Improving the Endoscopic Detection and Management of Gastric Intestinal Metaplasia Through Training: A Practical Guide

Abstract

Gastric intestinal metaplasia (GIM) is a premalignant condition of the stomach characterized by the replacement of the normal gastric mucosa by intestinal epithelium in response to chronic gastric inflammation. Chronic infection with Helicobacter pylori is the most common trigger for GIM, but other etiologies are recognized, including autoimmune gastritis. GIM is associated with a baseline 0.16% annual risk of gastric adenocarcinoma.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar However, the baseline risk of gastric cancer (GC) among patients with GIM may be significantly higher depending on the anatomic extent of GIM in the stomach, stage and severity of GIM, histological subtype of GIM, and the presence of H pylori infection, among other factors.Improved detection, risk stratification, and management of GIM represents a major opportunity for GC prevention and early detection. Unfortunately, little if any training on GIM detection and management occurs during standard GI fellowship, especially in the United States, which is in direct contrast to the attention focused on other precancerous gastrointestinal (GI) conditions, namely, colorectal adenomas and Barrett’s esophagus. Hand in hand with training in fellowship, GI proceduralists at large should also have focused training given the low baseline awareness of GIM management and highly variable practice patterns observed, even among providers routinely caring for populations at high risk for GC.2Vance R.B. Kubiliun N. Dunbar K.B. How do we manage gastric intestinal metaplasia? A survey of clinical practice trends for gastrointestinal endoscopists in the united states.Dig Dis Sci. 2016; 61: 1870-1878Crossref PubMed Scopus (10) Google Scholar,3Shah S.C. Nunez H. Chiu S. et al.Low baseline awareness of gastric cancer risk factors amongst at-risk multiracial/ethnic populations in New York City: results of a targeted, culturally sensitive pilot gastric cancer community outreach program.Ethn Health. 2020; 25: 189-205Crossref PubMed Scopus (10) Google Scholar The primary objective of this article is to provide an overview of the essential elements of GIM detection, risk stratification, and management that should be incorporated into training and clinical practice.Understand Who Is at RiskIt goes without saying that we should be performing a high-quality upper endoscopy for every patient, but it is helpful to have a pretest probability for gastric (pre)neoplasia before the endoscopic examination (Figure 1A). This process is analogous to performing high-quality colonoscopies for everyone, but having a heightened sense in someone presenting for colonoscopy for the evaluation of a positive Cologuard test. Based on data from Western populations, GIM is observed in approximately 5%–15% of patients undergoing upper endoscopy with gastric biopsies.4Sonnenberg A. Genta R.M. Changes in the gastric mucosa with aging.Clin Gastroenterol Hepatol. 2015; 13: 2276-2281Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,5Altayar O. Davitkov P. Shah S.C. et al.AGA technical review on gastric intestinal metaplasia-epidemiology and risk factors.Gastroenterology. 2020; 158: 732-744.e16Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar However, the prevalence is significantly higher in certain populations, including non-White groups and first-generation immigrants from countries where H pylori and GC are endemic, approaching or exceeding 40%, particularly in those who are older and with additional risk factors.5Altayar O. Davitkov P. Shah S.C. et al.AGA technical review on gastric intestinal metaplasia-epidemiology and risk factors.Gastroenterology. 2020; 158: 732-744.e16Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 6Huang RJ, Epplein M, Hamashima C, et al. An approach to the primary and secondary prevention of gastric cancer in the United States [published online ahead of print October 6, 2021]. Clin Gastroenterol Hepatol https://doi.org/10.1016/j.cgh.2021.09.039.Google Scholar, 7Choi C.E. Sonnenberg A. Turner K. et al.High prevalence of gastric preneoplastic lesions in East Asians and Hispanics in the USA.Dig Dis Sci. 2015; 60: 2070-2076Crossref PubMed Scopus (41) Google Scholar, 8Fennerty M.B. Emerson J.C. Sampliner R.E. et al.Gastric intestinal metaplasia in ethnic groups in the southwestern United States.Cancer Epidemiol Biomarkers Prev. 1992; 1: 293-296PubMed Google Scholar, 9Tan M.C. Jamali T. Nguyen T.H. et al.Race/ethnicity and birthplace as risk factors for gastric intestinal metaplasia in a multiethnic united states population.Am J Gastroenterol. 