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Background and Objective: A multidisciplinary committee updated the 2012 European evidence-based recommendations on diagnosis and management of patients with intestinal metaplasia (IM) and atrophic gastritis (AG) based on a systematic literature review.
What's Changed: The recommended endoscopic surveillance interval for advanced atrophy and/or intestinal metaplasia — previously 3 years for all patients — is now 1 to 2 years in patients with a family history of gastric cancer.
Diagnosis
For diagnosis of IM, AG, and early neoplastic lesions, use high-definition endoscopy with chromoendoscopy (CE).
Use virtual CE, with or without magnification, to guide biopsy for staging AG and IM and to target neoplastic lesions.
Take biopsy samples from the antrum and the corpus, at the lesser and greater curvature of each and additional samples of visible neoplastic suspicious lesions.
Surveillance
In patients with dysplasia but no endoscopically defined lesion, conduct immediate high-quality endoscopic reassessment with CE (virtual or dye-based). If no lesion is detected, conduct biopsy for staging of gastritis (if not previously done) and perform endoscopic surveillance within 6 months for high-grade dysplasia or 12 months for low-grade dysplasia.
In patients with IM at a single location and a family history of gastric cancer; incomplete IM; or persistent Helicobacter pylori gastritis, consider endoscopic surveillance with CE and guided biopsies in 3 years.
Advanced AG (severe atrophic changes or IM in both antrum and corpus) warrants a high-quality endoscopy every 3 years.
Advanced AG and a family history of gastric cancer may warrant more-intensive surveillance (e.g., every 1–2 years after diagnosis).
No surveillance is necessary for mild-to-moderate atrophy restricted to the antrum.
For autoimmune gastritis, consider endoscopic follow-up every 3–5 years.
Treatment
Provide H. pylori eradication therapy to patients with nonatrophic chronic gastritis or AG, as well as in patients with gastric neoplasia after endoscopic therapy.
Pimentel-Nunes P 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; 51:365. (https://doi.org/10.1055/a-0859-1883)
Comment
Currently there is no U.S. guideline for the management of patients with gastric intestinal metaplasia and atrophic gastritis, and this European guideline is an excellent resource. In other areas of the world such as Southeast Asia, screening for gastric cancer is already a widely accepted practice. I believe that screening for gastric cancer should be offered to high-risk patient populations in North America, such as patients who have immigrated from Southeast Asia.