Management of Hyperplastic Polyps
Small, distally located hyperplastic polyps require no treatment beyond removal during colonoscopy and should be followed with average-risk screening at 10-year intervals, as they carry no increased risk for colorectal cancer. 1, 2
Risk-Based Treatment Algorithm
Small Distal Hyperplastic Polyps (Low Risk)
- No intensified surveillance is needed for patients with small hyperplastic polyps in the rectosigmoid region 1, 2
- These patients should return to average-risk screening intervals with colonoscopy in 10 years 2
- A single hyperplastic polyp found during proctosigmoidoscopy does not warrant full colonoscopy 3
Large or Proximal Hyperplastic Polyps (Higher Risk)
- Complete endoscopic resection is mandatory for hyperplastic polyps ≥1 cm, sessile morphology, or proximal location (right colon) 1, 2, 4
- These atypical variants show architectural features suggesting progression through the serrated pathway to microsatellite instability colorectal cancer 1
- Surveillance similar to adenomas may be warranted for large, sessile, proximally located polyps with atypical features 1, 2, 4
- Large solitary hyperplastic polyps in the right colon carry higher malignancy risk and require particular attention 2
Hyperplastic Polyposis Syndrome (Highest Risk)
The syndrome is defined by any of the following criteria 1, 2:
- ≥5 hyperplastic polyps proximal to sigmoid colon, with 2 being >1 cm diameter
- Any number of hyperplastic polyps proximal to sigmoid in a patient with a first-degree relative with hyperplastic polyposis
30 hyperplastic polyps of any size throughout the colon
These patients have increased colorectal cancer risk and require intensive surveillance, though optimal management protocols remain under investigation 1, 2
Technical Considerations for Removal
- Document all polyp characteristics clearly: size, location, number, and morphology in the pathology report to guide surveillance decisions 2
- Standard polypectomy techniques are appropriate for most hyperplastic polyps 5
- Endoscopic mucosal resection (EMR) may be required for larger sessile lesions 6, 7
- Ensure complete excision, particularly for larger or proximal lesions, as incomplete removal may miss serrated adenoma components 1, 2
Common Pitfalls to Avoid
- Do not intensify surveillance for small distal hyperplastic polyps – this leads to unnecessary procedures and healthcare costs 4, 3
- Do not assume all hyperplastic polyps are benign – large (≥1 cm), sessile, proximally located polyps with atypical architecture can progress to cancer through the serrated pathway 1, 2
- Do not miss hyperplastic polyposis syndrome – failure to recognize this pattern results in inadequate surveillance for high-risk patients 1, 2
- Left-sided hyperplastic polyps may serve as markers for synchronous proximal adenomas, warranting complete colonoscopy rather than limited sigmoidoscopy 8