AGA Releases Practice Guideline for Gastric Intestinal Metaplasia Found During Endoscopy

The American Gastroenterological Association (AGA) has released a clinical practice guideline for the management of gastric intestinal metaplasia (GIM) identified during routine upper endoscopy.¹ The guideline is the first of its kind to be supported by a comprehensive literature review in the United States and includes recommendations that can aid in clinical decision-making during upper endoscopy in North America.²

“There is wide variation in practice patterns for the management of [GIM] among endoscopists in the [United States], even those caring for populations at increased risk based on their race, ethnicity, or immigration status,” guideline lead author Samir Gupta, MD, MSCS, from the University of San Diego, California, and the Veterans Affairs San Diego Healthcare System, said in a press release.²

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In an effort to standardize clinical practice, the guideline panel sought to answer 4 clinically relevant questions for the management of GIM found at routine endoscopy:

1. In patients with GIM, does testing and treating for Helicobacter pylori vs no testing and treatment affect patient important outcomes?
2. In patients with GIM who are identified as low risk, does subsequent surveillance upper endoscopy vs no follow-up affect patient important outcomes?
3. In patients with GIM who are identified as high risk, does subsequent surveillance upper endoscopy vs no follow-up affect patient important outcomes?
4. In patients with GIM without dysplasia, does short-term follow-up (less than 1 year) with biopsies to determine the extent of GIM vs no short-term follow-up affect patient important outcomes?

Early gastric cancer detection, reduced morbidity/mortality from gastric cancer, complications associated with endoscopy, psychological outcomes, and resource implications were some of the patient important outcomes that the panel took into account.

The panel developed the following 3 recommendations for clinicians for the management of GIM:

1. Consider testing for H pylori followed by eradication over no testing and eradication.
2. Consider not routinely using endoscopic surveillance.
3. Consider not performing routine short-interval repeated endoscopy with biopsies for the purpose of risk stratification.

The first was a strong recommendation, while the other two were conditional recommendations. 

According to the authors, the recommendations highlight several knowledge gaps, including a lack of observational studies and randomized trials on impact of surveillance vs no surveillance on outcomes such as early detection and prevention of gastric cancer, as well as the importance of extensive vs limited (antral/incisura only) GIM on risk of gastric cancer. 

The guideline also includes a suggested algorithm for the management of GIM.

“In conclusion, the AGA recommends patients with GIM be tested and treated for H pylori to reduce risk for gastric cancer,” the guideline authors wrote.¹ “In light of current evidence gaps, the AGA suggests against routine use of short-interval repeat endoscopy with biopsies for the purpose of risk stratification and routine endoscopic surveillance but encourages patients and physicians to participate in shared decision-making regarding potential pros and cons of these strategies in light of current evidence gaps.”

—Colleen Murphy

References:

1. Gupta S, Li D, El Serag HB, et al. AGA clinical practice guidelines on management of gastric intestinal metaplasia [published online December 6, 2019]. Gastroenterology. doi:10.1053/j.gastro.2019.12.003.

2. AGA releases guideline on management of gastric intestinal metaplasia found during routine endoscopy [press release]. Bethesda, MD: American Gastroenterological Association; December 10, 2019. https://www.gastro.org/press-release/aga-releases-guideline-on-management-of-gastric-intestinal-metaplasia-found-during-routine-endoscopy. Accessed December 11, 2019.