From the Guidelines
Intestinal metaplasia found during endoscopy is a precancerous condition that requires monitoring due to its potential to develop into cancer over time, and management should be guided by the latest evidence-based guidelines.
Definition and Cause
Intestinal metaplasia is a condition where the normal cells lining the esophagus or stomach change into intestinal-type cells, often due to chronic inflammation from acid reflux or H. pylori infection [ 1 ]. This change can slightly increase the risk of developing cancer, making regular surveillance essential [ 1 ].
Management and Surveillance
The management of intestinal metaplasia typically involves treating underlying causes, such as acid reflux with proton pump inhibitors, and eradicating H. pylori if present [ 1 ]. Regular surveillance endoscopies every 3-5 years are recommended for patients with high-risk gastric intestinal metaplasia (GIM) phenotypes, such as corpus-extended GIM, OLGIM stages III/IV, or incomplete GIM subtype [ 1 ]. However, low-risk phenotypes, which comprise most patients with GIM, do not require surveillance [ 1 ].
Lifestyle Modifications
Lifestyle modifications are also crucial in managing intestinal metaplasia, including weight loss if overweight, avoiding smoking and excessive alcohol, elevating the head of the bed, and avoiding meals within 3 hours of bedtime [ 1 ].
Key Considerations
- Patients with GIM at higher risk for gastric cancer, such as those with incomplete vs complete GIM, extensive vs limited GIM, or family history of gastric cancer, may benefit from surveillance [ 1 ].
- Racial/ethnic minorities, immigrants from high incidence regions, and individuals with a family history of first-degree relative with gastric cancer are also at increased risk [ 1 ].
- The optimal surveillance interval is not well established, but repeat upper endoscopy with careful mucosal visualization and gastric biopsies may be considered in 3-5 years among patients with incidentally detected GIM [ 1 ].
From the Research
Definition and Diagnosis of Intestinal Metaplasia
- Intestinal metaplasia is a premalignant condition where normal gastric mucosa is replaced by mucin-secreting intestinal mucosa 2.
- It is usually diagnosed by upper endoscopy with biopsy, and histologic scoring systems have been developed to risk-stratify patients at highest risk for progression to gastric cancer 2.
- Intestinal metaplasia can be found in patients with Helicobacter pylori infection, and eradication of H. pylori can result in significant reduction in the severity and activity of chronic gastritis 3.
Association with Helicobacter pylori Infection
- Helicobacter pylori infection is the most common etiologic agent of gastric intestinal metaplasia development worldwide 2.
- The prevalence of intestinal metaplasia is heterogeneous among different regions of the world and correlates with the population endemicity of H. pylori carriage, among other environmental factors 2.
- Increasing age, H. pylori infection, smoking, and anti-parietal cell antibodies are all associated with the diagnosis of gastric intestinal metaplasia 4.
Role of Proton Pump Inhibitors
- Proton pump inhibitor use appears to be associated with a dose-dependent increased likelihood of gastric intestinal metaplasia among H. pylori-positive patients 4.
- Upper quartiles of cumulative proton pump inhibitor doses were associated with a 5-10-fold increased risk of low-grade dysplasia 4.
- However, another study found no significant difference in resolution of intestinal metaplasia by using different proton pump inhibitors between the groups of eradicated and noneradicated patients 3.
Clinical Implications
- Intestinal metaplasia is a necessary precursor to adenocarcinoma of the esophagus, and its presence is crucial for the diagnosis of Barrett's esophagus 5.
- Endoscopic abnormalities are common in gastric ulcer patients and persist after proton-pump inhibitor-based triple therapy for H. pylori eradication 6.
- Follow-up endoscopy and histology may be necessary, even in patients with apparently non-malignant gastric ulcers, to improve the detection rate of gastric malignancy in populations with a high prevalence of gastric cancer 6.