From the Guidelines
Management of intestinal metaplasia in a gastric hyperplastic polyp requires complete endoscopic resection of the polyp followed by regular surveillance endoscopies, as recommended by the most recent guidelines 1. The polyp should be removed using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), depending on its size and location. After removal, the tissue should be sent for histopathological examination to confirm the diagnosis and rule out dysplasia or early gastric cancer. Some key points to consider in the management of intestinal metaplasia in gastric hyperplastic polyps include:
- The presence of H. pylori infection, which should be tested for and eradicated if present, as it is a significant risk factor for gastric cancer development 1
- The extent of intestinal metaplasia, which can influence the risk of gastric cancer and the need for surveillance
- The patient's individual risk factors, such as family history of gastric cancer, which can also influence the need for surveillance For surveillance, patients should undergo follow-up endoscopies every 1-3 years, with the interval determined by individual risk factors. If H. pylori is present, eradication therapy should be administered using a proton pump inhibitor (such as omeprazole 20mg twice daily) combined with antibiotics (typically amoxicillin 1g twice daily and clarithromycin 500mg twice daily) for 14 days, as recommended by recent guidelines 1. Lifestyle modifications are also important, including smoking cessation, reduced alcohol consumption, and a diet rich in fruits and vegetables. This approach is recommended because intestinal metaplasia within hyperplastic polyps represents a precancerous condition that can progress to dysplasia and eventually gastric cancer, particularly when associated with persistent H. pylori infection or other risk factors. The latest guidelines from the AGA suggest that patients with gastric intestinal metaplasia should be tested for H. pylori and undergo eradication therapy if positive, and that surveillance endoscopies should be individualized based on risk factors 1. In terms of surveillance intervals, the AGA suggests that repeat upper endoscopy with careful mucosal visualization and gastric biopsies of the antrum and body and any concerning lesions may be considered in 3–5 years among patients with incidentally detected GIM, if shared decision-making favors surveillance 1. Overall, the management of intestinal metaplasia in gastric hyperplastic polyps requires a comprehensive approach that takes into account the patient's individual risk factors, the presence of H. pylori infection, and the extent of intestinal metaplasia, as well as lifestyle modifications and regular surveillance endoscopies.
From the Research
Management of Intestinal Metaplasia in Gastric Hyperplastic Polyps
- The management of intestinal metaplasia in gastric hyperplastic polyps involves removal of the polyp, especially if it is larger than 5 mm in size, to prevent potential malignant transformation 2.
- After excision of the polyp, endoscopic surveillance is recommended, depending on the histopathological diagnosis and the completeness of endoscopic resection 2.
- If Helicobacter pylori (H. pylori) infection is confirmed, treatment strategies should include eradication of the bacteria, which may prevent progression of intestinal metaplasia 2.
- The efficacy of H. pylori eradication should be checked 3-6 months later 2.
Risk Factors for Neoplastic Transformation
- The risk of neoplastic transformation is increased in large gastric hyperplastic polyps (>25 mm) and in polyps with intestinal metaplasia and dysplasia in adjacent mucosa 3.
- Antrum location is a predictor of recurrence, but not necessarily neoplastic transformation 3.
- Intestinal metaplasia in the polyp or adjacent mucosa is a risk factor for neoplastic transformation 4, 3.
Diagnosis and Surveillance
- Gastric intestinal metaplasia is a premalignant condition that can lead to intestinal-type gastric adenocarcinoma, and its diagnosis is typically histologic 5.
- Various techniques have been developed to enable the endoscopic identification of gastric intestinal metaplasia, but there are no widely accepted guidelines on screening and surveillance strategies in patients with gastric intestinal metaplasia 5.
- Endoscopic surveillance is recommended for patients with gastric hyperplastic polyps, especially those with risk factors for neoplastic transformation 2, 3.