# Stomach Precancer and Helicobacter pylori: New Asia-Pacific Expert Recommendations for Endoscopic Surveillance

Stomach cancer remains a major health challenge in Asia, and this new Asia-Pacific guideline—created by an international task force of experts—offers the first unified regional recommendations for finding, tracking, and managing the precancerous stomach conditions that precede it. The guideline focuses on conditions triggered by long-term *Helicobacter pylori* infection and distills a systematic review of the evidence into 28 practical consensus statements. For patients, the key message is reassuring: mild precancerous changes may not require any special surveillance, while high-risk changes call for a careful endoscopic check every two years. The recommendations emphasize high-quality endoscopy, standardized biopsy protocols, and risk-based follow-up tailored to each individual patient's findings.

# Stomach Precancer and *Helicobacter pylori*: New Asia-Pacific Expert Recommendations for Endoscopic Surveillance

## Table of Contents

- Key Points
- Why This Research Matters: Stomach Cancer in Asia
- About the New Asia-Pacific Guideline: Who Made It and How
- Epidemiology — Key Findings on Who Develops These Conditions
- Diagnosis — How Doctors Endoscopically Identify Precancerous Change
- Surveillance Intervals and Management: What the Experts Recommend
- Clinical Implications: What This Means for Patients
- Limitations: What This Guideline Could Not Fully Answer
- Recommendations: What Patients Should Do
- Frequently Asked Questions
- Source Information

## Key Points

- Mild precancerous stomach changes (OLGA/OLGIM stage I) may not require routine surveillance if no other risk factors exist.
- High-risk changes (OLGA/OLGIM stages III–IV) warrant endoscopic surveillance every two years, according to the new guideline.
- Stomach cancer risk for chronic atrophic gastritis is about 1–2 per 1,000 people yearly; for intestinal metaplasia, about 3 per 1,000.
- High-quality endoscopy with at least 7 minutes of inspection time improves detection of precancerous changes and lesions.
- H. pylori eradication is foundational, but diet, smoking, and genetics also influence progression to stomach cancer.

## Why This Research Matters: Stomach Cancer in Asia

Stomach (gastric) cancer is the fifth most common cancer in the world and the fourth leading cause of cancer-related death. According to the latest GLOBOCAN 2022 data cited in the guideline, there were **968,784 new cases** and **659,853 deaths** globally in a single year.

The burden is not shared equally around the globe. More than **70% of new cases and deaths** occur in the Asia-Pacific region. The highest rates are found in East Asia—particularly in **China, Japan, and Korea**—where *Helicobacter pylori* infection has long been widespread.

Early-stage stomach cancer usually causes no symptoms at all. That is why detection and treatment at an early stage matter so much: when the cancer is caught early, **5-year survival rates exceed 90%**. Modern gastrointestinal endoscopy—including high-definition scopes and image-enhanced techniques—has become the most direct and widely used tool for early detection, and it also allows doctors to spot precancerous changes before cancer ever develops.

Those precancerous changes are common. In a recent meta-analysis (a statistical combination of many studies), the global prevalence was estimated at **25.4% for chronic atrophic gastritis** (thinning and loss of glands in the stomach lining), **16.2% for gastric intestinal metaplasia** (stomach cells transforming into intestine-like cells), and **2.0% for dysplasia** (abnormal, precancerous cells). Rates were generally higher in countries with medium-to-high stomach cancer incidence and among people infected with *H. pylori*.

Until now, no unified regional guideline existed for the Asia-Pacific—even though the region carries most of the world's stomach cancer burden. Individual countries such as Japan, China, and Korea have their own guidance, and European and North American societies have published separate recommendations. But the experts behind this task force identified a pressing need for a single, evidence-based regional framework. They were commissioned by the **Asian Pacific Association of Gastroenterology (APAGE)** to fill that gap.

## About the New Asia-Pacific Guideline: Who Made It and How

The task force was formed in January 2024. Its members included **18 gastroenterologists, endoscopists, pathologists, and epidemiologists from nine Asia-Pacific countries and regions**, selected based on local stomach cancer rates and individual expertise. Two international experts from Europe and North America were also invited to comment and vote on the draft statements.

