Should a benign polyp in the gastrointestinal (GI) tract be removed?

Should Benign GI Polyps Be Removed?

The decision to remove benign GI polyps depends critically on polyp type, size, location, and malignant potential—with adenomatous polyps requiring resection due to cancer risk, while management of hyperplastic and fundic gland polyps is more selective based on specific features.

Gastric Polyps

Fundic Gland Polyps (FGPs)

• FGPs do not require excision unless they have atypical features 1
• Remove FGPs if they are >1 cm in size, located in the antrum, show ulceration, or have an unusual appearance 1
• For typical small FGPs, targeted biopsies suffice when excision is not undertaken 1
• No surveillance gastroscopy is needed for FGPs except in familial adenomatous polyposis (FAP) 1

Hyperplastic Gastric Polyps

• Consider H. pylori eradication first, as up to 70% of hyperplastic polyps regress after eradication 1
• Perform repeat endoscopy 3-6 months after H. pylori eradication to assess for regression 1
• Resect polyps >1 cm, pedunculated polyps, or symptomatic polyps (causing obstruction or bleeding) 1
• Always resect polyps >3 cm regardless of H. pylori status, as cancer risk is high 1
• Hyperplastic polyps can harbor dysplasia in 1.9-19% of cases, especially when >1 cm 1

Gastric Adenomas

• All gastric adenomas should be resected due to significant cancer progression risk 1
• Up to 30% of patients with gastric adenomas have synchronous gastric adenocarcinoma 1
• 50% of adenomas >2 cm contain foci of adenocarcinoma 1
• Use endoscopic submucosal dissection (ESD) for sessile polyps >15 mm to achieve en bloc resection and reduce recurrence 1
• Perform follow-up gastroscopy at 6-12 months after resection, then yearly surveillance 1

Duodenal Polyps

Non-Neoplastic Duodenal Lesions

• Non-neoplastic lesions (metaplastic foveolar epithelium, gastric heterotopia, Brunner gland hamartomas) do not require resection unless symptomatic or bleeding 1
• Brunner gland hamartomas should be removed if >2 cm or causing symptoms like obstruction, pain, or bleeding 1

Duodenal Adenomas

• Endoscopic resection of duodenal adenomas is generally recommended given their malignant transformation risk 1
• Up to 20% may progress to high-grade dysplasia and approximately 5% to cancer 1
• Initial surveillance after complete resection should occur at 6 months 1
• In FAP patients, resect duodenal adenomas ≥1 cm, those with high-grade dysplasia, or based on Spiegelman criteria 1
• Be aware that postprocedural bleeding risk is increased compared to other GI sites, with >25% bleeding risk for lesions >3 cm 1

Colorectal Polyps

Hyperplastic Colorectal Polyps

• Small hyperplastic polyps in the rectosigmoid region require no intensified surveillance—rescreen as average-risk patients in 10 years 2
• Large (≥1 cm), sessile, proximally located hyperplastic polyps should be completely removed and may warrant adenoma-like surveillance 2
• These proximal large hyperplastic polyps can progress to colorectal cancer through the serrated pathway 2

Adenomatous Colorectal Polyps

• All colorectal adenomas should be removed endoscopically, as they are precursor lesions to colorectal cancer 3
• Complete polyp removal is essential, especially for larger or proximal lesions 2
• Document polyp characteristics (size, location, number, morphology) clearly to guide surveillance 2

Malignant Colorectal Polyps

• En bloc resection with adequate margins is critical for proper histologic assessment 1
• Surgical resection is indicated when unfavorable histologic features are present (lymphovascular invasion, poor differentiation, positive margins, deep submucosal invasion) 1
• In healthy patients with any unfavorable histologic criterion, surgical resection is generally advisable 1
• For poor surgical candidates with no unfavorable features, surgery should be avoided 1

Key Clinical Pitfalls

Common mistakes to avoid:

• Failing to assess for H. pylori before resecting gastric hyperplastic polyps, missing the opportunity for medical regression 1
• Not evaluating the entire stomach for synchronous neoplasia when adenomas are found (present in 30% of cases) 1
• Removing small distal hyperplastic colorectal polyps and inappropriately intensifying surveillance 2
• Attempting piecemeal resection of large duodenal or gastric adenomas when en bloc resection is feasible and safer 1
• Underestimating bleeding risk with duodenal polyp resection, particularly for lesions >3 cm 1