Review article: pre-neoplastic states of the gastric mucosa - a practical approach for the perplexed clinician

The sequence leading to gastric cancer can be schematically reduced to Heli cobacter pylori infection-chronic gastritis-atrophy-intestinal metaplasia-d ysplasia-neoplasia. Although clinicians have not yet developed a uniform ap proach to the treatment of gastritis (when should H. pylori infection be tr eated?), the entity itself is not the subject of controversy. An other lesi ons are still the focus of debate. There are no guidelines for the manageme nt of patients with intestinal metaplasia; pathologists are still searching for universal diagnostic criteria for atrophic gastritis; dysplasia and ea rly neoplasia have elicited scientific diatribes between Japanese and Weste rn pathologists. Amidst such controversies and in the absence of guidelines to regulate the management of gastric lesions, the responsibility to provi de sensible clinical advice is often bestowed upon pathologists. This review discusses whether pathologists have access to sufficient eviden ce to provide the requested advice, and whether a consensus on the manageme nt of gastric 'pre-neoplastic' states is within reach. We conclude that, al though many sensible and useful definitions, criteria and classifications a re being generated, the final decision on how to manage the individual pati ent with gastric lesions will continue to be based on the communication bet ween pathologist and clinician.