A Pre-Cancerous Condition of the Stomach and Esophagus

By Sherry Christiansen 

 Medically reviewed by Robert Burakoff, MD

Intestinal metaplasia is when the epithelial cells that line the stomach and esophagus are changed into cells resembling those in the intestines (goblet cells). These changes are not normal and increase the risk of cancer.

Although the reason that intestinal metaplasia develops is unknown, there is a strong theory that it may be linked to the bacteria Helicobacter pylori (H. pylori).

This article discusses symptoms of intestinal metaplasia, who is at increased risk of it, the diagnostic process, and how it is treated.

Symptoms of Intestinal Metaplasia

Most people do not experience noticeable effects of intestinal metaplasia. In fact, the condition is not typically associated with any symptoms.1

When they occur, symptoms can include stomach distress, such as acid reflux, ulcers, gastritis, or gastroesophageal reflux disease (GERD).

However, even for people who have intestinal metaplasia, these symptoms can occur for other reasons.

Complications

Intestinal metaplasia may be precancerous. When left untreated, the abnormal cells in the stomach or esophagus can undergo a change referred to as dysplasia. Dysplasia is the presence of abnormal cells in a tissue, which constitutes a stage that may be present before the cells become cancerous.

Causes

It is not known why some people develop intestinal metaplasia. An H. pylori infection is commonly thought of as the primary underlying culprit.

Atrophic gastritis, which is inflammation and tissue loss of the stomach lining, can occur before intestinal metaplasia develops. Each of these two conditions can involve H. pylori, and they can each lead to gastric (stomach) cancer. But they can also occur completely separately.2

What Is H. Pylori?

H. pylori bacteria are known to attack the lining of the stomach. According to a study published in the journal Gastroenterology, over 50% of people worldwide may have an H. pylori infection.3 This infection usually occurs during childhood and is a very common cause of peptic (stomach) ulcer disease.

In fact, a 2019 study in Africa of people with H. pylori found that approximately 90% to 100% of all duodenal ulcers (ulcers in the first segment of the small intestine) and 70% to 80% of peptic ulcers were caused by H. pylori infection.3 In the same study, 38.6% of those with intestinal metaplasia were also diagnosed with H. pylori infection.

Another study performed in China involved over 1,600 healthy participants (at an average age of 42) with H. pylori infections. Nearly a third of the participants (29.3%) were found to have intestinal metaplasia.1

Risk Factors

Intestinal metaplasia is very common across the globe; one in every four people who have had an upper endoscopy (a flexible tube inserted into the nose, then down into the upper digestive system for diagnostic purposes), is found to have intestinal metaplasia.1

Aside from the presence of an H. pylori infection, specific factors that increase the risk of intestinal metaplasia include:

• Having a first-degree relative with gastric cancer

• Lack of vitamin C in the diet

• Smoking

• Older age (risk increases with age)

Reducing risk factors may lower the possibility of getting intestinal metaplasia, as well as reduce the risk of progression from dysplasia to the cancer stage.

The progression of intestinal metaplasia to cancer may be more likely to occur if someone has the following risk factors:

• A family history of stomach cancer or other conditions of the intestinal tract

• Alcohol consumption

• Long-term incidence of acid reflux

• Secondhand smoke (and other toxins in the environment)

• Smoking

Smoking may increase the risk of developing many health-related conditions, including increasing the risk of intestinal metaplasia in the esophagus—known as Barrett’s esophagus. Smoking increases the rate of stomach cancer in the upper portion of the stomach, near the esophagus; the rate of stomach cancer is also double in smokers.4

Diagnosis

In many cases, intestinal metaplasia is diagnosed incidentally during an evaluation for other digestive problems. For example, it may be discovered during an endoscopy that's done to evaluate gastrointestinal symptoms, which are usually caused by something other than intestinal metaplasia.

In order to make a diagnosis, a biopsy may be taken during the endoscopy. This involves removing a small sample of tissue for laboratory examination.1

Endoscopy and Biopsy

If you are having an endoscopy, your healthcare provider will discuss preparation and recovery with you. Preparation may involve stopping blood thinners that you regularly take, and possibly dietary adjustments for several hours before the test.

During an endoscopy, a long, thin tube with a camera and a viewing platform is inserted into the mouth, through the esophagus, and into the stomach.

A biopsy is often taken during an endoscopy. The tissue sampled during a biopsy is examined with a microscope, and it may also be tested for H. Pylori. The biopsied cells may show characteristics of goblet cells, inflammation, dysplasia, or cancer.

The presence of goblet cells confirms the diagnosis. Goblet cells are large, round, and hollow. They are expected in the intestine, where they preserve and protect the intestinal lining by producing and secreting a thick mucus layer. They are not found in the stomach or esophagus unless intestinal metaplasia is present.

Follow Up

Once you are diagnosed with intestinal metaplasia, your provider will recommend treatment, which can include dietary modifications and medication. You will need regular follow up to determine whether the condition is well controlled or whether it's progressing.

Monitoring your condition may include imaging tests, endoscopy, biopsy, or a stool test for H. Pylori.

Treatment

According to a study in the World Journal of Gastrointestinal Oncology, stomach cancer is the second most common cause of cancer-related death in the world. In addition, the study noted that intestinal metaplasia increases the risk of stomach cancer six-fold.1

Therefore, it's important to treat intestinal metaplasia in order to prevent a progression to stomach cancer.

