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Targeting biopsies on the basis of visual recognition of mucosal changes in the stomach instead of the currently accepted random biopsy sampling may be attractive.The aim of this study was to evaluate the accuracy of endoscopic findings using flexible spectral imaging colour enhancement (FICE) for intestinal metaplasia (IM) in the gastric mucosa.A consecutive cohort of 126 individuals aged over 50 years (27% men) was subjected to upper endoscopy using FICE. Histological assessment (per patient and per biopsy) was considered the gold standard to accuracy estimates.Histological assessment revealed IM in 50% of the individuals [OLGIM (operative link on gastric intestinal metaplasia assessment) stages I–IV]. Overall, endoscopy presented sensitivities, specificities, positive likelihood ratio, negative likelihood ratio and accuracies per patient of 60% [95% confidence interval (95% CI) 48–72], 87% (95% CI 79–95), 4.7 (95% CI 2.4–93), 0.45 (95% CI 0.33–0.62) and 74% (95% CI 0.66–0.82), respectively, for IM diagnosis and 71% (95% CI 37–100), 87% (95% CI 79–95), 5.6 (95% CI 2.5–12.5), 0.32 (95% CI 0.10–1.0) and 86% (95% CI 77–94), respectively, for selecting individuals with OLGIM (III–IV). The proportions of agreement (and κ values) for IM in the antrum and the corpus were 75% (0.37) and 81% (0.19), respectively.FICE endoscopy yielded favourable results in the endoscopic diagnosis of IM of the gastric mucosa, and this is a very practical and easy method to use in daily clinical practice for unselected patients. Our study demonstrated a good specificity for FICE endoscopy to detect IM in the stomach. Further improvement in disseminating and training of this assessment is required to improve the reliability.