MKSAP Quiz: Evaluation for intestinal metaplasia
A 40-year-old woman is evaluated for intestinal metaplasia found on recent upper endoscopy to assess postprandial pain. No ulcers were visualized but generalized erythema and irregular mucosal pattern was noted. Following biopsy specimens, what is the most appropriate next step in management?
A 40-year-old woman is evaluated for intestinal metaplasia found on recent upper endoscopy to assess postprandial pain. No ulcers were visualized but generalized erythema and irregular mucosal pattern was noted. Biopsy specimens from the gastric antrum and gastric body showed extensive metaplasia, no dysplasia, and no Helicobacter pylori. Her father died of gastric cancer. Her only medication is omeprazole. She is of Korean descent.
Which of the following is the most appropriate next step in management?
A. Discontinue omeprazole
B. Initiate chemoprophylaxis with ascorbic acid
C. Initiate chemoprophylaxis with aspirin
D. Perform surveillance endoscopy
MKSAP Answer and Critique
The correct answer is D. Perform surveillance endoscopy. This content is available to MKSAP 19 subscribers as Question 76 in the Gastroenterology & Hepatology section. More information about MKSAP is available online.
The most appropriate next step in management is surveillance endoscopy (Option D). Gastric intestinal metaplasia (GIM) is a premalignant condition; patients have up to a 10-fold increase in the risk for gastric cancer compared with the general population. The risk for GIM and progression to gastric cancer is largely mediated by a history of Helicobacter pylori infection, ethnicity, age, family history, and other environmental factors, such as autoimmune metaplasia, infection with Epstein-Barr virus, high salt intake, consumption of pickled foods, and use of tobacco products. Although gastric cancer is the fifth most commonly diagnosed cancer worldwide and the third most deadly cancer worldwide (nearly 800,000 deaths annually), it is uncommon in North America, with an estimated incidence of only 6 in 100,000. Given the low risk for gastric cancer in the United States, routine use of endoscopic surveillance is not recommended for GIM. Surveillance should therefore be tailored to the characteristics of GIM in addition to risk factors. Risk factors for gastric cancer identified by the American Gastroenterological Association include the presence of incomplete or extensive GIM; having a first-degree relative with gastric cancer; race/ethnicity (African American, Asian, Hispanic, or Native American/Alaskan Native); and/or being first- or second-generation immigrants from high-incidence areas, including South America, Central America, Mexico, Caribbean nations, East Asia, Southeast Asia, post-Soviet states, Iran, and Turkey. The American Gastroenterological Association recommends that individuals with higher risk should be considered for surveillance endoscopy based on shared decision-making in which the patient puts a high value on the possible increased risk for gastric cancer and a low value on the risks associated with repeat endoscopy. The optimal interval for surveillance endoscopy remains unknown; however, indirect data suggest a 3- to 5-year interval for endoscopy.
There is no evidence that long-term treatment with proton pump inhibitors promotes the development of GIM; therefore, omeprazole does not need to be discontinued (Option A).
Studies of antioxidant therapy with ascorbic acid (Option B) and β-carotene have not consistently demonstrated a benefit in patients with GIM; therefore, this treatment cannot be routinely recommended.
No randomized controlled trials have demonstrated that chemoprophylaxis with aspirin (Option C) or NSAIDs decreases the risk for gastric cancer or progression of GIM. Some evidence of benefit has been described in observational studies.
Key Point
- Gastric intestinal metaplasia is a premalignant condition; patients have up to a 10-fold increased risk for gastric cancer compared with the general population.