2022; 117: 280-287Crossref PubMed Scopus (4) Google Scholar As expected, high-risk populations for GIM parallel high-risk populations for GC. GC is significantly more common in non-White groups compared with non-Hispanic Whites6Huang RJ, Epplein M, Hamashima C, et al. An approach to the primary and secondary prevention of gastric cancer in the United States [published online ahead of print October 6, 2021]. Clin Gastroenterol Hepatol https://doi.org/10.1016/j.cgh.2021.09.039.Google Scholar,10Shah S.C. McKinley M. Gupta S. et al.Population-based analysis of differences in gastric cancer incidence among races and ethnicities in individuals age 50 years and older.Gastroenterology. 2020; 159: 1705-1714.e2Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar; in fact, the rates of GC in the former greatly exceed rates of esophageal cancer and, in some (eg, Korean Americans) even approach the rates of colorectal cancer. Additional risk factors for GIM include persistent H pylori infection, male sex, smoking, and having a first-degree relative with GC, each conferring an independent risk of GIM ranging from approximately 1.5- to 3.5-fold.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,5Altayar O. Davitkov P. Shah S.C. et al.AGA technical review on gastric intestinal metaplasia-epidemiology and risk factors.Gastroenterology. 2020; 158: 732-744.e16Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,9Tan M.C. Jamali T. Nguyen T.H. et al.Race/ethnicity and birthplace as risk factors for gastric intestinal metaplasia in a multiethnic united states population.Am J Gastroenterol. 2022; 117: 280-287Crossref PubMed Scopus (4) Google Scholar,11Tan M.C. Mallepally N. Liu Y. et al.Demographic and lifestyle risk factors for gastric intestinal metaplasia among US veterans.Am J Gastroenterol. 2020; 115: 381-387Crossref PubMed Scopus (21) Google ScholarKnow What You Are Looking For: Endoscopic Features of GIMEndoscopic detection of GIM is not a routine focus of GI training in the United States, despite its prevalence and designation as a precancerous condition. GIM has different endoscopic features depending on the type of image enhancement (eg, narrow band imaging [NBI], linked color imaging, blue laser imaging). The most routinely available technology in the United States is high-definition white light endoscopy (HD-WLE) and NBI. Under HD-WLE, GIM often appears as subtle nodularity with ridged or tubulovillous mucosal pattern, which is more readily appreciated using NBI (Figure 1B–G). GIM can be appreciated even without magnifying endoscopy, which is not routinely available in the United States, although newer endoscopes in the United States have near-focus capability, which similarly enhances mucosal features (Figure 1D–G). One large prospective multicenter study demonstrated that the respective sensitivity and specificity of HD-WLE with NBI (without magnification) was 87% and 97% for GIM, and 92% and 99% for dysplasia.12Pimentel-Nunes P. Dinis-Ribeiro M. Soares J.B. et al.A multicenter validation of an endoscopic classification with narrow band imaging for gastric precancerous and cancerous lesions.Endoscopy. 2012; 44: 236-246Crossref PubMed Scopus (122) Google Scholar Other characteristic features of GIM that can be appreciated with NBI include the light blue crest sign (Figure 1D, E), which has a high sensitivity and specificity (≥90%) for GIM and the presence of white opaque fields,”13Shah S.C. Piazuelo M.B. Kuipers E.J. et al.AGA clinical practice update on the diagnosis and management of atrophic gastritis: expert review.Gastroenterology. 2021; 161: 1325-1332.e7Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar which is also appreciated using HD-WLE and has very high specificity, but limited sensitivity. Recognizing the endoscopic features of atrophic gastritis is also relevant, because GIM almost invariably implies a background of atrophic gastritis.13Shah S.C. Piazuelo M.B. Kuipers E.J. et al.AGA clinical practice update on the diagnosis and management of atrophic gastritis: expert review.Gastroenterology. 2021; 161: 1325-1332.e7Abstract Full Text Full Text PDF PubMed Scopus (32) Google ScholarEndoscopic features of gastric neoplasia are beyond the scope of this article, but it cannot be emphasized enough that gastric neoplastic lesions are often very subtle, especially in patients who are H pylori negative. Even in expert hands, endoscopic miss rates are approximately 10%, with several series reporting rates as high as 20%–25%.14Pimenta-Melo A.R. Monteiro-Soares M. Libânio D. et al.Missing rate for gastric cancer during upper gastrointestinal endoscopy: a systematic review and meta-analysis.Eur J Gastroenterol Hepatol. 