Management of Hyperplastic Antral Polyp
For hyperplastic antral polyps, test for H. pylori and attempt eradication first before resection, as up to 70% will regress; however, polyps >1 cm, pedunculated polyps, symptomatic polyps, or those >3 cm must be completely resected regardless of H. pylori status due to significant risk of dysplasia and malignancy. 1
Initial Diagnostic Approach
Confirm diagnosis histologically through biopsy to verify the polyp is hyperplastic and exclude dysplasia, as hyperplastic polyps can harbor dysplasia in 1.9-19% of cases and malignant transformation, especially when >1 cm 1
Carefully evaluate the entire stomach for synchronous neoplasia (present in approximately 6% of cases with dysplastic hyperplastic polyps), degree and extent of gastric atrophy (GA), and gastric intestinal metaplasia (GIM) 1
Test for H. pylori infection in all cases, as hyperplastic polyps are associated with H. pylori gastritis in 25% of cases 1
Size-Based Management Algorithm
Small Polyps (<1 cm)
Attempt H. pylori eradication first if infection is present, as regression occurs in up to 70% of cases after eradication 1
Perform repeat endoscopy 3-6 months after eradication to assess for polyp regression before considering resection 1
Medium Polyps (1-3 cm)
Complete resection is mandatory for polyps >1 cm, pedunculated morphology, or symptomatic polyps (causing obstruction or bleeding), even if H. pylori is present 1
The risk of dysplasia and cancer increases significantly with size >1 cm, particularly in postgastrectomy stomachs 1
Large Polyps (>3 cm)
- Always resect immediately regardless of H. pylori status, as the risk of dysplasia and cancer is high 1
Symptomatic Polyps
Immediate endoscopic resection is indicated for polyps causing gastric outlet obstruction, bleeding, or other symptoms 2, 3, 4
Endoscopic mucosal resection (EMR) provides both definitive histopathologic diagnosis and symptomatic relief 2, 3
Symptomatic antral polyps can prolapse through the pylorus causing intermittent gastric outlet obstruction and should be removed at initial diagnostic endoscopy 3, 4, 5
Surveillance Strategy
Endoscopic surveillance is recommended to monitor for further gastric neoplasia when there is evidence of dysplasia, gastric atrophy, or gastric intestinal metaplasia 1
The surveillance interval should be determined by the stage of chronic atrophic gastritis (CAG) rather than the polyp itself 1
Critical Pitfalls to Avoid
Do not assume all antral polyps are hyperplastic - the differential includes adenomatous polyps (which have 30% synchronous gastric adenocarcinoma rate and 50% contain cancer when >2 cm) 1
Do not delay resection of large polyps (>3 cm) for H. pylori eradication - these must be resected immediately due to high malignancy risk 1
Do not overlook the surrounding gastric mucosa - dysplastic hyperplastic polyps are associated with synchronous neoplastic lesions in approximately 6% of cases 1
Recognize that there are no significant gross appearance differences between pure hyperplastic polyps and those with neoplastic transformation, making histologic confirmation essential 2