Stomach cancer on endoscopy: what it looks like
Diagnosis · Endoscopy Center · Digestive Oncology
What Stomach Cancer Looks Like on an Endoscopy: Findings and Early Diagnosis
Colombia has one of the highest gastric cancer rates in the world — and endoscopy is the only tool that detects it when it is still curable. A complete guide to endoscopic findings of gastric cancer and when to suspect it
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GSMED Imaging medical team — oncological endoscopy Colombia
Based on: IARC Cancer Incidence Colombia 2024, Minsalud Colombia Gastric Cancer Clinical Practice Guideline 2023, JGCA Classification of Gastric Carcinoma (Japanese Gastric Cancer Association) 2021, ESGE Guideline on Gastric Cancer Screening 2023 and Choi IJ et al. (NEJM 2020 — endoscopic screening for gastric cancer).
Colombia has the fifth highest gastric cancer mortality rate in the world — with particularly high incidence in Nariño, Cauca, Boyacá, and the Coffee Axis. The tragedy is that gastric cancer detected at an early stage by endoscopy has a 5-year survival rate of over 90% — but when detected only after advanced symptoms appear, that figure falls below 20%. Endoscopy not only diagnoses gastric cancer: it detects it when it is still curable.
1. Why Colombia is a high-risk area for gastric cancer
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Colombia among the countries with the highest gastric cancer mortality in the world (IARC 2024)
70%
Of gastric cancers in Colombia are diagnosed at an advanced stage — when curative surgery is no longer possible
H. pylori
Present in 60–70% of the Colombian population — the main modifiable risk factor
>90%
5-year survival if detected at an early stage (T1a/T1b) by endoscopy
The risk factors for gastric cancer with the strongest evidence in Colombia are: Helicobacter pylori infection (the most important and the only modifiable one), excessive salt consumption and smoked or cured foods, family history of gastric cancer in first-degree relatives, smoking, intestinal metaplasia and gastric dysplasia diagnosed by previous biopsy, and a history of partial gastrectomy more than 15 years ago.
2. Precancerous lesions — what appears before cancer
Intestinal-type gastric cancer (the most frequent in Colombia) follows a progressive cascade described by Pelayo Correa — a Colombian researcher who defined the model of gastric carcinogenesis that bears his name:
| Correa cascade stage | Endoscopic finding | Risk of progression | Recommended follow-up |
|---|---|---|---|
| Active chronic gastritis (due to H. pylori) | Erythematous, edematous mucosa, altered vascular pattern — LCI Fujifilm shows inflammation with an intense violet-magenta color | Low on its own — but it is the first link | H. pylori eradication · Follow-up in 1 year |
| Atrophic chronic gastritis | Thin mucosa, submucosal vessels visible through the mucosa, loss of the normal rugose pattern — gastric folds are flattened or absent | Moderate — 6× higher risk than normal mucosa | Endoscopy every 3 years if atrophy is mild-moderate |
| Intestinal metaplasia (IM) | Areas of bluish-white mucosa with an irregular villous pattern visible with NBI/BLI · Patchy distribution — antrum and lesser curvature | High — 10× risk if IM is extensive and bilateral | Endoscopy every 1–3 years depending on extent and type |
| Low-grade dysplasia | Flat, elevated, or depressed lesion with an irregular surface, loss of the normal vascular pattern — requires biopsy for histological diagnosis | Very high — 10–20% progress to carcinoma in 5 years | Endoscopy every 6–12 months or endoscopic resection |
| High-grade dysplasia / Carcinoma in situ | Lesion with irregular, friable mucosa, with abnormal vessels or bleeding area — NBI/BLI shows an irregular microvascular pattern (JNET 2B-3 type) | Very high — immediate resection indicated | Endoscopic resection (EMR/ESD) or surgery |
3. What early gastric cancer looks like on endoscopy
The Japanese Gastric Cancer Association (JGCA) created the internationally recognized morphological classification for superficial gastric lesions — the Paris Classification:
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Type I — Polypoid (elevated)
Lesion protruding more than 2.5 mm above the surrounding mucosa. Irregular or lobulated surface. Variable color — can be the same shade as the mucosa or paler. Less common in gastric cancer than in colon. With NBI/BLI, the microvascular pattern of the surface is irregular and the tumor vessels have an irregular caliber.
→ Protrusion >2.5mm · Irregular surface · NBI abnormal vessels
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Type II — Flat (the hardest to detect)
It is the most important type to recognize — and the one most often missed. Three subtypes: IIa (slightly elevated, <2.5 mm), IIb (completely flat, without elevation or depression) and IIc (slightly depressed). Type IIc lesions are at the highest risk of submucosal invasion. With white light, they can be practically invisible — NBI (Olympus) or BLI (Fujifilm) reveal the altered vascular pattern of the surface.
→ The hardest · IIc = higher risk · INVISIBLE without chromoendoscopy
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Type III — Excavated (malignant ulcer)
Ulcer with irregular, raised, and friable edges — different from benign peptic ulcer, which has regular edges and a clean base. The base of the malignant ulcer has irregular necrotic tissue. Any gastric ulcer that does not heal with medical treatment in 6–8 weeks should be considered malignant until proven otherwise with multiple biopsies.
→ Irregular edges · Necrotic base · Always biopsy · Does not heal
The rule with no exceptions — every gastric ulcer requires a biopsy
Unlike duodenal ulcers (which are almost always benign), every gastric ulcer must be biopsied at the time of endoscopy — regardless of its appearance. Macroscopic appearance does not allow for the reliable differentiation of a benign ulcer from a malignant one. 6–8 biopsies are taken from the edges of the ulcer (not from the base, which is necrotic tissue with no histological value). And if the biopsy is negative but the ulcer does not heal in 8 weeks, the endoscopy is repeated with a new biopsy.