The process was rigorous and transparent. Researchers conducted a systematic literature review across multiple medical databases—including **PubMed, the Cochrane Library, and Embase**—focusing on studies related to gastric premalignant conditions and their surveillance, with special attention to research from Asia. They also manually checked the reference lists of identified studies and relevant systematic reviews to ensure nothing important was missed.

To judge the quality of the evidence, the task force used the **GRADE system** (Grading of Recommendations Assessment, Development and Evaluation), the international standard for evaluating evidence quality and recommendation strength. Each recommendation was rated as either **strong** or **conditional (weak)**, based on factors including the quality of the evidence, how closely the study populations matched the target population, the extent of clinical benefit, and cost considerations.

The experts organized their work into four subgroups covering four key areas:

1. Epidemiology of gastric premalignant conditions and neoplastic lesions
1. Histopathological (tissue-based) and endoscopic diagnosis
1. Risk stratification for endoscopic surveillance
1. Management of gastric premalignant conditions

They used a modified **Delphi process**—a structured method for building expert agreement. The first round of anonymous voting happened online in early November 2024. Experts voted on a five-point scale from "strongly agree" to "strongly disagree." Consensus was defined as at least **80% agreement** (strongly agree plus agree). After the first round, the group met face-to-face in November 2024 in Bali, Indonesia, during the Asia-Pacific Digestive Week to discuss the statements and provide feedback. Two further rounds of online voting followed in December 2024 and January 2025, after incorporating members' suggestions. In the end, all 28 statements achieved consensus.

It is worth noting what this guideline does *not* cover. The recommendations focus specifically on premalignant conditions arising through the *H. pylori*-associated "Correa cascade"—chronic atrophic gastritis, intestinal metaplasia, and dysplasia. They do not address hereditary stomach cancer syndromes, cancers arising in stomachs never infected with *H. pylori*, gastric polyps, or autoimmune gastritis, because those conditions have distinct causes and require different diagnostic, surveillance, and management strategies covered in other dedicated guidelines.

## Epidemiology — Key Findings on Who Develops These Conditions

This section of the guideline contains six consensus statements summarizing what is known about how common these conditions are, who is at highest risk, and what causes them.

### Finding 1: The Definition — What Are "Gastric Premalignant Conditions"?

The term refers to **mucosal environments marked by chronic inflammation** that produce specific changes in the stomach lining and raise the long-term risk of stomach cancer. The experts note an important distinction between "conditions" and "lesions." Premalignant *conditions* typically require monitoring and surveillance only. Neoplastic *lesions*, by contrast, are endoscopically visible, discrete abnormalities—either dysplastic lesions or early stomach cancer—that require endoscopic or surgical removal.

The Correa cascade explains how these conditions evolve. It describes a stepwise process starting with chronic non-atrophic gastritis (simple long-term inflammation), then progressing through chronic atrophic gastritis, intestinal metaplasia, and dysplasia, and potentially culminating in stomach adenocarcinoma (cancer). Importantly, having a premalignant condition does not mean cancer is immediate or inevitable—it means the tissue environment is predisposed to carcinogenesis, and the risk builds gradually over time.

Specifically, **chronic atrophic gastritis (CAG)** involves the loss of gastric glandular cells, replaced by fibrosis (scar tissue) or intestine-type cells. **Gastric intestinal metaplasia (GIM)** is the transformation of stomach lining cells into structures resembling the small intestine (complete type) or colon (incomplete type), marked by the appearance of goblet and absorptive cells. When GIM is widespread—for example, involving the fundus and body of the stomach—it carries a higher risk of malignant transformation than localized GIM. Incomplete-type GIM indicates a further increased risk. Recent evidence suggests certain subsets of GIM may act as direct precursors of stomach cancer, although whether adenocarcinoma mainly develops from GIM remains debated. This statement was rated **low quality evidence**, with 80% of experts strongly agreeing and 20% agreeing.