2016; 28: 1041-1049Crossref PubMed Scopus (95) Google Scholar The core metrics of mucosal visualization and inspection time are associated with improved detection rates (discussed elsewhere in this article) (Figure 1A). Creating online resources such as photo and video libraries and interactive learning modules may help to train endoscopists to recognize the endoscopic features of gastric (pre)neoplasia, especially in low- to intermediate-risk countries such as the United States, where such resources do not currently exist.Set Yourself up for Success: Performing a High-quality Upper EndoscopyGIM and gastric neoplasia are subtle. Achieving excellent gastric mucosal visualization through cleansing and insufflation and spending sufficient time carefully inspecting all aspects of the gastric mucosa ensuring no areas are missed are critical to the endoscopic detection of (pre)neoplasia (Figure 1A); indeed, these concepts parallel the impact of colonic bowel preparation quality and withdrawal time on adenoma detection rates. Water irrigation alone is often insufficient, and defoaming and mucolytic agents (eg, simethicone) may be needed.13Shah S.C. Piazuelo M.B. Kuipers E.J. et al.AGA clinical practice update on the diagnosis and management of atrophic gastritis: expert review.Gastroenterology. 2021; 161: 1325-1332.e7Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Adequate insufflation allows a broad survey of the entire gastric mucosa for abnormalities. Subtle features that might suggest gastric neoplasia include incomplete distensibility of gastric folds or disruption or abnormal convergence of folds. The optimal gastric inspection time for neoplasia detection has not been established, but ≥6–7 minutes measured from the time of adequate mucosal visualization is a proposed threshold.15Sharma P. Parasa S. Shaheen N. Developing quality metrics for upper endoscopy.Gastroenterology. 2020; 158: 9-13Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 16Teh J.L. Tan J.R. Lau L.J.F. et al.Longer examination time improves detection of gastric cancer during diagnostic upper gastrointestinal endoscopy.Clin Gastroenterol Hepatol. 2015; 13: 480-487.e2Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar, 17Kawamura T. Wada H. Sakiyama N. et al.Examination time as a quality indicator of screening upper gastrointestinal endoscopy for asymptomatic examinees.Dig Endosc. 2017; 29: 569-575Crossref PubMed Scopus (26) Google ScholarThe endoscopic examination should be performed with HD-WLE at a minimum. Image-enhancing technology, such as NBI, has been consistently demonstrated to improve detection of GIM compared with HD-WLE alone. There have been many advances in endoscopic technologies to improve the detection of GIM, and, more important, gastric neoplasia (eg, image-enhancement with linked color imaging). Notwithstanding important considerations and relevant limitations, which are beyond the scope of this article, training in advanced endoscopic technology, including artificial intelligence, will ideally be incorporated into training programs with as much enthusiasm in the stomach as for other parts of the GI tract. Regardless, training efforts should at least focus on ensuring that the basic metrics of gastric mucosal visualization, inspection time, and photo-documentation of landmarks are routinely achieved and monitored.Understand Risk Stratification Factors for Patients With GIMIn the United States, a diagnosis of GIM necessitates histopathological confirmation and, therefore, biopsies are required (Figure 2A). Obtaining appropriate biopsies is also a pillar for risk stratification, because this process allows for the determination and confirmation of the (1) anatomic extent, (2) histopathological stage and severity, (3) histological subtype (incomplete vs complete vs mixed), and (4) presence of H pylori (although it should be noted that the sensitivity for H pylori diagnosis is lower in the presence of GIM, and other nonserological modalities, such as fecal antigen testing, should be considered). These factors alone may be associated with a significant 2-to 20-fold (eg, OLGIM III/IV) higher risk of incident advanced gastric neoplasia and are critical to determining whether or not patients warrant endoscopic surveillance and, if so, at what interval.