What is the recommended management for a patient 14 days post-sigmoidoscopy (sigmoidoscopy) with banding procedure and removal of a hyperplastic polyp, who now presents with a painless lump in the rectum?

Management of Painless Rectal Lump 14 Days Post-Sigmoidoscopy with Banding and Hyperplastic Polyp Removal

The patient requires urgent flexible sigmoidoscopy or proctoscopy within 2-6 months to evaluate the rectal lump, as this timeframe is recommended for follow-up after polypectomy to assess for incomplete resection, recurrence, or complications. 1

Immediate Assessment Priorities

The painless lump at 14 days post-procedure requires evaluation for several key possibilities:

• Incomplete polyp removal or early recurrence: Piecemeal resection of hyperplastic polyps can result in incomplete removal, with residual tissue presenting as a palpable mass 1
• Post-banding complications: Hemorrhoid banding can result in residual tissue, thrombosed external hemorrhoids, or mucosal tags that present as painless lumps 1
• New or missed lesion: The lump may represent a synchronous lesion not identified during the initial procedure 1

Recommended Diagnostic Approach

Schedule flexible sigmoidoscopy or proctoscopy within the next 2-6 months (ideally sooner given the patient's concern) to directly visualize the rectal lump and determine its nature. 1 This timing aligns with guideline recommendations for early follow-up after piecemeal polypectomy, where histological evaluation often cannot assess completeness of resection. 1

Key Elements of the Follow-Up Examination

• Direct visualization of the polypectomy site: Photo documentation should have been performed at the initial procedure to enable identification of the resection site 1
• Assessment for residual tissue: If the hyperplastic polyp was removed piecemeal, residual adenomatous or hyperplastic tissue may be present 1
• Evaluation of banding sites: Examine for complications including mucosal ulceration, residual hemorrhoidal tissue, or thrombosis 1
• Biopsy any suspicious tissue: Complete histological evaluation is essential to rule out dysplasia or neoplastic transformation 1

Risk Stratification Based on Initial Findings

The patient's baseline finding of a hyperplastic polyp in the rectum has specific surveillance implications:

• Small distal hyperplastic polyps (<10 mm in rectum/sigmoid) typically require no surveillance beyond routine 10-year screening intervals 2
• However, large hyperplastic polyps (≥10 mm) require 3-5 year surveillance due to increased risk 2
• If the polyp was incompletely removed, particularly if it showed high-grade dysplasia, repeat examination is warranted to verify complete removal 1

Critical Pitfalls to Avoid

Do not assume the lump is benign hemorrhoidal tissue without direct visualization. 1 While post-banding changes are common, the differential diagnosis includes:

• Residual or recurrent polyp (particularly if the original polyp was ≥10 mm or removed piecemeal) 1, 2
• New synchronous lesion that was missed on initial examination 1
• Post-procedure complication requiring intervention 1

Do not delay evaluation beyond 6 months. 1 Early follow-up endoscopy after piecemeal resection is advocated due to potentially high rates of incomplete resection and early lesion recurrence. 1 Recurrence levels increase with longer intervals before follow-up. 1

Patient Counseling

Provide written information about:

• Post-procedure bleeding risk extends up to 2 weeks (and rarely up to 30 days) after polypectomy 1
• Emergency contact information should symptoms worsen or bleeding occurs 1
• Expected timeline for follow-up examination and rationale 1

Long-Term Surveillance Plan

Once the current lump is evaluated and managed:

• If the hyperplastic polyp was small (<10 mm) and completely removed: Return to routine 10-year screening 2
• If the polyp was large (≥10 mm) or showed concerning features: 3-5 year surveillance colonoscopy 2
• If incomplete resection is confirmed: Consider repeat examination at 2-6 month intervals until complete removal is verified 1