To analyze the risk factors for pathological upgrade in patients with gastric intraepithelial neoplasia (GIN) after endoscopic submucosal dissection（ESD）procedure.

A retrospective analysis was conducted on 682 patients diagnosed with GIN by gastric endoscopic forceps biopsy (EFB) pathology at the Digestive Endoscopy Center of Wuxi People's Hospital from January 2018 to December 2024 (490 with low-grade intraepithelial neoplasia(LGIN) and 192 with high-grade intraepithelial neoplasia (HGIN). Demographic characteristics (gender, age, BMI, chronic disease history, fecal occult blood), endoscopic features of lesions (location, morphology, size), and pathology data after ESD procedure were collected. Univariate, multivariate, and stepwise logistic regression analyses were performed to identify independent risk factors for pathological up grade.

The total pathological upgrade rate after ESD was 59.4% (51.2% in the LGIN group and 80.2% in the HGIN group). Stepwise regression analysis revealed that a maximum lesion diameter ≥ 2 cm (OR=2.49) was the most significant risk factor for pathological upgrade. Meanwhile, age ≥ 70 years, comorbid hypertension, Paris classification type IIc lesion, and a lesion location at the gastric angle or cardia were independent risk factors for pathological upgrade, whereas a type IIb lesion demonstrated a protective effect (OR=0.61).

Advanced age (≥70 years), hypertension, lesion size ≥2 cm, type IIc morphology, and lesions in the gastric angle/cardia significantly increase the risk of pathological upgrade after ESD. These findings provide a basis for preoperative risk assessment and individualized treatment strategies for GIN patients.