What is the management plan for a patient with a hyperplastic polyp and an otherwise unremarkable colonoscopy?

Management of Hyperplastic Polyps in Colonoscopy

Patients with small distally located hyperplastic polyps and an otherwise unremarkable colonoscopy should be managed with routine screening as appropriate for average-risk patients, with no need for special surveillance. 1

Understanding Hyperplastic Polyps

Hyperplastic polyps are the most common non-neoplastic lesions found during colonoscopy. They have the following characteristics:

• Constitute 18-70% of all colonic polyps
• Usually small (0.5-1.5 cm) and located in the distal colon
• Typically appear as smooth, dome-shaped lesions
• Generally considered benign with low malignant potential

Management Algorithm

For Typical Small Distal Hyperplastic Polyps:

1. No special surveillance required - Follow average-risk screening intervals (10 years) 1
2. Document the number, location, morphology, and size in the colonoscopy report
3. Confirm histological diagnosis to rule out serrated variants

Special Considerations Requiring Different Management:

1. Size > 1 cm: Consider complete resection 1
2. Proximal location: Higher risk of serrated pathway to cancer 1
3. Atypical features: Sessile, large, or unusual appearance requires complete removal 1
4. Multiple polyps: Be alert for hyperplastic polyposis syndrome 1

Hyperplastic Polyposis Syndrome

Be vigilant for this condition, defined by WHO as:

• At least 5 hyperplastic polyps proximal to sigmoid colon (with 2 > 1 cm), OR
• Any hyperplastic polyps proximal to sigmoid in a patient with first-degree relative with hyperplastic polyposis, OR
• More than 30 hyperplastic polyps throughout the colon 1

These patients have increased colorectal cancer risk and require specialized management.

Important Clinical Considerations

• Certain hyperplastic polyp variants (sessile serrated adenomas) may progress to cancer through the serrated pathway 1
• These variants show atypical architectural and cytologic features, are often large, sessile, and proximally located
• Recent evidence suggests hyperplastic polyps may serve as markers for synchronous adenomatous polyps elsewhere in the colon 2

Common Pitfalls to Avoid

1. Over-surveillance: Routine surveillance for small distal hyperplastic polyps is inappropriate and wastes valuable colonoscopy resources 3
2. Under-recognition of serrated variants: Be alert for larger (>1 cm) or proximal hyperplastic polyps that may represent serrated adenomas
3. Failure to recognize hyperplastic polyposis syndrome: This rare condition requires more intensive surveillance
4. Incomplete documentation: Always document size, location, and appearance of all polyps

By following these evidence-based guidelines, clinicians can provide appropriate care while avoiding unnecessary procedures for patients with hyperplastic polyps.