### Finding 2: Who Is at Highest Risk?

Patients with **advanced chronic atrophic gastritis (OLGA stages III–IV)**, **advanced intestinal metaplasia (OLGIM stages III–IV or incomplete-type)**, and **gastric dysplasia** face a clearly increased risk of developing stomach cancer. This statement earned a **high quality of evidence** rating, with 85% of experts strongly agreeing and 15% agreeing.

How big is the risk in absolute terms? Overall, the incidence of stomach cancer in patients with CAG and GIM is relatively low. One pooled analysis reported:

-
**1.24 cases per 1,000 person-years for CAG** (95% CI 0.80 to 1.76). In practical terms, if 1,000 people with CAG are followed for one year, about 1 to 2 will develop stomach cancer.
-
**3.38 cases per 1,000 person-years for GIM** (95% CI 2.13 to 4.85). That means roughly 3 to 5 cases per 1,000 people each year—about 0.3%.

A 12-year follow-up study by Rugge and colleagues showed that **high-risk CAG (OLGA stages III–IV)** was consistently associated with invasive or intra-epithelial gastric neoplasia, while mild atrophy (OLGA stages I–II) carried a lower risk. The staging systems referenced here are important tools:

-
**OLGA** (Operative Link on Gastritis Assessment) stages atrophy based on biopsy findings.
-
**OLGIM** (Operative Link on Gastric Intestinal Metaplasia) stages intestinal metaplasia specifically.

A prospective, multicenter cohort study from Singapore found that participants with **OLGIM stages III–IV** were at the highest risk of developing early gastric neoplasia, with an **adjusted hazard ratio of 20.7** (95% CI 5.04 to 85.60). In plain language, these patients were about **20 times more likely** to develop early stomach neoplasia than those with lower stages—a striking increase. Another meta-analysis by Akbari and colleagues found that incomplete-type GIM was associated with a higher estimated stomach cancer incidence rate of **6.60 per 1,000 person-years** (95% CI 2.73 to 11.75), compared with **3.24 per 1,000 person-years** for complete-type GIM (95% CI 0.12 to 9.01).

### Finding 3: How Common Are These Conditions Across Asia?

The prevalence of CAG and GIM varies widely across Asian countries and populations, with **CAG generally more common than GIM**. This statement was rated **moderate quality evidence**, with 60% strongly agreeing, 35% agreeing, and 5% neutral.

Reported rates in the literature typically range from **10% to 30% for CAG** and from **8% to 25% for GIM**. However, these figures should be interpreted cautiously due to potential sampling bias and variability in study methods. Most existing data come from small-scale, hospital-based, or regional studies using heterogeneous diagnostic criteria and age groups. In broad terms, **Southern Asia has a higher CAG prevalence**, while **Eastern Asia has a higher GIM prevalence**. Data from Oceania countries remain sparse, and the experts agreed that providing a single Asia-Pacific prevalence rate is simply not possible given these uncertainties.

### Finding 4: Is the Problem Getting Better or Worse?

The good news: the prevalence of CAG and GIM in Asia is **declining overall**, though the rate of decline varies. This statement was rated **moderate quality evidence**, with 65% strongly agreeing, 25% agreeing, and 10% neutral.

The decline likely results from improved public health, socioeconomic development, and reduced *H. pylori* infection in younger birth cohorts. A pooled analysis showed that **GIM prevalence fell from 30% (1991–2000) to 21.1% (2011–2022)**, with little change in CAG. The improvement was most evident in high-income countries with better healthcare systems, widespread screening, and national screening programs—notably **Japan and South Korea**.

There is a caveat, however: higher endoscopy rates in these countries may also lead to increased detection, inflating apparent prevalence. Meanwhile, data from low-resource countries remain limited, and true prevalence there may be underestimated due to diagnostic constraints.

