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Precancerous gastric lesions

What's new

The American College of Gastroenterology (ACG) has published a new guideline on gastric premalignant conditions. Routine screening for gastric premalignant conditions is not recommended in the general U.S. population, and data is lacking for high-risk individuals based on immigration status, race, ethnicity, or environmental factors. Endoscopic resection is recommended for dysplasia with visible margins, while repeat endoscopic evaluation is suggested if margins are not visible. Endoscopic surveillance every 3 years is recommended in patients with gastric intestinal metaplasia (GIM) at high risk for gastric cancer but not for low-risk cases. .

Guidelines

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 American College of Gastroenterology (ACG 2025,2023), the American Gastroenterological Association (AGA 2025,2020), the European Society of Gastrointestinal Endoscopy (ESGE/ESP/EHMSG 2025), the Korean College of Helicobacter and Upper Gastrointestinal Research (KCHUGR 2023), the British Society of Gastroenterology ...
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Screening and diagnosis

Indications for screening
As per ACG 2025 guidelines:
Avoid obtaining routine screening with upper endoscopy for gastric cancer and gastric premalignant conditions in the general population in the US.
D
Insufficient evidence to recommend opportunistic screening for gastric cancer and gastric premalignant conditions with upper endoscopy in patients deemed high-risk for gastric cancer based on immigration status, race, ethnicity, and certain environmental factors.
I
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  • Screening of family relatives

Diagnostic investigations

H. pylori testing: as per ACG 2025 guidelines, test for H. pylori infection in patients with gastric premalignant conditions or resected early gastric cancer, followed by eradication if positive to reduce the risk of progression to gastric cancer and metachronous early gastric cancer, respectively.
B
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  • Serum biomarkers

  • Diagnostic imaging

Diagnostic procedures

Diagnostic endoscopy, indications: as per EHMSG/ESGE/ESP 2025 guidelines, perform a high-quality endoscopy, including virtual chromoendoscopy, for screening, diagnosis, and surveillance of gastric precancerous conditions and lesions.
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  • Diagnostic endoscopy (technical considerations)

  • Diagnostic endoscopy (staging and reporting)

  • EUS

  • Biopsy

Medical management

General principles
As per EHMSG/ESGE/ESP 2025 guidelines:
Consider taking age and comorbidities into account when selecting patients for endoscopic treatment of an early gastric lesion.
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Obtain staging and offer treatment in patients with an endoscopically visible lesion harboring dysplasia (low grade or high grade) or carcinoma.
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  • H. pylori eradication

  • NSAIDs

  • PPIs

  • Chemoprevention

Nonpharmacologic interventions

Smoking cessation: as per EHMSG/ESGE/ESP 2025 guidelines, advise smoking cessation in patients with precancerous conditions or after endoscopic treatment of superficial lesions.
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Therapeutic procedures

Endoscopic resection: as per ACG 2025 guidelines, consider performing endoscopic resection in patients with dysplasia (indefinite for dysplasia, low-grade dysplasia, or high-grade dysplasia) with visible margins, if clinically appropriate.
C
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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.
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Specific circumstances

Patients with hereditary syndromes: as per EHMSG/ESGE/ESP 2025 guidelines, perform endoscopic surveillance in patients with hereditary syndromes with increased risk of gastric cancer following recommendations for the specific syndrome or according to the gastric mucosal changes, whichever interval is shorter.
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  • Patients with autoimmune gastritis

  • Patients with common variable immunodeficiency

Preventative measures

Antioxidants: as per BSG 2019 guidelines, do not use antioxidants to reduce the prevalence of premalignant gastric lesions.
D
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Follow-up and surveillance

Endoscopic surveillance: as per ACG 2025 guidelines, consider obtaining endoscopic surveillance at 3-year intervals in patients with gastric intestinal metaplasia deemed high risk for gastric cancer. High-risk groups include patients with gastric intestinal metaplasia with at least one of the following:
high-risk gastric intestinal metaplasia histology: incomplete gastric intestinal metaplasia histological subtype versus complete subtype; corpus-extension defined as corpus involvement also with antrum or incisura involvement
any gastric intestinal metaplasia histology with one of the following risk factors for gastric cancer: family history of gastric cancer in a first-degree relative; foreign-born with emigration from a high-incidence nation; high-risk race or ethnicity including East Asian, Latino/a, Black, and American Indian or Alaska Native.
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  • Post-resection surveillance