Table 1 Recommendations for the guideline
From: Chinese integrated guideline on the management of gastric precancerous conditions and lesions
Section | Item | Statement | Evidence level | Recommendation | Agreement |
|---|---|---|---|---|---|
Definition and epidemiology | Epidemiology | S1. The prevalence rate of chronic atrophic gastritis in China is relatively high and increases with age | Moderate | Strong | 100% |
S2. The occurrence of chronic atrophic gastritis is closely related to H. pylori infection | High | Strong | 100% | ||
S3. The sensitivity of white light endoscopy in diagnosing atrophic gastritis is poor, and the coincidence rate with the pathological diagnosis is low | Moderate | Weak | 96.4% | ||
Syndrome distribution of gastric precancerous lesions | S4. There is a lack of consolidated standards of gastric precancerous lesions for syndrome differentiation | Low | Weak | 92.7% | |
Diagnosis and grading | Endoscopy diagnosis | S5. The application of defoaming agents and mucolytic agents can improve the visibility of gastric mucosa, which is helpful for detecting gastric mucosal lesions | High | Strong | 100% |
S6. When gastric peristalsis severely affects the observation, proper antispasmodic treatment can improve the visual field of observation and facilitate the detection of lesions | Low | Strong | 100% | ||
S7. Intraoperative sedatives are recommended for patients with severe anxiety | Low | Strong | 98.2% | ||
S8. Conventional white-light endoscopy could be used for PLGC screening. High-definition conventional chromoendoscopy, virtual chromoendoscopy and magnifying endoscopy should be used for the diagnosis of patients who are at high risk for gastric carcinoma | High | Strong | 100% | ||
S9. The evaluation and diagnosis of H. pylori infection status should be included in endoscopic examinations | Moderate | Strong | 100% | ||
Biopsy | S10. An adequate number, depth and size of biopsy samples are essential for the accurate diagnosis and evaluation of PLGC | Low | Strong | 100% | |
S11. Targeting biopsy of suspicious lesions is conducive to the evaluation of curative effects and follow-up monitoring | Low | Strong | 100% | ||
S12. Additional biopsies are required for visible lesions and suspected neoplastic lesions under endoscopy | Low | Strong | 100% | ||
Pathological diagnosis and evaluation | S13. Standardizing the protocol of biopsy specimen processing will help improve the accuracy of pathological diagnosis | Low | Strong | 100% | |
S14.Subtyping incomplete intestinal metaplasia has clinical significance | Low | Strong | 98.2% | ||
S15. Gastric dysplasia needs to be differentiated from reactive hyperplasia | Low | Strong | 98.2% | ||
Mucosa Syndrome Differentiation under Gastroscopy | S16. Mucosal syndrome differentiation under gastroscopy is an extension of inspection in traditional Chinese medicine. It focuses on discriminating gastric mucosal lesions. It is an important reference for the overall syndrome differentiation of traditional Chinese medicine and an objective basis for guiding local treatment | Low | Weak | 92.7% | |
Monitoring | Dysplasia | S17. Patients with dysplasia found on random biopsy should be re-evaluated by high-definition virtual or dyeing chromoendoscopy. If no visible lesions are found in the re-evaluation, the patient should be monitored once again by high-definition virtual or dyeing chromoendoscopy, with an interval of 6–12 months | Low | Strong | 100% |
S18. Screening and monitoring of dysplasia under endoscopy should be given great attention | Moderate | Strong | 100% | ||
S19. Patients with uncertain dysplasia diagnosed by non-targeted biopsy can benefit from reevaluation with endoscopic examination | Moderate | Strong | 100% | ||
S20. In patients with high-grade dysplasia, immediate high-quality endoscopic reassessment with Chromoendoscopy (virtual or dye-based) is recommended to determine whether endoscopic or surgical treatment should be performed | Moderate | Strong | 98.18% | ||
CAG and IM | S21. Patients with high-risk atrophic gastritis should be followed up with high-quality endoscopy or white-light endoscopy combined with biopsy every year, especially those with a family history of gastric cancer, who need more intensive follow-up | Low | Weak | 100% | |
S22. Patients with low-risk atrophic gastritis should be followed up with endoscopy every 3 years, and those with a family history of gastric cancer should be followed up every 1–2 years | Low | Weak | 98.2% | ||
Autoimmune gastritis | S23. Patients with autoimmune gastritis may benefit from endoscopic follow-up every 3Â years | Low | Weak | 96.36% | |
Noninvasive screening method | S24. PGI, PGI/II (PGR), G-17 and H. pylori -IgG can be used to screen CAG patients at high-risk of gastric cancer from general population | High | Strong | 100% | |
S25. Histological and serological MG7 testing can be used to assist in the screening of groups at high-risk of gastric cancer | Moderate | Strong | 90.91% | ||
Risk monitoring of precancerous lesions of gastric cancer by combining disease and syndrome | S26. In carrying out risk monitoring and management with integrated traditional Chinese and Western medicine, in addition to serology, the Kimura-Takemoto classification, OLGA/OLGIM risk assessment, and TCM syndromes can be included | Low | Weak | 94.55% | |
