Management of gastric intestinal metaplasia should include H. pylori testing, eradication

Last Updated: 2019-12-13

By Will Boggs MD

NEW YORK (Reuters Health) - The management of patients with gastric intestinal metaplasia (GIM) should include testing for Helicobacter pylori and eradication when it is identified, according to new guidelines from the American Gastroenterological Association (AGA).

"Patients with incidentally detected gastric intestinal metaplasia should routinely be tested and treated for H. pylori," said Dr. Samir Gupta of Veterans Affairs San Diego Healthcare System and the University of California, San Diego, in La Jolla.

"The AGA recommends against routine use of surveillance endoscopy after GIM diagnosis because of the weak evidence base to support the practice." he told Reuters Health by email.

Non-cardia intestinal-type cancer, the most common histologic subtype of gastric cancer, follows a stepwise progression from normal mucosa to non-atrophic gastritis to atrophic gastritis to intestinal metaplasia to gastric adenocarcinoma. Chronic infection with H. pylori is the primary risk factor for this cancer.

Dr. Gupta and colleagues reviewed existing evidence in order to develop clinical-practice guidelines for the management of patients with GIM incidentally detected on gastric biopsies in routine clinical practice. The complete guidelines along with reports detailing the supporting evidence appear in Gastroenterology.

AGA recommends testing for H. pylori followed by eradication in patients with GIM, but discourages routine use of endoscopic surveillance or routine short-interval endoscopy with biopsies for the purpose of risk stratification in these patients.

Surveillance may be reasonable for patients with GIM specifically at higher risk of gastric cancer, including those with incomplete or extensive GIM, family history of gastric cancer, racial/ethnic minorities and immigrants from high-incidence regions.

Similarly, repeat endoscopy within one year may be reasonable for risk stratification in these higher-risk individuals.

The quality of evidence supporting these last two recommendations is very low, however, the authors note.

"Our recommendation against routine surveillance may be considered controversial by some," Dr. Gupta said. "While surveillance may theoretically allow for early detection or prevention of gastric cancer, we did not find sufficient evidence to routinely support this practice."

"It is very likely that future research could change the current recommendations," he said.

Dr. Shailja C. Shah of Vanderbilt University Medical Center, in Nashville, Tennessee, who co-authored three technical reviews underlying these recommendations and a fourth article on study design considerations, told Reuters Health by email, "The lack of comparative high-quality data on GIM surveillance versus no surveillance with respect to patient-important outcomes, including gastric-cancer mortality, warrants greatest emphasis. We conducted a comprehensive systematic review of the literature and did not find any direct evidence to inform three of our four main clinically relevant 'PICO'-format questions (population (P), intervention (I), comparator (C), and outcomes (O)), which were predefined by the AGA clinical-practice-guidelines panel."

"Gastric cancer is the third most common cause of cancer-related death worldwide," she said. "In the U.S. alone, it is estimated that over 27,500 new cases and 11,140 related deaths will occur in 2019. However, the risk is not equally distributed among all populations in the U.S. and there are even some groups among whom the incidence and related mortality are increasing."

"A diagnosis of GIM should not be ignored by clinicians," Dr. Shah said. "On the contrary, it should prompt clinicians to evaluate for additional risk factors for gastric cancer and should also serve as an opportunity for patient education regarding gastric-cancer risk and adjunctive risk-reduction efforts, such as H. pylori eradication and smoking cessation, if applicable. The importance of a high-quality upper endoscopic exam with complete mucosal visualization should also be highlighted, given the subtlety of gastric preneoplastic and even neoplastic lesions which may be missed."

She concluded, "While currently there is insufficient evidence to support routine surveillance in all patients with GIM, we hope that this will also be seen as a massive opportunity and 'call-to-action' to generate the needed evidence profiles."

Dr. Joo Ha Hwang of Stanford University in California, who recently reviewed the diagnosis and management of GIM but was not involved in the guidelines, told Reuters Health by email, "The new AGA clinical practice guidelines will hopefully help educate and guide clinicians in managing gastric intestinal metaplasia, which has perplexed many clinicians due to the lack of understanding of this entity."

"Do not be dogmatic about managing patients with gastric intestinal metaplasia using the new guidelines, since the recommendation regarding surveillance is conditional and based on very-low-quality evidence," he said. "If a patient is at high risk for gastric cancer due to ethnicity or findings on endoscopy, discuss options with the patient. I still feel strongly that patients who are at high risk for gastric cancer should undergo some form of endoscopic surveillance. Endoscopy is a relatively safe procedure and we can cure gastric cancer with endoscopic resection if we identify it early. This has been demonstrated by the screening and surveillance programs in Japan and Korea."

"Not all gastric intestinal metaplasia is necessarily pre-neoplastic," Dr. Hwang concluded. "We need more U.S.-based studies to understand which patients with gastric intestinal metaplasia are at risk for gastric cancer to determine who should undergo surveillance and at what interval."

SOURCE: https://bit.ly/2qQELIz, https://bit.ly/34geelC, https://bit.ly/2PgXwhF, https://bit.ly/34or9SF and https://bit.ly/38CYfRO Gastroenterology, online December 6, 2019.