### Finding 5: The Central Role of *Helicobacter pylori*

There is usually a **strong positive correlation between *H. pylori* infection and gastric premalignant conditions in Asia**, though exceptions exist in some regions—exceptions that may be modulated by host, bacterial, and environmental factors. This statement rated **high quality evidence**, with 65% strongly agreeing, 30% agreeing, and 5% neutral.

*H. pylori* is classified as a **Group 1 carcinogen** (a definite cause of cancer in humans) by the International Agency for Research on Cancer. A previous meta-analysis in Asian populations found that *H. pylori* infection was associated with an **odds ratio of 2.16 for CAG** (95% CI 2.09 to 2.22) and **1.64 for GIM** (95% CI 1.57 to 1.72). East Asian countries such as China, Japan, and South Korea have a higher prevalence of CAG/GIM than other Asian countries.

Yet there are fascinating exceptions. The "Asian enigma" and "Indian enigma" refer to regions where *H. pylori* prevalence is high but stomach cancer rates are low. These paradoxes suggest that other factors—such as differences in *H. pylori* virulence strains, host genetic polymorphisms, and dietary habits—may mitigate the risk of progression to malignancy.

### Finding 6: Risk Factors Beyond the Bacteria

Apart from *H. pylori* infection, **dietary habits, smoking, genetic factors, and lower socioeconomic status** are all associated with the development of gastric premalignant conditions. This statement rated **moderate quality evidence**, with 40% strongly agreeing, 55% agreeing, and 5% neutral—the lowest strongly-agree percentage of the epidemiology statements, reflecting some differences in expert opinion on how strongly these factors contribute.

Key evidence cited by the guideline includes:

-
**Diet:** The WHO's International Agency for Research on Cancer has classified diet-related factors—including high salt intake, pickled and preserved food, and smoked and grilled foods—as Group 1 carcinogens for stomach cancer. An endoscopy-based study in South Korea found that high salt intake was associated with CAG and GIM (**OR 2.87, 95% CI 1.34 to 6.14**). Deficiencies in fresh fruits and vegetables increase oxidative stress and diminish antioxidant defenses (such as flavonoids), contributing to chronic inflammation and mucosal damage.
-
**Smoking:** Cigarette smoke is rich in free radicals and reactive oxygen species that penetrate the gastric epithelium and induce oxidative stress. Nicotine also causes vasoconstriction, reducing blood flow to the gastric mucosa, impairing nutrient delivery, and diminishing mucosal healing capacity.
-
**Genetics:** Polymorphisms (naturally occurring genetic variations) in genes associated with inflammatory and immune responses—such as **TNF-α, IL-22, and IL-1B**—correlate with heightened susceptibility to premalignant conditions.
-
**Socioeconomic status:** A US population-based study found that CAG and GIM prevalence decreased significantly with higher income or college education. In a Chinese population, individuals with lower educational attainment or socioeconomic status were at higher risk of developing both premalignant conditions and stomach cancer.

## Diagnosis — How Doctors Endoscopically Identify Precancerous Change

Part 2 of the guideline addresses how these conditions should be diagnosed, beginning with two statements on endoscopy technique. The endoscopic appearance of CAG and GIM can be subtle and inconspicuous, which is why systematic, high-quality examination is essential.

### Recommendation 1: Maximize Visualization and Inspection Time

APAGE recommends implementing measures to ensure **optimal mucosal visualization, adequate inspection time, and adequate photographic documentation** during endoscopic examination of the stomach. This recommendation was rated **moderate quality evidence with a strong recommendation strength**, approved by 85% strongly agreeing and 15% agreeing.

What does a high-quality examination involve in practice?

