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Precancerous gastric lesions

Key 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 European Society of Gastrointestinal Endoscopy (ESGE/ESP/SPED/EHMSG 2019), the British Society of Gastroenterology (BSG 2019), and the American Society for Gastrointestinal Endoscopy (ASGE 2017; 2015).
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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
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
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2.Diagnostic investigations

Evaluation for Helicobacter pylori infection: test for H. pylori followed by eradication in patients with gastric intestinal metaplasia.
B

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  • Serum pepsinogen levels

3.Diagnostic procedures

Diagnostic endoscopy, indications, BSG
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

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  • Diagnostic endoscopy (staging and reporting)

  • EUS

  • Biopsy

4.Medical management

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
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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
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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

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