Clinical Efficacy of Endoscopic Ultrasound-Guided Gastroenterostomy, Enteral Stenting, and Surgical Gastrojejunostomy for Malignant Gastric Outlet Obstruction: A Network Meta-Analysis.

Evaluate with high-quality upper endoscopy: adequate mucosal cleansing and insufflation, high-definition white light endoscopy with image-enhanced endoscopy, and photodocumentation of anatomic landmarks. Take systematic biopsies per the updated Sydney protocol in at least two separate containers (antrum/incisura and corpus), with any targeted biopsies of mucosal abnormalities in additional separate containers; histology must report gastric intestinal metaplasia subtype (incomplete, complete, or mixed) and the severity and extent of atrophic gastritis and metaplasia, because subtype and extent are what drive risk stratification. ACG suggests surveillance endoscopy every 3 years for patients at high risk of progression, that is, patients whose GIM or atrophic gastritis carries at least one higher-risk feature: incomplete or mixed intestinal metaplasia subtype, extensive metaplasia/atrophy involving the corpus in addition to the antrum/incisura (advanced-stage disease, OLGA/OLGIM III/IV), a first-degree relative with gastric cancer, or membership in a high gastric-cancer-incidence population (high-risk race/ethnicity, or birth in or immigration from a high-incidence region), with the explicit qualifier that the interval may be individualized; patients with advanced-stage disease (OLGA/OLGIM III/IV) plus a first-degree relative with gastric cancer may warrant more intensive follow-up every 1-2 years. ACG suggests AGAINST endoscopic surveillance for low-risk GIM or atrophy (limited antral, complete-subtype metaplasia without additional risk factors), and recommends against routine endoscopic screening of the general US population; it found insufficient direct evidence from US populations to recommend screening on the basis of immigration status, race, or ethnicity alone. ACG strongly recommends testing for H. pylori by non-serologic methods with eradication if positive in all patients with gastric premalignant conditions and in patients with resected early gastric cancer, and recommends confirmation of eradication (strong recommendation, moderate-quality evidence). For dysplasia: endoscopic resection is suggested when the lesion has visible margins; if dysplasia is not endoscopically visible, repeat endoscopy with HDWLE and image-enhanced endoscopy by an experienced endoscopist; patients appropriate for endoscopic resection, particularly ESD, should be referred to a high-volume center with expertise in diagnosis and therapeutic resection of gastric neoplasia (strong recommendation). Individualized surveillance may be considered in autoimmune gastritis given increased neuroendocrine tumor and possible gastric cancer risk. Patients whose family history suggests a hereditary cancer syndrome should be referred for genetic counseling, with endoscopic screening individualized according to syndrome-specific guidelines and patient preference, ACG explicitly defers rather than specifying CDH1 or Lynch protocols itself.