hemoglobin absorption spectrum.…”

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.)…”

Usefulness of cricoid pressure in patients with poor gastric wall extension as a result of eructation in upper gastrointestinal endoscopy

“…Sufficient stomach extension by insufflation in upper gastrointestinal endoscopy and treatment is essential in finding lesions and securing sufficient field of view necessary for treatment by endoscopy. In particular, while viewing the greater curvature of the upper gastric body, it is not possible to observe spaces between folds unless there is sufficient air supply . However, in cases where lower esophagus sphincter contraction is weak, frequent eructation does not allow sufficient gastric wall extension by insufflation.…”

“…In particular, while viewing the greater curvature of the upper gastric body, it is not possible to observe spaces between folds unless there is sufficient air supply. 3 However, in cases where lower esophagus sphincter contraction is weak, frequent eructation does not allow sufficient gastric wall extension by insufflation. Lesions may be overlooked and securing the necessary visual field for treatment may be difficult.…”