Management of Small (5mm) Gastric Fundal Polyps
For small gastric fundic gland polyps of 5mm, no resection or routine surveillance is required; diagnosis can be made endoscopically based on typical appearance, with biopsy reserved only for atypical features. 1
Diagnostic Approach
Endoscopic diagnosis alone is sufficient when typical features are present, which include multiple small (<1 cm) polyps in the fundus/corpus with pale, smooth, glassy, translucent appearance and visible lacy blood vessels through the surface. 1
When to Biopsy
Biopsy confirmation should be obtained only when atypical features are present: 1
- Size >1 cm (your 5mm polyp does not meet this threshold)
- Antral location (fundal polyps are typical)
- Ulceration or erosion
- Redness or irregular surface structure
- Depression or unusual appearance
- Pedunculated morphology
**The risk of dysplasia in fundic gland polyps <1 cm is extremely low (1.9%)**, making routine biopsy unnecessary for typical-appearing small polyps. 1 This is critical because the evidence shows that larger FGPs (>1 cm) have been dysplastic in 1.9% and contain focal cancer in 1.9%, but your 5mm polyp falls well below this threshold. 1
Management Algorithm for 5mm Fundal Polyps
No intervention is required for typical-appearing fundic gland polyps of 5mm. 1, 2
Medication Review
Evaluate current proton pump inhibitor (PPI) use, as FGPs are strongly associated with long-term PPI therapy and can spontaneously regress when PPIs are discontinued. 1 Re-evaluate the appropriateness of continued PPI use in all patients with fundic gland polyps. 1
Surveillance Strategy
No endoscopic surveillance is indicated for typical fundic gland polyps, regardless of size, unless the patient has familial adenomatous polyposis (FAP). 1 This represents a strong departure from colon polyp management and is specific to gastric fundic gland polyps.
Critical Distinctions from Other Gastric Polyps
The management differs dramatically based on polyp type:
Hyperplastic polyps (which can appear similar) require different management: 3
- Small hyperplastic polyps (<1 cm) should undergo H. pylori testing and eradication if positive, as 70% regress after treatment
- Polyps >1 cm require complete resection due to 1.9-19% risk of dysplasia
However, fundic gland polyps specifically do not require H. pylori testing or eradication, as patients with FGPs are consistently free from H. pylori colonization. 4
Key Pitfalls to Avoid
Do not assume all fundal polyps are fundic gland polyps. While FGPs are now the most common gastric polyps in Western countries due to widespread PPI use, the differential includes hyperplastic polyps and adenomatous polyps. 5 The endoscopic appearance must be typical to forgo biopsy.
Do not apply colon polyp management principles to gastric polyps. The evidence provided about diminutive colon polyps (<5mm) 6 is not applicable to gastric fundal polyps, which have entirely different natural history and malignant potential.
Do not perform routine surveillance endoscopy for typical fundic gland polyps, as this represents unnecessary cost and patient risk without benefit. 1 Surveillance should only be determined by the presence of gastric atrophy or intestinal metaplasia in the background mucosa, not by the polyps themselves. 3, 2