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,18Lee J.W.J. Zhu F. Srivastava S. et al.Severity of gastric intestinal metaplasia predicts the risk of gastric cancer: a prospective multicentre cohort study (GCEP).Gut. 2022; 71: 854-863Crossref PubMed Scopus (14) Google ScholarFigure 2(A, B) Schematic diagram of the updated Sydney protocol biopsy system and Operative Link for Gastric Intestinal Metaplasia Assessment (OLGIM) classification system. Obtaining biopsies according to the updated Sydney protocol biopsy system allows for determination of the topographic extent of gastric intestinal metaplasia (GIM) as well as the severity of GIM (and underlying atrophy), both of which are important prognostic factors for gastric cancer (GC) risk. These are incorporated in the OLGIM stage, which ranges from I (mild) to IV (severe). Compared with the Operative Link for Gastritis Assessment (OLGA), OLGIM has improved interobserver agreement but might down-stage some high-risk individuals. OLGA and OLGIM have similar prognostic value for GC, with OLGA/OLGIM III/IV being associated with a significantly higher risk of GC compared with lower OLGA/OLGIM scores. (Figure 2A adapted from Shah SC, et al. Gastroenterology 2020;158:704; and Figure 2B adapted from Capelle LG, et al. Gastrointest Endosc 2010;71:1150.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)In patients with established or suspected GIM or who are at elevated risk, biopsies according to the updated Sydney protocol should be obtained (Figure 2A) and should be targeted to areas concerning for GIM. One should ensure that the incisura angularis is biopsied since GIM often involves this area and it is needed for histological risk stratification using the Operative Link for Gastritis (OLGA) and Gastric Intestinal Metaplasia (OLGIM) Assessment (described elsewhere in this article) (Figure 2B).19Rugge M. Meggio A. Pennelli G. et al.Gastritis staging in clinical practice: the OLGA staging system.Gut. 2007; 56: 631-636Crossref PubMed Scopus (322) Google Scholar,20Capelle L.G. de Vries A.C. Haringsma J. et al.The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis.Gastrointest Endosc. 2010; 71: 1150-1158Abstract Full Text Full Text PDF PubMed Scopus (337) Google Scholar Any concerning lesions should be photodocumented with their location clearly described in the procedure report, biopsied, and placed in a separately labeled jar. The data obtained from the preprocedure assessment supplements the histological risk assessment. Older age, family history of GC in a first-degree relative, tobacco smoking, and certain dietary factors (eg, diets high in salt or smoked/preserved meats and low in fresh produce) are also associated with increased risk of GC among patients with GIM.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Race, ethnicity, and birth country of origin are certainly associated with higher GIM prevalence, but it is not established as to whether these factors are associated independently with progression to GC once GIM is diagnosed.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google ScholarFellowship training should routinely emphasize the importance of determining and documenting each of these histological and demographic risk stratification factors, because these are currently our best measures of risk to guide recommendations surrounding surveillance intervals. Such practice is not dissimilar to using the Prague classification for nondysplastic Barrett’s esophagus, and the number, size, and histology for colorectal polyps, along with clinical factors, to determine surveillance recommendations. It is fully acknowledged that surveillance recommendations are still evolving in the United States, although there is a robust body of data outside of the United States. That said, a diagnosis of GIM should not be ignored and every effort should be made to determine patients’ individual risk. In addition to training and education, creating automated pathology result templates that record information on risk stratification and link to GIM surveillance reminders in patients’ medical charts may decrease practice pattern variability.Understand the Importance of HistopathologyHistopathological staging and GIM subtype are among the best GC risk predictors in our toolbox. OLGIM (and OLGA) is a validated GC risk assessment system that incorporates both the severity and topographic distribution of GIM (and atrophy) (Figure 2B). OLGIM has greater interobserver reproducibility than OLGA, with similar prognostic performance for advanced gastric neoplasia.18Lee J.W.J. Zhu F. Srivastava S. et al.Severity of gastric intestinal metaplasia predicts the risk of gastric cancer: a prospective multicentre cohort study (GCEP).Gut. 2022; 71: 854-863Crossref PubMed Scopus (14) Google Scholar Indeed, based on a recently published large, prospective, multicenter cohort of targeted endoscopic surveillance of patients residing in regions of low to intermediate GC incidence, patients with OLGIM