-
**Clear the view:** Endoscopists should aspirate luminal contents and adequately inflate the stomach to expand mucosal folds. Pre-procedure use or irrigation with mucolytic agents—such as **simethicone, 1% N-acetylcysteine, and proteolytic enzymes (pronase)**—may improve mucosal visualization compared with water irrigation alone. However, theoretical concerns about aspiration during the procedure may limit routine adoption of this practice.
-
**Take enough time:** Longer inspection time is strongly associated with increased detection of gastric lesions. In a retrospective cohort study of **837 Singaporean patients**, an inspection time of more than 7 minutes was associated with increased detection of CAG and GIM (**OR 2.5, 95% CI 1.52 to 4.12**). In a large Japanese retrospective cohort of **55,786 patients**, inspection time over 7 minutes was also associated with increased detection of gastric neoplastic lesions; compared with the fast group, the odds ratios for detecting neoplastic lesions were **1.90 (95% CI 1.06 to 3.40)** in the moderate group and **1.89 (95% CI 0.98 to 3.64)** in the slow group.
-
**Follow the 7-minute rule:** Both the American Gastroenterological Association (AGA) and the European Society of Gastrointestinal Endoscopy (ESGE) recommend that the total inspection time for upper endoscopy be **at least 7 minutes**.
-
**Standardize training:** The task force advocates standardized training programs to ensure endoscopists are adequately equipped to visually identify gastric premalignant conditions and neoplastic lesions.

### Recommendation 2: Use High-Definition White Light Endoscopy Systematically

APAGE recommends using **high-definition white light endoscopy** to systematically evaluate the whole gastric mucosa and avoid blind spots. This recommendation was rated **low quality evidence but strong recommendation strength**, with 70% strongly agreeing and 30% agreeing.

The concern is real: a systematic review reported that the rate of **missed gastric cancer during upper endoscopy was 9.4%** (95% CI 5.7 to 13.1%). Missed cancers were mainly located in the gastric body, presumably due to blind spots that were not examined or lesions that were not recognized despite being in the field of examination. The ESGE recommends precise photographic documentation encompassing at least one illustrative image of key anatomical landmarks, including the duodenum, major papilla, antrum, incisura, corpus, retroflexed view of the fundus, diaphragmatic indentation, the upper aspect of the gastric folds, the squamocolumnar junction, and the distal and proximal esophagus. The AGA and World Endoscopy Organization endorse similar systematic approaches.

What should the endoscopist look for? The guideline describes recognizable visual patterns through the endoscope:

-
**Normal stomach:** Gastric folds are straight and preserved circumferentially, with regular arrangement of collecting venules along the lesser curvature of the corpus.
-
**Chronic atrophic gastritis:** The atrophic mucosa appears as loss of gastric folds, pale color, and increased visibility of blood vessels, typically seen in the corpus along the lesser curvature.
-
**Intestinal metaplasia:** Areas of metaplasia appear as slightly whitish regions against the normal pink mucosa.

These visual findings, combined with a standardized biopsy protocol and proper pathological reporting, allow accurate risk stratification.

## Surveillance Intervals and Management: What the Experts Recommend

The full guideline contains 28 consensus statements. Parts 3 and 4—covering risk-based surveillance intervals and management strategies—were summarized in the guideline's key findings and represent the practical "bottom line" for patients.

Two recommendations stand out as most relevant to everyday clinical care:

-
**For most individuals with mild changes**—specifically, OLGA or OLGIM stage I—and in the absence of other risk factors, **surveillance is not mandatory**. These patients can generally be reassured and may not need repeated endoscopic checks.
-
**For the highest-risk patients**—those with OLGA or OLGIM stages III–IV—the experts suggest **biennial (every 2 years) endoscopic surveillance** as a standard recommendation.

This risk-stratified approach represents a significant step forward. The guideline offers a comprehensive, evidence-based framework designed to assist clinicians across the Asia-Pacific region in early detection and management—particularly valuable in Asian countries that lack nationwide stomach cancer screening programs. It also standardizes the approach to endoscopic diagnosis and surveillance in a region where practices have previously varied widely from country to country and even hospital to hospital.

## Clinical Implications: What This Means for Patients

For patients, the most important takeaways from this guideline are practical and actionable.