Dietary Changes

There is not enough clinical research to date to definitively prove that lifestyle changes are effective in treating intestinal metaplasia. However, your healthcare provider may recommend a change of diet to lower the acid level in the stomach.5

Diet is thought to help prevent the progression of intestinal metaplasia to stomach cancer, because chronic acid reflux and conditions such as GERD (involving an excessive amount of stomach acid) may increase the risk of abnormal cells in the stomach becoming cancerous.

Dietary changes thought to treat intestinal metaplasia—while possibly helping to lower the growth of H. pylori—may include;

• A bland diet (a non-spicy diet, low in fats and oils)

• A high-fiber, whole-food diet (rich in fresh fruits and vegetables, without processed, sugary, or fatty foods)

• A diet with plenty of fresh vegetables, nuts, and fruits

• A diet with whole grains (instead of foods made from white flour)

• A low-salt diet (some studies show a low-salt diet may lower the risk of stomach cancer)5

Medications

The authors of a 2019 study reported: “Finding ways to get rid of H. pylori bacteria may help reduce the risk of intestinal metaplasia.”3

If a person with intestinal metaplasia tests positive for H. pylori, antibiotics are the treatment of choice to clear up the infection. Antibiotic therapy is usually given for approximately 14 days and may include drugs such as:6

• Amoxicillin

• Metronidazole

• Clarithromycin

• Tetracycline

Treatment for intestinal metaplasia may also include medications that lower the acid in the stomach and esophagus to reduce inflammation in tissues that endure the effects of the high acidity levels from excess stomach acid on a long-term basis. Over-the-counter drugs that reduce stomach acid include:

• Pepto Bismol (bismuth subsalicylate)

• Prilosec (omeprazole)

In May 2022, the Food and Drug Administration (FDA)  approved two treatments for H. pylori infection in adults:

• Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin)

• Voquezna Dual Pak (vonoprazan, amoxicillin)

Vonoprazan is a potassium-competitive acid blocker (P-CAB), and amoxicillin and clarithromycin are antibiotics used to kill the bacterium.

It's important to note that H. pylori are a very common type of bacteria that grows in the digestive tract. But when there's an overgrowth of this bacteria, it can cause an imbalance in the intestinal flora (the types and amounts of bacteria In the digestive system). Eating a healthy diet rich in whole foods and low in saturated fats and unhealthy sugar may lower the risk of intestinal metaplasia.

Sources

Zullo A, Hassan C, Romiti A, et al. Follow-up of intestinal metaplasia in the stomach: When, how and why. World J Gastrointest Oncol. 2012;4(3):30-6. doi:10.4251/wjgo.v4.i3.30

Park YH, Kim N. Review of atrophic gastritis and intestinal metaplasia as a premalignant lesion of gastric cancer. J Cancer Prev. 2015 Mar;20(1):25-40. doi:10.15430/JCP.2015.20.1.25

Smith S, Fowora M, Pellicano R. Infections with Helicobacter pylori and challenges encountered in Africa. World J Gastroenterol. 2019;25(25):3183-3195. doi:10.3748/wjg.v25.i25.3183 

The American Cancer Society. Stomach cancer risk factors.

Yale Cancer Center. Stomach (gastric) cancer prevention (PDQ).

Marcus EA, Sachs G, Scott DR. Eradication of Helicobacter pylori Infection. Curr Gastroenterol Rep. 2016;18(7):33. doi:10.1007/s11894-016-0509-x

Zullo A, Hassan C, Romiti A, et al. Follow-up of intestinal metaplasia in the stomach: When, how and why. World Journal of Gastrointestinal Oncology. 2012;4(3):30-36. doi:10.4251%2Fwjgo.v4.i3.30

Buckland G, Travier N, Huerta JM, et al. Healthy lifestyle index and risk of gastric adenocarcinoma in the epic cohort study: healthy lifestyle index and gastric cancer risk in epic. Int J Cancer. 2015;137(3):598-606. doi:10.1002/ijc.29411

Holmes HM, Jove AG, Tan MC, El-Serag HB, Thrift AP. Alcohol consumption and the risk of gastric intestinal metaplasia in a U.S. Veterans population. PLoS ONE. 2021;16(11):e0260019.

Aumpan N, Vilaichone R, Nunanan P et al. Predictors for development of complete and incomplete intestinal metaplasia (IM) associated with H. pylori infection: A large-scale study from low prevalence area of gastric cancer (IM-HP trial). PLoS One. 2020;15(10):e0239434. doi:10.1371/journal.pone.0239434

Lam S, Lau G. Novel treatment for gastric intestinal metaplasia, a precursor to cancer. JGH Open. 2020;4(4):569-573. doi:10.1002/jgh3.12318

Aumpan N, Vilaichone R, Pornthisarn B et al. Predictors for regression and progression of intestinal metaplasia (IM): A large population-based study from low prevalence area of gastric cancer (IM-predictor trial). PLoS One. 2021;16(8):e0255601. doi:10.1371/journal.pone.0255601

By Sherry Christiansen
Sherry Christiansen is a medical writer with a healthcare background. She has worked in the hospital setting and collaborated on Alzheimer's research.