stage III or IV had a significant 20.8-fold (95% confidence interval, 5.04–85.6) higher risk of early gastric neoplasia compared with patients without GIM (note: low-risk GIM, OLGIM stage I demonstrated no increased risk). The median time to early gastric neoplasia among patients with OLGIM stage III or IV was <2 years (22.7 months; 95% confidence interval, 12.7–44.8).18Lee J.W.J. Zhu F. Srivastava S. et al.Severity of gastric intestinal metaplasia predicts the risk of gastric cancer: a prospective multicentre cohort study (GCEP).Gut. 2022; 71: 854-863Crossref PubMed Scopus (14) Google Scholar These patients may, therefore, warrant more aggressive surveillance, especially if there are additional risk factors. Unfortunately, histopathologic stage is not routinely reported on pathology reports among patients diagnosed with gastric preneoplasia in the United States. The reasons are multifactorial including lack of sufficient gastric sampling, since determination of OLGIM stage necessitates biopsies from the corpus, antrum, and incisura (Figure 2B). Buy-in from pathologists is also needed.Reporting the histological subtype of GIM—that is, complete, incomplete, or mixed—in each gastric biopsy sample also aids in risk stratification; incomplete-type GIM is associated with a >3-fold higher risk of GC compared with the complete type and may, therefore, warrant endoscopic surveillance.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,21Shah S.C. Gawron A. Mustafa R. et al.Histologic subtyping of gastric intestinal metaplasia: overview and considerations for clinical practice.Gastroenterology. 2020; 158: 745-750Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Importantly, OLGA/OLGIM stage and histological subtype are readily determined using standard hematoxylin and eosin staining and require little additional time, yet provide a wealth of information for determining whether surveillance should be recommended and at what interval.The routine reporting of these prognosticators in pathology reports will not occur overnight and training efforts among gastroenterologists and pathologists alike are needed. One immediate step that gastroenterologists can take is to meet with their GI pathologists to discuss the evidence and rationale for GIM staging and histological subtyping, specifically citing the impact on clinical decision-making with respect to determination of surveillance intervals (including no surveillance).1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,18Lee J.W.J. Zhu F. Srivastava S. et al.Severity of gastric intestinal metaplasia predicts the risk of gastric cancer: a prospective multicentre cohort study (GCEP).Gut. 2022; 71: 854-863Crossref PubMed Scopus (14) Google Scholar,21Shah S.C. Gawron A. Mustafa R. et al.Histologic subtyping of gastric intestinal metaplasia: overview and considerations for clinical practice.Gastroenterology. 2020; 158: 745-750Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 22Pimentel-Nunes P. Libânio D. Marcos-Pinto R. et al.Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019.Endoscopy. 2019; 51: 365-388PubMed Google Scholar, 23Gupta S. Li D. El Serag H.B. et al.AGA clinical practice guidelines on management of gastric intestinal metaplasia.Gastroenterology. 2020; 158: 693-702Abstract Full Text Full Text PDF PubMed Scopus (97) Google ScholarEnsure Follow-upTraining should incorporate standard processes to ensure that patients diagnosed with GIM receive appropriate follow-up. The first evidence-based United States guidelines on GIM were recently published by the American Gastroenterological Association, and generally align with international guidelines recommending a risk-stratified approach for determining whether endoscopic surveillance should be pursued. A full overview of the management of patients with GIM is beyond the scope of this article, but the core items are to ensure23Gupta S. Li D. El Serag H.B. et al.AGA clinical practice guidelines on management of gastric intestinal metaplasia.Gastroenterology. 