Guideline sources The following summarized guidelines for the evaluation and management of precancerous gastric lesions are prepared by our editorial team based on guidelines from the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the American College of Gastroenterology (ACG 2023), the American Gastroenterological Association (AGA 2020), the British Society of Gastroenterology (BSG 2019), the European Society of Gastrointestinal Endoscopy (ESGE/ESP/SPED/EHMSG 2019), and the American Society for Gastrointestinal Endoscopy (ASGE 2017; 2015). 1 2 3 4 5 6 7 Guidelines 1. Screening and diagnosis Etiology: Recognize that: patients with chronic atrophic gastritis or intestinal metaplasia are at risk for gastric adenocarcinoma A patients with advanced stages of gastritis, that is, atrophy and/or intestinal metaplasia affecting both antral and corpus mucosa, are at higher risk for gastric adenocarcinoma B https://web.pathway.md/diseases/reclmBlPAZEX3O4ca 1/6 6/29/23, 11:25 PM Precancerous gastric lesions Pathway histologically confirmed intestinal metaplasia is the most reliable marker of atrophy in gastric mucosa. A Recognize that the management of patients with chronic atrophic gastritis or intestinal metaplasia intends to prevent high-grade dysplasia and invasive carcinoma. B 2. Diagnostic investigations Evaluation for Helicobacter pylori infection: test for H. pylori followed by eradication in patients with gastric intestinal metaplasia. B Serum pepsinogen levels: obtain serum pepsinogen levels to identify patients with advanced stages of atrophic gastritis (low serum pepsinogen I levels and/or low pepsinogen I/II ratio). B 3. Diagnostic procedures Diagnostic endoscopy, indications: As per BSG 2019 guidelines: Perform a full systematic endoscopy (examination time of a minimum of 7 minutes) of the stomach with clear photographic documentation of gastric regions and pathology in patients at higher risk for gastric adenocarcinoma, including atrophic gastritis and gastric intestinal metaplasia. B Consider performing a baseline endoscopy with biopsies in 50 years old patients with laboratory evidence of pernicious anemia, defined by vitamin B12 deficiency and either positive gastric parietal cell or intrinsic factor antibodies. C As per SPED/ESP/EHMSG/ESGE 2019 guidelines, perform endoscopy in patients with advanced stages of atrophic gastritis, particularly if H. pylori serology is negative. B Diagnostic endoscopy, technical considerations: As per KCHUGR 2023 guidelines: Consider performing image-enhanced endoscopy in addition to white light endoscopy to increase the diagnostic accuracy of intestinal metaplasia. C Do not rely on white light endoscopy findings to determine whether to perform a biopsy when considering a biopsy to confirm atrophic gastritis or intestinal metaplasia. D As per BSG 2019 guidelines, do not perform white-light endoscopy alone for establishing a diagnosis or risk stratification in patients with atrophic gastritis or gastric intestinal metaplasia. D Show 5 more As per SPED/ESP/EHMSG/ESGE 2019 guidelines: Prefer high-definition endoscopy with chromoendoscopy over high-definition white-light endoscopy alone for the diagnosis of gastric precancerous conditions and early neoplastic lesions. A Use virtual chromoendoscopy with or without magnification, whenever available and after proper training, for the diagnosis of gastric precancerous conditions, by guiding biopsy for staging atrophic and metaplastic changes and by helping to target neoplastic lesions. B https://web.pathway.md/diseases/reclmBlPAZEX3O4ca 2/6 6/29/23, 11:25 PM Precancerous gastric lesions Pathway Diagnostic endoscopy, staging and reporting: As per BSG 2019 guidelines, document the location and extent of atrophic gastritis and gastric intestinal metaplasia clearly with photographic evidence. Document endoscopic grading as distal gastric (affecting antrum or incisura: low risk) or proximal gastric (affecting the corpus with or without the antrum and incisura: high risk). B Show 3 more As per SPED/ESP/EHMSG/ESGE 2019 guidelines, stage lesions and initiate treatment in patients with an endoscopically visible lesion harboring low- or high-grade dysplasia or