Gastric precancerous conditions (GPC), including chronic atrophic gastritis and intestinal metaplasia, are associated with increased risk of gastric adenocarcinoma, necessitating early detection and risk stratification for appropriate surveillance. Contemporary data on GPC prevalence in Germany, a low-to-intermediate gastric cancer incidence country, are lacking. This study aimed to determine the prevalence and severity of GPC in H. pylori-positive individuals undergoing screening endoscopy in Germany.

This single-center prospective study was conducted at the LMU University Hospital in Munich from June 2021 to November 2025. 5,069 unselected individuals underwent H. pylori serology screening (ELISA), identifying 1,056 seropositive cases (20.8%). Subjects with positive serology were offered confirmatory urea breath testing (UBT), with 400 confirming active infection. A total of 279 patients (mean age 48.9 ± 15.3 years; males:females 110:160) underwent esophagogastroduodenoscopy, during which gastric biopsies were obtained according to the standardized Sydney protocol (two from the antrum, two from the corpus, one from the incisura angularis). Histopathological evaluation was performed according to the updated Sydney classification with OLGA/OLGIM staging for gastric precancerous conditions.

Overall GPC prevalence was 38.7% (108/279). OLGA/OLGIM stage I conditions were found in 75 patients (26.9%), stage II in 27 (9.7%), and high-risk stages III-IV in 6 (2.2%). All patients with advanced-stage lesions (OLGA/OLGIM III-IV) were >50 years of age. There was a strong association between higher age and GPC prevalence, with patients >50 years having approximately 2.7-fold higher odds of GPC compared to those ≤50 years (OR 2.70, 95% CI 1.64-4.35; p<0.001). In the age-stratified subgroup analysis among patients >50 years (n=136), GPC prevalence increased to 50.7% (69/136): stage I in 43 patients (31.6%), stage II in 20 (14.7%), and stages III-IV in 6 (4.4%).

The age-dependent increase in GPC prevalence supports the national guidelines’ recommendation for targeted risk stratification rather than population-based screening in low-to-intermediate gastric cancer incidence countries. The low proportion of patients requiring endoscopic surveillance highlights the need for more efficient, non-invasive patient selection strategies to optimize resource utilization in low-prevalence settings. Comprehensive cost-effectiveness analyses are also needed to validate screening and surveillance strategies in Germany’s healthcare context.