What is the management approach for polypoid foveolar hyperplasia?

Management of Polypoid Foveolar Hyperplasia

Polypoid foveolar hyperplasia requires no specific treatment or surveillance when small (<1 cm), as these lesions have no malignant potential and are distinct from true hyperplastic polyps. 1, 2

Diagnostic Confirmation and Classification

• Polypoid foveolar hyperplasia is a distinct benign entity that must be differentiated from true hyperplastic polyps, as it lacks malignant potential and requires different management 2
• These lesions appear endoscopically as small, white, flat plaques typically in the fundus with the appearance of hyperplastic polyps 1
• Histologic confirmation through biopsy is essential when there is diagnostic uncertainty, particularly to distinguish from true hyperplastic polyps which carry a 1.9-19% risk of dysplasia 3, 4

Size-Based Management Algorithm

Small Lesions (<1 cm)

• No resection or surveillance is required for confirmed polypoid foveolar hyperplasia <1 cm, as these have no documented malignant transformation risk 1, 2
• If H. pylori is present, eradication should be pursued for gastritis management rather than polyp-specific concerns 3

Larger Lesions (≥1 cm)

• Complete resection is mandatory for any polypoid lesion ≥1 cm regardless of presumed diagnosis, as size >1 cm significantly increases dysplasia and malignancy risk in true hyperplastic polyps 3, 5
• Lesions >1 cm in the antral or prepyloric location require immediate resection due to risk of gastric outlet obstruction and higher malignancy potential 3, 6
• Resection is preferred over biopsy alone, as histologic features can be patchy within lesions 7

Critical Diagnostic Pitfalls

• Do not assume all small gastric polyps are benign foveolar hyperplasia - nearly half of lesions initially diagnosed as hyperplastic polyps are actually polypoid foveolar hyperplasia (49%), while 31% are mucosal prolapse polyps with different clinical implications 2
• Atypical features requiring immediate excision include: size >1 cm, antral location, ulceration, unusual appearance, or pedunculated morphology 1, 3
• Evaluate the surrounding gastric mucosa carefully, as 6% of cases with dysplastic hyperplastic polyps have synchronous neoplastic lesions elsewhere in the stomach 3

When Surveillance Is NOT Needed

• No endoscopic surveillance is required for confirmed polypoid foveolar hyperplasia without dysplasia, gastric atrophy, or intestinal metaplasia 1, 3
• Surveillance intervals should be determined by the stage of chronic atrophic gastritis in the background mucosa rather than the polyp itself 3