carcinoma. A As per ASGE 2017 guidelines, consider regarding a firm, round subepithelial lesion with central umbilication along the greater curve of the antrum of the stomach as diagnostic for a pancreatic rest. C Endoscopic ultrasound: As per ACG 2023 guidelines, consider performing EUS for the diagnosis of nonlipomatous subepithelial lesions. C Show 2 more As per ASGE 2017 guidelines: Consider performing EUS to further characterize indeterminate subepithelial lesions. C Do not perform further EUS for a pancreatic rest. D As per ASGE 2015 guidelines, perform EUS with or without FNA in the evaluation of gastric submucosal lesions. A Biopsy: As per ACG 2023 guidelines, avoid performing bite-on-bite biopsies in the evaluation of subepithelial lesions before an EUS. D Show 2 more As per BSG 2019 guidelines, perform biopsy to confirm the diagnosis in patients with image- enhanced features of chronic atrophic gastritis. Direct biopsies at mucosal sites within Sydney protocol areas where enhanced imaging discloses gastric intestinal metaplasia. Collect biopsy samples in separate containers and label them as either 'directed' or 'random' to corroborate the endoscopic staging assessment. B Show 3 more As per ESGE 2019 guidelines, perform gastric biopsies both for H. pylori infection diagnosis and identification of advanced stages of atrophic gastritis during the first diagnostic upper gastrointestinal endoscopy, to adequately stage gastric precancerous conditions. B Show 2 more As per ASGE 2017 guidelines, consider performing FNA or fine needle biopsy of lesions arising from the muscularis propria for histologic evaluation. C As per ASGE 2015 guidelines, perform biopsy or resection of solitary gastric polyps when possible. A Show 4 more 4. Medical management https://web.pathway.md/diseases/reclmBlPAZEX3O4ca 3/6 6/29/23, 11:25 PM Precancerous gastric lesions Pathway Helicobacter pylori eradication: As per KCHUGR 2023 guidelines, initiate H. pylori eradication therapy to prevent gastric cancer in patients with H. pylori-associated gastritis. B Show 2 more As per BSG 2019 guidelines: Initiate H. pylori eradication therapy to reduce the risk of gastric adenocarcinoma development in patients with atrophic gastritis. A Consider initiating H. pylori eradication therapy to reduce the risk of developing gastric adenocarcinoma in patients with H. pylori-associated gastric intestinal metaplasia or dysplasia. B As per ESGE 2019 guidelines, initiate H. pylori eradication therapy for the management of non-atrophic chronic gastritis, regression of atrophic gastritis, and to reduce the risk of gastric cancer in patients with non-atrophic and atrophic gastritis. A Show 2 more Nonsteroidal anti-inflammatory drugs: As per BSG 2019 guidelines, do not use NSAIDs or COX-2 inhibitors to reduce the risk of progression of premalignant lesions of the stomach. D As per ESGE 2019 guidelines: Do not use COX-1 or COX-2 inhibitors to slow the progression of gastric precancerous conditions. D Consider offering daily low-dose aspirin for the prevention of various cancers, including gastric cancer, in selected patients. C 5. Therapeutic procedures Endoscopic resection: As per ACG 2023 guidelines, consider performing endoscopic mucosal resection or endoscopic submucosal dissection for the resection of type 1 gastric NETs. C Show 2 more As per BSG 2019 guidelines, perform en bloc resection of all gastric dysplasia and early gastric adenocarcinoma. Recognize that an endoscopic mucosal resection technique can achieve en bloc excision for lesions 10 mm in size, but only an endoscopic submucosal dissection technique can ensure en bloc excision for lesions > 10 mm in size. A Show 3 more As per ASGE 2017 guidelines, consider removing lesions with malignant potential requiring treatment either endoscopically or surgically based on the type of lesion, size, location, patient preference, and available expertise. C As per ASGE 2015 guidelines: Perform endoscopic resection and surveillance endoscopy in patients with confirmed gastric intestinal metaplasia with high-grade dysplasia when feasible. B Consider performing polypectomy of fundic gland polyps 1 cm, hyperplastic polyps 0.5 cm, and