Treatment | Orientation of intervention | S27. Atrophy, intestinal metaplasia and obvious active inflammation can be treated by eradicating H. pylori (if positive) and the short-term use of proton pump inhibitors (PPIs) or gastro-protecting agents | Low | Strong | 100% |
S28. Chronic atrophic gastritis of the operative link on gastric atrophy (OLGA) and operative link on gastric intestinal metaplasia (OLGIM) stages III/IV are targets of internal medicine interventions | Moderate | Strong | 98.2% | ||
S29. Medical intervention is required for low-grade dysplasia, and endoscopy treatment is required for high-grade dysplasia and some low-grade dysplasia with visible lesions | Moderate | Strong | 98.18% | ||
S30. Surveillance and interventions should be included for indefinite for neoplasm/dysplasia lesions, and pathological consultation can be conducted. A biopsy can be repeated, if necessary, to confirm the diagnosis | Moderate | Strong | 98.2% | ||
S31. Patients with HGD or early gastric cancer can be treated with a combination of Chinese and Western medicine after endoscopic treatment | Moderate | Strong | 100% | ||
Eliminating the risk factors | S32. There is no definite evidence that PPIs can induce or aggravate gastric precancerous lesions such as atrophic gastritis or intestinal metaplasia, but the long-term use of PPI preparations is not recommended in clinical practice | Low | Strong | 100% | |
S33. A high-salt diet is a risk factor for gastric precancerous lesions. Patients with gastric precancerous lesions should avoid high-salt and pickled foods | Moderate | Strong | 100% | ||
S34. A history of long-term smoking significantly increases the risk of the occurrence and progression of gastric precancerous lesions. Patients with gastric precancerous lesions should quit smoking | High | Strong | 100% | ||
S35. Bile reflux is a risk factor for intestinal metaplasia, and interventions targeting bile reflux may be beneficial to block the occurrence and progression of gastric precancerous lesions | High | Strong | 98.2% | ||
Eradication of H. pylori | S36. The eradication of H. pylori can prevent or slow down the occurrence and progression of atrophic gastritis, thus reducing the risk of gastric cancer | High | Strong | 100% | |
S37. The eradication of H. pylori in patients with gastric mucosa atrophy and intestinal metaplasia can reduce the risk of gastric cancer to varying degrees, but regular follow-up should be performed | High | Strong | 100% | ||
S38. H. pylori eradication therapy after endoscopic treatment of early gastric cancer or high-grade dysplasia can effectively prevent metachronous gastric cancer | High | Strong | 100% | ||
S39. Some Chinese patent medicines can be used in the treatment of H. pylori | Low | Weak | 92.7% | ||
Folic acid, antioxidant vitamins | S40. Folic acid, antioxidant vitamins, etc. may delay the process of atrophic gastritis in some people, thus reducing the risk of gastric cancer | High | Strong | 100% | |
S41.The combination of antioxidant vitamins and H. pylori eradication therapy can delay or even block the occurrence and progression of gastric precancerous lesions, thereby reducing the risk of cancer | Moderate | Strong | 96.4% | ||
Treatment by integrated traditional Chinese and Western medicine | S42.Traditional Chinese medicine has certain efficacy in treating gastric precancerous lesions, and integrated traditional and western medicine has advantages | Moderate | Strong | 94.55% | |
Efficacy evaluation | Research design | S43. Strict research designs, procedure quality control, and standardized report are important prerequisites for improving the level of evidence in intervention studies for gastric precancerous lesions | High | Strong | 98.2% |
S44.The clinical intervention research process of precancerous lesions of gastric cancer should generally not be less than 6Â months, followed by no less than 6Â months of follow-up | Low | Strong | 96.4% | ||
Positioning and goals of medical interventions | S45. The intervention of chronic atrophic gastritis should be aimed at gastric body or total gastric atrophy and/or intestinal metaplasia to promote the regression of the disease and reduce the risk of gastric cancer. Medical interventions for gastric precancerous lesions should target uncertain dysplasia and low-grade dysplasia, with the goal of promoting the reversal of the disease | Moderate | Strong | 96.4% | |
Key technologies | S46.The efficacy of the evaluation of dysplasia needs to be accurate and to be focused. Targeted monitoring based on MTB technology can help to improve the consistency of biopsy sites before and after treatment | Low | Strong | 96.4% | |
Efficacy evaluation methods | S47. The efficacy of the evaluation of gastric precancerous lesions should be based on histopathology, supplemented by a comprehensive evaluation of gastroscopy, symptoms, and quality of life | Low | Strong | 98.2% | |
Histological semiquantitative evaluation of dysplasia | S48. The histological semiquantitative evaluation of gastric mucosal dysplasia can be carried out from the microscopic level of cell structure atypia and gland disorders to refine the efficacy evaluation research | Low | Weak | 87.3% |