What is the management plan for a patient found to have a hyperplastic polyp during a colonoscopy (Colonoscopy)?

Management of Hyperplastic Polyps Found on Colonoscopy

For patients with small, distally located hyperplastic polyps, no additional surveillance beyond standard average-risk screening (repeat colonoscopy in 10 years) is required, as these polyps carry no increased risk of colorectal cancer. 1

Risk Stratification Based on Polyp Characteristics

The management of hyperplastic polyps depends critically on their size, location, and number:

Standard Small Distal Hyperplastic Polyps

• Patients with small hyperplastic polyps in the rectosigmoid region should be rescreened as average-risk patients with colonoscopy in 10 years. 1
• These polyps carry no increased colorectal cancer risk and require no intensified surveillance. 1
• This represents the vast majority of hyperplastic polyps encountered in clinical practice. 2

High-Risk Hyperplastic Polyp Variants (Serrated Lesions)

However, certain hyperplastic polyp variants require more aggressive management similar to adenomas:

• Large (≥1 cm), sessile, proximally located hyperplastic polyps with atypical architectural features should be completely removed and may warrant surveillance similar to adenomas. 1
• These variants (also called sessile serrated adenomas or serrated polyps with abnormal proliferation) can progress to microsatellite instability colorectal cancer through the serrated pathway. 1
• Complete endoscopic removal is essential for these lesions. 1, 3
• While specific surveillance intervals are not definitively established, treating them like adenomas (3-5 year intervals) is reasonable given their malignant potential. 1

Hyperplastic Polyposis Syndrome

All endoscopists must remain vigilant for hyperplastic polyposis syndrome, which requires intensive surveillance:

The syndrome is defined by any of the following 1:

• At least 5 hyperplastic polyps proximal to the sigmoid colon, with 2 being >1 cm in diameter

• Any number of hyperplastic polyps proximal to the sigmoid in a patient with a first-degree relative with hyperplastic polyposis

• More than 30 hyperplastic polyps of any size distributed throughout the colon

• Patients meeting these criteria have increased colorectal cancer risk and require more intensive surveillance than standard intervals, though optimal management remains under study. 1

Key Clinical Pitfalls to Avoid

• Do not assume all hyperplastic polyps are benign—carefully assess size, location, and morphology. 1, 4
• Large solitary hyperplastic polyps in the right colon warrant particular attention as they carry higher malignancy risk. 5, 6
• Ensure complete polyp removal, especially for larger or proximal lesions. 1, 3
• Document polyp characteristics (size, location, number, morphology) clearly in the pathology report to guide surveillance decisions. 3

Practical Algorithm

1. Small (<1 cm) distal (rectosigmoid) hyperplastic polyps → Remove → Return to average-risk screening (10 years) 1

2. Large (≥1 cm), proximal, or sessile hyperplastic polyps with atypical features → Complete removal → Consider adenoma-like surveillance (3-5 years) 1

3. Multiple hyperplastic polyps meeting polyposis criteria → Complete removal → Intensive surveillance (interval determined by clinical judgment, likely <3 years) 1

The quality of the baseline colonoscopy is paramount—ensure excellent bowel preparation, complete examination to the cecum, and adequate withdrawal time (≥6 minutes) to minimize missed lesions. 1