Initial assessment
In the presence of histological changes suggestive of premalignant gastric lesions, including atrophic gastritis, intestinal metaplasia or dysplasia, the first step is to confirm the histological diagnosis and ensure the quality of the endoscopy performed. A high-quality upper gastrointestinal endoscopy should be ensured, with mapping biopsies according to the Sydney protocol (antrum, incisura and corpus), allowing reliable assessment of disease extent. Whenever present, eradication of Helicobacter pylori is mandatory, as it is the main modifiable aetiological factor in gastric carcinogenesis.
Staging and risk stratification
After histological confirmation, clinical decision-making is based on the extent of gastric atrophy or intestinal metaplasia and the presence of high-risk factors. Staging should be performed according to OLGA or OLGIM, preferably OLGIM because of its greater reproducibility. The distinction between disease limited to one compartment and extensive disease (antrum + corpus) is essential to guide endoscopic surveillance and avoid unnecessary examinations in low-risk contexts.
Premalignant disease without dysplasia — limited disease
When intestinal metaplasia is limited to a single compartment, in the absence of high-risk factors, routine systematic endoscopic surveillance is not indicated. In these cases, the risk of progression is low, and management should focus on eradication of H. pylori, correction of modifiable factors, such as smoking, and clinical reassessment if the context changes.
Premalignant disease without dysplasia — extensive disease
In the presence of extensive gastric atrophy or intestinal metaplasia, involving both the antrum and corpus, periodic endoscopic surveillance is indicated. The standard recommended interval is every 3 years. This interval may be shortened to 1–2 years when high-risk factors coexist, such as family history of gastric cancer in a first-degree relative, incomplete intestinal metaplasia, OLGIM/OLGA stage III–IV, autoimmune gastritis or pernicious anaemia, or persistent H. pylori infection.
Management of dysplasia — general principles
The presence of dysplasia always requires a differentiated and specialist approach. Histology should be confirmed, ideally by a pathologist experienced in gastrointestinal pathology, and high-definition endoscopy should be performed in a reference centre, using NBI or chromoendoscopy and targeted biopsies. The main objective is to identify a visible lesion, as this directly guides curative endoscopic treatment.
Low-grade dysplasia without a visible lesion
In low-grade dysplasia, if no visible lesion is identified after specialist endoscopic assessment and histology is confirmed, endoscopic surveillance with repeat upper gastrointestinal endoscopy after 12 months may be appropriate. This strategy allows detection of progression or emergence of a treatable lesion, while avoiding excessive intervention at early stages.
High-grade dysplasia without a visible lesion
High-grade dysplasia is associated with a high risk of synchronous carcinoma. Even in the absence of an initially visible lesion, early endoscopic reassessment is indicated, typically within a short interval (≤3 months), with a proactive approach to identifying suspicious areas and a low threshold for diagnostic or therapeutic endoscopic resection.
Visible lesion associated with dysplasia
Whenever a visible lesion is identified, the preferred strategy is endoscopic resection by EMR or ESD, depending on lesion characteristics and centre expertise. Resection allows not only potentially curative treatment, but also complete histological staging, which is essential to guide follow-up.
Follow-up after endoscopic resection
Follow-up after resection should be individualized, taking into account lesion type, margin status (R0 vs R1) and the risk of metachronous lesions. Endoscopic surveillance is an integral part of secondary prevention and should be adapted to the patient’s overall risk profile.
Long-term maintenance and prevention
Management of premalignant gastric lesions should integrate long-term prevention measures, including confirmed eradication of H. pylori, smoking cessation and risk-adjusted endoscopic surveillance. A structured and consistent approach makes it possible to focus resources on patients most likely to progress, reduce clinical variability and align daily practice with current European recommendations.