4. Advanced gastric cancer — what it looks like when it is already late
Advanced gastric cancer (T2 or more — invading beyond the submucosa) has a more obvious endoscopic appearance but a worse prognosis:
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Fungating or vegetating mass
Tumor protruding like an irregular cauliflower into the gastric lumen — friable, bleeds easily on contact with the endoscope, necrotic and irregular surface. It is the most "obvious" presentation — any doctor recognizes it. But at this stage, the tumor is usually already T2 or T3, with a high probability of lymph node involvement.
→ Easy to see · But already advanced · High probability of lymph node metastasis
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Linitis plastica (Borrmann IV)
The most devastating presentation — the tumor diffusely infiltrates the entire gastric wall without forming a visible mass. The stomach appears rigid, with non-distensible folds and absent peristalsis. It can look almost normal on the surface with white light — only the rigidity of the wall and the absence of peristalsis are alarming. Very serious prognosis — median survival of less than 12 months.
→ Rigid stomach · No visible mass · Absent peristalsis · Very poor prognosis
5. Technologies that improve endoscopic detection
| Technology | How it helps in gastric cancer | Equipment |
|---|---|---|
| NBI (Narrow Band Imaging) | Narrow band light (415 nm blue + 540 nm green) that highlights the superficial vessels of the mucosa — malignant lesions have an irregular microvascular pattern of JNET 2B or 3 type | Olympus EVIS X1 / EXERA III |
| BLI (Blue Light Imaging) | Equivalent to Olympus NBI — LED source with selective illumination of the superficial mucosa. Especially useful for type IIb (flat) lesions | Fujifilm ELUXEO 7000 |
| LCI (Linked Color Imaging) | Exclusive Fujifilm technology that amplifies color contrast — differentiates the intense red of H. pylori inflamed mucosa from the orange-yellow of healthy mucosa. Very useful for mapping the extent of gastritis and metaplasia | Fujifilm ELUXEO 7000 |
| Endoscopic magnification (zoom) | Optical zoom of up to 136× in EVIS X1 — allows viewing the pattern of the crypts and surface vessels at a near-microscopic level. Real-time JNET classification without biopsy | Olympus EVIS X1 (GIF-H290Z) |
| AI — ENDO-AID (Olympus) | Deep learning algorithm that detects suspicious lesions in real time and flags them for the endoscopist — reduces the risk of "missing" flat type IIb lesions | Olympus EVIS X1 + ENDO-AID |
6. Who should get a screening endoscopy in Colombia
Minsalud Colombia 2023 recommendations — gastric cancer screening
The Minsalud Colombia Gastric Cancer Clinical Practice Guideline 2023 recommends screening endoscopy in: (1) everyone over 40 years old in high-incidence areas (Nariño, Cauca, Boyacá, Coffee Axis, Santanderes) with persistent dyspeptic symptoms; (2) people with a family history of gastric cancer in first-degree relatives — 10 years before the relative's age of diagnosis; (3) patients with a previous diagnosis of extensive intestinal metaplasia or gastric dysplasia — regardless of age.
If I have H. pylori and eradicate it, do I no longer have a risk of gastric cancer?
H. pylori eradication significantly reduces the risk of gastric cancer — but does not eliminate it completely if intestinal metaplasia or established atrophy already exists. The Choi et al. study published in the NEJM (2020) with more than 1,600 patients showed that H. pylori eradication reduces the risk of gastric cancer by 73% in patients with no previous precancerous lesions. But if you already have established intestinal metaplasia, eradication slows progression but does not completely reverse it — that is why it is essential to continue periodic endoscopic follow-up even after eradicating H. pylori.
How many biopsies should be taken in an endoscopy so as not to miss gastric cancer?
For a complete assessment of gastric risk, the updated Sydney Protocol recommends taking 5 systematic biopsies in every endoscopy of a patient at risk: 2 from the antrum (greater and lesser curvature), 1 from the gastric angle (the area of highest risk for metaplasia) and 2 from the body (greater and lesser curvature). Additional targeted biopsies from any suspicious area (irregularity, color change, elevated or depressed lesion). The angle biopsy is critical and frequently omitted in quick endoscopies — it is the area where intestinal metaplasia first appears.
Endoscopes with NBI, BLI and LCI for gastric cancer detection — GSMED Colombia
Olympus EVIS X1 with NBI and ENDO-AID, Fujifilm ELUXEO with BLI and LCI — the most advanced systems for gastric oncological screening in Colombia.
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Sources
- IARC. Global Cancer Observatory — Colombia. gco.iarc.fr. 2024. Gastric cancer incidence and mortality Colombia. IARC 2024
- Minsalud Colombia. Clinical Practice Guideline — Gastric Cancer. gpc.minsalud.gov.co. 2023. Minsalud Colombia 2023
- JGCA. Japanese Classification of Gastric Carcinoma. 3rd English ed. Gastric Cancer. 2021. Paris Classification, JNET. JGCA 2021
- ESGE. Guideline on Gastric Cancer Screening and Surveillance. esge.com. 2023. ESGE 2023
- Choi IJ et al. Helicobacter pylori Therapy for the Prevention of Metachronous Gastric Cancer. NEJM. 2020;382:1299–1307. Choi NEJM 2020
