Endoscopic risk factors to inform early detection of gastric cancer after Helicobacter pylori eradication: Meta-analysis and systematic review

Abstract

Objectives: Helicobacter pylori eradication reduces but cannot eliminate the risk of gastric cancer (GC). The prevalence of post-eradication GC has been rising. Characterization of the endoscopic findings of post-eradication GC may facilitate its early detection. We performed a meta-analysis and systematic review to clarify endoscopic risk factors to accelerate the early diagnosis of post-eradication GC.

Methods: Medline and PubMed were searched for randomized controlled trials, cohort studies, and case-control studies published in the English-language medical literature between January 1997 and July 2023. The included articles assessed the correlation between post-eradication GC and pre- and post-eradication endoscopic findings, and associated post-eradication GC with gastric atrophy, intestinal metaplasia (IM), map-like redness, and xanthoma.

Results: A total of 963 articles were retrieved. In these articles, 66 papers were finally included, comprising randomized controlled trials, cohort studies, and case-control studies. The included articles addressed gastric atrophy (16 studies), IM (eight studies), map-like redness (six studies), and xanthoma (two studies). Risk ratio (RR) of incident post-eradication GC was 3.40 (95%confidence interval [95%CI]: 1.98-5.84; p < 0.001) in cases of severe atrophy, 5.38 (95%CI: 3.62-8.00) in cases of severe IM, 2.34 (95%CI: 1.16-4.68) in cases with post-eradication map-like redness, and 2.75 (95% CI: 1.78-4.26) in cases with xanthoma.

Conclusions: Endoscopic atrophy, IM, and xanthoma observed at pre- and post-eradication time points and post-eradication map-like redness were suggested as endoscopic risk factors for post-eradication GC. Further studies are needed to clarify the risk of post-eradication GC based on these risk factors.

Keywords: Helicobacter pylori; atrophic gastritis; eradication; gastric cancer; intestinal metaplasia.

FIGURE 1

Flow diagram of search and study selection. Flow diagram of search and study selection according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines (PRISMA 2020 Checklist in Supporting information). The included articles addressed gastric atrophy (16 studies), intestinal metaplasia (eight studies), map‐like redness (six studies), and xanthoma (two studies).

FIGURE 2

Forest plot analyzing the occurrence of post‐eradication gastric cancer according to severity of gastric atrophy.

FIGURE 3

Forest plot analyzing the occurrence of post‐eradication gastric cancer according to the severity of gastric atrophy, Sub‐analysis with and without GC at baseline. (a) Forest plot of Atrophy without GC. (b) Forest plot of Atrophy with GC. GC: gastric cancer.

FIGURE 4

Forest plot analyzing the occurrence of post‐eradication gastric cancer according to severity of intestinal metaplasia. IM: intestinal metaplasia.

FIGURE 5

Forest plot analyzing the occurrence of post‐eradication gastric cancer according to post‐eradication onset of map‐like redness. (a) Forest plot analyzed using all articles. (b) Forest plot analyzed using selected two prospective cohort studies.

FIGURE 6

Forest plot analyzing the incidence of post‐eradication gastric cancer according to the appearance of xanthoma.

FIGURE 7

Funnel plots of atrophy analyzed. (a) Atrophy of all 16 articles, (b) atrophy of seven articles without gastric cancer (GC), and (c) atrophy of nine articles with GC.

FIGURE 8

Funnel plots of intestinal metaplasia, map‐like redness, and xanthoma analyzed. (a) Intestinal metaplasia, (b) map‐like redness of all six articles, (c) map‐like redness of selected two articles, and (d) xanthoma.