adenomatous polyps of any size when possible. C https://web.pathway.md/diseases/reclmBlPAZEX3O4ca 4/6 6/29/23, 11:25 PM Precancerous gastric lesions Pathway 6. Surgical interventions Surgical resection: As per ACG 2023 guidelines: Consider performing either submucosal tunneling endoscopic resection or surgical resection, when resection is necessary, for the management of subepithelial lesions originating from the muscularis propria layer of the esophagus and GEJ. C Insufficient evidence to recommend surveillance versus resection of gastric gastrointestinal stromal tumors < 2 cm in size. Consider resecting gastric gastrointestinal stromal tumors > 2 cm and all non-gastric gastrointestinal stromal tumors owing to their malignant potential. I As per ASGE 2017 guidelines: Perform surgery for gastric gastrointestinal stromal tumors > 2 cm in size or with high-risk features. B Consider removing lesions with malignant potential requiring treatment, either endoscopically or surgically, based on the type of lesion, size, location, patient preference, and available expertise. C 7. Preventative measures Antioxidants: do not use antioxidants to reduce the prevalence of premalignant gastric lesions. D 8. Follow-up and surveillance Endoscopic surveillance: As per AGA 2020 guidelines: Avoid obtaining routine endoscopic surveillance in patients with gastric intestinal metaplasia. D Avoid performing a routine short-interval repeat endoscopy for risk stratification of patients with gastric intestinal metaplasia. D As per BSG 2019 guidelines, obtain endoscopic surveillance every 3 years in patients with extensive atrophic gastritis or gastric intestinal metaplasia, defined as affecting the antrum and body. B Show 4 more As per ESGE 2019 guidelines, perform immediate high-quality endoscopic reassessment with chromoendoscopy (virtual or dye-based) in patients with dysplasia in the absence of an endoscopically defined lesion. Perform biopsies for the staging of gastritis (if not previously done) and endoscopic surveillance within 6 months (if high-grade dysplasia) to 12 months (if low-grade dysplasia), if no lesion is detected in this high-quality endoscopy. B Show 6 more As per ASGE 2017 guidelines, consider obtaining surveillance with EUS for gastric gastrointestinal stromal tumors < 2 cm in size. C https://web.pathway.md/diseases/reclmBlPAZEX3O4ca 5/6 6/29/23, 11:25 PM Precancerous gastric lesions Pathway Show 2 more As per ASGE 2015 guidelines, consider performing endoscopy within 6 months of the diagnosis of pernicious anemia or the development of upper gastrointestinal symptoms in patients with pernicious anemia. C Show 3 more References 1. Banks M, Graham D, Jansen M et al. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut. 2019 Sep;68 9 1545 1575. Open 2. ASGE Standards of Practice Committee, John A Evans, Vinay Chandrasekhara et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015 Jul;82 1 1 8. Open 3. Seung Joo Kang, Jae Gyu Kim, Hee Seok Moon et al. Clinical Practice Guideline for Gastritis in Korea. J Korean Med Sci. 2023 Apr 3;38 13):e115. Open 4. Standards of Practice Committee, Ashley L Faulx, Shivangi Kothari et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc. 2017 Jun;85 6 1117 1132. Open 5. Pedro Pimentel-Nunes, Diogo Lib nio, Ricardo Marcos-Pinto et al. Management of epithelial precancerous conditions and lesions in the stomach MAPS II European Society of Gastrointestinal Endoscopy ESGE , European Helicobacter and Microbiota Study Group EHMSG , European Society of Pathology ESP , and Sociedade Portuguesa de Endoscopia Digestiva SPED guideline update 2019. Endoscopy. 2019 Apr;51 4 365 388. Open 6. Samir Gupta, Dan Li, Hashem B El Serag et al. AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia. Gastroenterology. 2020 Feb;158 3 693 702. Open 7. Brian C Jacobson, Amit Bhatt, Katarina B Greer et al. ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions. Am J Gastroenterol. 2023 Jan 1;118 1 46 58. Open 8. Shailja C Shah, M Blanca Piazuelo, Ernst J Kuipers et al. AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review. Gastroenterology. 2021 Oct;161 4 1325 1332.e7. Open https://web.pathway.md/diseases/reclmBlPAZEX3O4ca 6/6