Gastric premalignant conditions

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.

References

1.ACG Clinical Guideline: Diagnosis and Management of Gastric Premalignant Conditions (2025) (2025)