What are the American College of Gastroenterology (ACG) guidelines for managing gastric polyps identified as tubular adenomas?

Management of Gastric Tubular Adenomas: ACG Guidelines

Gastric tubular adenomas should be completely resected when clinically appropriate and safe to do so, followed by annual surveillance gastroscopy due to their significant risk of progression to cancer. 1

Classification and Risk Assessment of Gastric Adenomas

Gastric adenomas are epithelial polyps that require careful management due to their malignant potential. They differ significantly from other gastric polyp types:

• Prevalence and Characteristics:

  • Usually single (82%)
  • Typically small (<2 cm)
  • Most commonly located in the antrum and incisura angularis
  • Prevalence in Western countries: 0.5-10%
  • Endoscopically appear with velvety pink lobulated appearance, sessile or pedunculated 1

• Associated Risk Factors:

  • Strongly associated with background gastric atrophy and intestinal metaplasia
  • Up to 30% of patients with gastric adenomas have synchronous gastric adenocarcinoma
  • 50% of adenomas >2 cm contain foci of adenocarcinoma 1

Management Algorithm for Gastric Tubular Adenomas

1. Initial Diagnosis and Assessment

• Confirm diagnosis and degree of dysplasia histologically before treatment
• Carefully evaluate the entire stomach for:
  • Synchronous neoplasia (present in up to 30% of cases)
  • Gastric atrophy
  • Intestinal metaplasia
  • H. pylori infection 1

2. Documentation Requirements

• Number of polyps (or estimated number)
• Location of polyps
• Size of largest polyp
• Photographic documentation of all polyps or representative polyps if numerous 1

3. Endoscopic Treatment

• Primary Treatment: Endoscopic resection is the preferred approach
• Technique Selection:
  • For sessile polyps >15 mm: En bloc excision with endoscopic submucosal dissection (ESD) is advisable
    • Rationale: Higher possibility of invasive neoplasia and lower risk of recurrence compared to EMR
  • For smaller lesions: Standard polypectomy techniques may be appropriate 1

4. Surveillance Protocol

• First Follow-up: Perform gastroscopy at 12 months after complete endoscopic excision
• Subsequent Follow-up: Continue surveillance gastroscopy annually thereafter when appropriate
• Surveillance interval may be adjusted based on:
  • Number of polyps
  • Size of polyps
  • Highest grade of dysplasia 1

Special Considerations

Optical Diagnosis

• Enhanced endoscopic imaging (NBI, i-Scan, FICE) can aid in characterization when diagnostic uncertainty exists
• Gastric adenomas often appear paler relative to background mucosa with slit-like crypt openings 1

Pitfalls to Avoid

• Misdiagnosis: Adenomas can be mistaken for hyperplastic polyps or fundic gland polyps
• Incomplete Evaluation: Failure to assess the background mucosa can miss synchronous neoplasia
• Inadequate Follow-up: Given the high risk of progression to cancer, annual surveillance is essential 1

Familial Adenomatous Polyposis (FAP)

• Patients with FAP have increased risk for gastric adenomas
• Gastric adenomas in FAP patients may be difficult to identify endoscopically
• Endoscopists should maintain high suspicion and low threshold for biopsy in FAP patients 2

By following these guidelines, clinicians can appropriately manage gastric tubular adenomas and minimize the risk of progression to gastric cancer while avoiding unnecessary procedures for lower-risk polyp types.