Red Flags
- High-grade dysplasia or early gastric cancer on biopsy — endoscopic submucosal dissection (ESD) or surgical referral; multidisciplinary discussion[1]
- Pernicious anaemia with autoimmune atrophic gastritis — neuroendocrine tumour and gastric adenocarcinoma surveillance; B12 replacement; haematology[1]
- First-degree relative with gastric cancer — earlier and more frequent surveillance; H. pylori testing and treatment[1]
- Persistent dyspepsia with weight loss, dysphagia, anaemia, or vomiting — early endoscopy regardless of age[1]
First-line treatment
Interventions
- Helicobacter pylori test and treat with confirmation of eradication[1]All patients with atrophic gastritis, intestinal metaplasia, or dysplasia; eradication slows progression and may reverse atrophy in some patients; confirm cure with urea breath test or stool antigen ≥4 weeks after therapy
- Endoscopic surveillance every 3 years for extensive intestinal metaplasia or atrophic gastritis[1]Antrum and corpus involvement (OLGIM/OLGA stage III–IV), incomplete-type IM, family history of gastric cancer, or high-risk ethnicity (East Asian, Latin American, Eastern European); shorter intervals (1–2 years) for high-risk subgroups
- Endoscopic submucosal dissection (ESD) for visible high-grade dysplasia or early gastric cancer[1]Lesion confined to mucosa, well-differentiated, ≤2 cm without ulceration meets standard ESD criteria; expanded criteria for selected larger or undifferentiated lesions at expert centres
- Endoscopic resection or close surveillance of low-grade dysplasia[1]Visible low-grade dysplasia: prefer endoscopic resection. Indefinite or non-visible low-grade dysplasia: repeat high-quality endoscopy in 6–12 months at expert centre
- Smoking cessation and dietary risk reduction[1]Smoking cessation reduces gastric cancer risk; reduce salt-preserved and processed meat intake; increase fresh fruit/vegetable consumption; alcohol moderation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Standard H. pylori eradication regimen[1] | Combination antimicrobial + acid suppression | Bismuth quadruple therapy: PPI BD + bismuth subcitrate 240 mg QID + tetracycline 500 mg QID + metronidazole 500 mg TDS × 14 days; or rifabutin triple if available | — | Avoid clarithromycin-containing regimens in regions with >15% resistance and in any patient with prior macrolide exposure; confirm cure with breath test or stool antigen ≥4 weeks after completion |
Standard H. pylori eradication regimen[1]
Combination antimicrobial + acid suppression
- Adult
- Bismuth quadruple therapy: PPI BD + bismuth subcitrate 240 mg QID + tetracycline 500 mg QID + metronidazole 500 mg TDS × 14 days; or rifabutin triple if available
- Paediatric
- —
Avoid clarithromycin-containing regimens in regions with >15% resistance and in any patient with prior macrolide exposure; confirm cure with breath test or stool antigen ≥4 weeks after completion
Safety-net
- Surveillance endoscopy must be done with high-quality preparation (anti-foam, simethicone, adequate insufflation, ≥7 minutes inspection time) — short or rushed exams miss lesions[1]
- Symptoms suggesting cancer (weight loss, dysphagia, vomiting, anaemia, GI bleeding) — same-day or urgent endoscopy regardless of last surveillance[1]
- Family members of patients with gastric cancer should be tested for H. pylori once between ages 30–40 — eradication reduces lifetime gastric cancer risk[1]
Referral criteria
- Any high-grade dysplasia or biopsy-proven early gastric cancerTertiary centre with ESD/EMR expertise and surgical oncology[1]
- Extensive intestinal metaplasia (OLGIM III–IV) or autoimmune metaplastic atrophic gastritisGastroenterology with surveillance pathway[1]
- Familial gastric cancer (≥2 first/second-degree relatives, or any first-degree <50 years)Genetics and high-risk gastric cancer surveillance clinic[1]
- Persistent H. pylori despite second-line therapyGastroenterology for culture-guided or rifabutin-based salvage therapy[1]
Clinical summary
Diagnosis, risk stratification, surveillance, and endoscopic management of atrophic gastritis, intestinal metaplasia, and gastric dysplasia.