**First, a diagnosis of a premalignant condition is not a cancer diagnosis.** Though the progression rates sound concerning at first glance—roughly 2 per 1,000 people per year for chronic atrophic gastritis and about 3 per 1,000 per year for intestinal metaplasia—most people with these conditions will never develop stomach cancer. The numbers may feel abstract, so consider them this way: even among patients with intestinal metaplasia, well over 99% in any given year do not progress to cancer. The purpose of surveillance is to catch the small minority who do progress, at a stage when intervention is highly effective.

**Second, risk is not uniform—and your surveillance plan should reflect your personal risk.** The OLGA and OLGIM staging systems are the key to this individualized approach. A patient with mild changes (stage I) and no other risk factors may not need routine surveillance at all, saving them from unnecessary procedures. A patient with advanced changes (stages III–IV) or incomplete-type metaplasia faces a substantially higher risk—up to 20 times higher in the Singapore study—and should have endoscopic checks every two years.

**Third, the quality of the endoscopy matters enormously.** The recommendation that upper endoscopy should take at least 7 minutes of inspection time is not arbitrary—it is grounded in data showing that longer inspection finds more lesions. Patients should feel empowered to ask whether their endoscopist follows systematic examination protocols, including photographic documentation of key landmarks.

**Fourth, eradicating *H. pylori* is foundational, but not the whole story.** While the bacterium is the main driver of the Correa cascade, diet, smoking, and genetics also contribute. Addressing these modifiable risk factors—reducing salt intake, eating fresh fruits and vegetables, and stopping smoking—complements any endoscopic surveillance plan.

## Limitations: What This Guideline Could Not Fully Answer

Like all medical guidelines, this one has important limitations that patients and clinicians should understand.

**The evidence base is uneven.** Quality ratings for the statements ranged from high to low. The epidemiology statements on high-risk groups and *H. pylori* correlation were supported by high-quality evidence, while the statement on endoscopic technique using high-definition white light was rated low quality—even though it received a strong recommendation because the experts judged the benefits clear and the harms minimal.

**Data gaps persist, especially in lower-resource settings.** Prevalence data from Oceania and many low-income Asian countries remain sparse, and true rates may be underestimated due to diagnostic constraints. Most existing prevalence data come from small-scale, hospital-based studies using heterogeneous diagnostic criteria and age groups, making it challenging to provide precise regional estimates.

**The "enigma" populations remain unexplained.** The guideline acknowledges that regions with high *H. pylori* prevalence can have low stomach cancer rates, suggesting that bacterial strain differences, host genetics, and diet interact in ways that are not yet fully understood. This means the risk associated with *H. pylori* infection is not the same everywhere.

**The guideline's scope is deliberately narrow.** It does not address hereditary cancer syndromes, *H. pylori*-negative gastric cancers, gastric polyps, or autoimmune gastritis—conditions that require distinct diagnostic and management approaches. Patients with those conditions should not assume this surveillance framework applies to them.

**Finally, this is a guideline, not a rule.** Individual patient circumstances—age, family history, other medical conditions, and personal preferences—may justify different surveillance intervals than those suggested. Shared decision-making between patient and physician remains essential.

## Recommendations: What Patients Should Do

Based on this expert guideline, patients can take several concrete steps:

1.
**Know your *H. pylori* status.** If you have never been tested for this bacterial infection, ask your doctor whether testing and eradication treatment are appropriate for you, particularly if you were born or lived in a high-prevalence region of Asia.
1.
**Ask about your OLGA or OLGIM stage if you have had a biopsy.** These staging systems determine your personal risk level and your recommended surveillance interval. If your biopsy report does not mention them, ask your doctor or a pathologist to clarify the findings.
1.
**Follow your recommended surveillance schedule.** If you have mild changes (stage I) with no other risk factors, the guideline says surveillance is not mandatory—but stay alert to new symptoms. If you have advanced changes (stages III–IV), plan for endoscopic surveillance every two years and do not delay appointments.
1.
**Choose your endoscopist wisely.** Ask about high-definition equipment, systematic examination protocols, and whether the procedure will include adequate inspection time (at least 7 minutes). A thorough examination is the single most important factor in not missing clinically significant lesions.
1.
**Address modifiable risk factors.** Reduce dietary salt and avoid pickled, preserved, smoked, and grilled foods. Eat plenty of fresh fruits and vegetables. If you smoke, seek help to quit—the evidence linking smoking to precancerous gastric changes is clear.
1.
**Understand that a premalignant condition is manageable.** The vast majority of people with CAG or GIM never develop stomach cancer. Surveillance exists precisely to catch progression early, when treatment can achieve survival rates above 90%. Knowledge of your condition puts you in a position of power, not vulnerability.