2020; 158: 693-702Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar that (1) H pylori is appropriately tested for, treated, and confirmed eradicated; (2) sufficient data are available for appropriate risk stratification in order to determine endoscopic surveillance vs no surveillance; (3) recommendations are discussed with patients through a shared decision-making conversation. Where applicable, additional risk modification strategies should also be discussed with patients, including smoking cessation. In the near future, there will ideally be processes in place to monitor and track how often and to what extent providers discuss follow-up recommendations with patients diagnosed with GIM, because adherence to these metrics represents an achievable opportunity to prevent or attenuate neoplastic progression in patients with GIM or at least detect gastric neoplasia at an early stage.In conclusion, we must take active steps to incorporate GIM detection and management into training and establish quality metrics, similar to that which already occurs for other precancerous conditions of the GI tract. This strategy is particularly critical in the United States, where there is expanding diversity and enrichment for individuals at an increased risk for GC. Gastric intestinal metaplasia (GIM) is a premalignant condition of the stomach characterized by the replacement of the normal gastric mucosa by intestinal epithelium in response to chronic gastric inflammation. Chronic infection with Helicobacter pylori is the most common trigger for GIM, but other etiologies are recognized, including autoimmune gastritis. GIM is associated with a baseline 0.16% annual risk of gastric adenocarcinoma.1Gawron A.J. Shah S.C. Altayar O. et al.AGA Technical review on gastric intestinal metaplasia-natural history and clinical outcomes.Gastroenterology. 2020; 158: 705-731Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar However, the baseline risk of gastric cancer (GC) among patients with GIM may be significantly higher depending on the anatomic extent of GIM in the stomach, stage and severity of GIM, histological subtype of GIM, and the presence of H pylori infection, among other factors. Improved detection, risk stratification, and management of GIM represents a major opportunity for GC prevention and early detection. Unfortunately, little if any training on GIM detection and management occurs during standard GI fellowship, especially in the United States, which is in direct contrast to the attention focused on other precancerous gastrointestinal (GI) conditions, namely, colorectal adenomas and Barrett’s esophagus. Hand in hand with training in fellowship, GI proceduralists at large should also have focused training given the low baseline awareness of GIM management and highly variable practice patterns observed, even among providers routinely caring for populations at high risk for GC.2Vance R.B. Kubiliun N. Dunbar K.B. How do we manage gastric intestinal metaplasia? A survey of clinical practice trends for gastrointestinal endoscopists in the united states.Dig Dis Sci. 2016; 61: 1870-1878Crossref PubMed Scopus (10) Google Scholar,3Shah S.C. Nunez H. Chiu S. et al.Low baseline awareness of gastric cancer risk factors amongst at-risk multiracial/ethnic populations in New York City: results of a targeted, culturally sensitive pilot gastric cancer community outreach program.Ethn Health. 2020; 25: 189-205Crossref PubMed Scopus (10) Google Scholar The primary objective of this article is to provide an overview of the essential elements of GIM detection, risk stratification, and management that should be incorporated into training and clinical practice. Understand Who Is at RiskIt goes without saying that we should be performing a high-quality upper endoscopy for every patient, but it is helpful to have a pretest probability for gastric (pre)neoplasia before the endoscopic examination (Figure 1A). This process is analogous to performing high-quality colonoscopies for everyone, but having a heightened sense in someone presenting for colonoscopy for the evaluation of a positive Cologuard test. Based on data from Western populations, GIM is observed in approximately 5%–15% of patients undergoing upper endoscopy with gastric biopsies.4Sonnenberg A. Genta R.M. Changes in the gastric mucosa with aging.Clin Gastroenterol Hepatol. 2015; 13: 2276-2281Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,5Altayar O. Davitkov P. Shah S.C. et al.AGA technical review on gastric intestinal metaplasia-epidemiology and risk factors.Gastroenterology. 2020; 158: 732-744.e16Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar However, the prevalence is significantly higher in certain populations, including non-White groups and first-generation immigrants from countries where H pylori and GC are endemic, approaching or exceeding 40%, particularly in those who are older and with additional risk factors.5Altayar O. Davitkov P. Shah S.C. et al.AGA technical review on gastric intestinal metaplasia-epidemiology and risk factors.Gastroenterology. 2020; 158: 732-744.e16Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 6Huang RJ, Epplein M, Hamashima C, et al. An approach to the primary and secondary prevention of gastric cancer in the United States [published online ahead of print October 6, 2021].