## Frequently Asked Questions

### I was told I have chronic atrophic gastritis. Does that mean I will get stomach cancer?

No. It means your stomach lining has changes that increase risk over time, not that cancer is certain or immediate. Among 1,000 people with chronic atrophic gastritis, about 1 to 2 develop stomach cancer in one year. Most people with this condition never develop stomach cancer.

### What is the OLGA or OLGIM stage on my biopsy report, and why does it matter?

OLGA stages atrophy and OLGIM stages intestinal metaplasia based on biopsy findings. Stage I is mild, and surveillance is not mandatory if you have no other risk factors. Stages III–IV are high-risk, and experts suggest endoscopic surveillance every two years. Ask your doctor to clarify your stage.

### How often should I have an endoscopy if I have high-risk stomach changes?

If your biopsy shows advanced changes — OLGA or OLGIM stages III–IV — the guideline recommends endoscopic surveillance every two years. This biennial check is intended to catch any progression early. If you have mild stage I changes and no other risk factors, routine surveillance is not mandatory.

### Does treating H. pylori infection eliminate my risk of stomach cancer?

No, but eradicating H. pylori is foundational. This bacterium is the main driver of the precancerous cascade. However, diet, smoking, and genetics also contribute. To complement surveillance, reduce salt, eat fresh fruits and vegetables, stop smoking, and follow your doctor's recommendations.

### What lifestyle changes should I make if I have precancerous stomach changes?

Reduce dietary salt and avoid pickled, preserved, smoked, and grilled foods. Eat plenty of fresh fruits and vegetables. If you smoke, seek help to quit, because smoking is clearly linked to precancerous gastric changes. These steps complement any endoscopic surveillance plan your doctor recommends.

### Should I get a second opinion after being diagnosed with stomach precancer (atrophic gastritis or intestinal metaplasia) to confirm my surveillance plan?

Consider seeking a second opinion if your biopsy report does not state an OLGA or OLGIM stage, since these stages determine whether endoscopic surveillance is needed. A second opinion can help confirm the diagnosis and clarify whether you are in the low-risk group (stage I, where surveillance is not mandatory) or the high-risk group (stages III–IV, where endoscopy every two years is recommended). Published guidance for H. pylori-associated precancer does not apply to hereditary cancer syndromes, autoimmune gastritis, gastric polyps, or H. pylori-negative cancers, so those conditions warrant different advice. Diagnostic Detectives Network provides independent expert second opinions.

## Source Information

**Original article title:** Asian Pacific Association of Gastroenterology task force recommendations on surveillance for <i>Helicobacter pylori</i> associated gastric premalignant conditions.

**Authors:** Leung WK, Ang TL, Shah S, Cheung KS, Li Y, Uedo N, Li WQ, Yeoh KG, Vilaichone RK, Lui TK, Quach DT, Wang LM, Choi IJ, Suzuki H, Jung HY, Dao HV, Wu K, Boussioutas A, Dinis-Ribeiro M, Lee YC.

**Publication:** *Gut*, 2025 (published online ahead of print). DOI: 10.1136/gutjnl-2025-335823. Published by BMJ Publishing Group under a CC BY-NC license (no commercial re-use permitted).

**Note:** This patient-friendly article is based on peer-reviewed research and was written to help patients and caregivers understand the key findings of the original guideline. It is not a substitute for personalized medical advice. Patients with questions about their own stomach health, *H. pylori* infection, or endoscopic surveillance should consult their healthcare provider.


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