What is the management approach for a patient presenting with stomach and duodenum polyps?

Management of Stomach and Duodenum Polyps

All gastric polyps should be characterized by type, size, and location to determine appropriate management, with adenomatous polyps requiring complete resection due to their significant malignant potential (up to 30% synchronous cancer risk), while fundic gland polyps <1 cm with typical appearance can be observed without intervention. 1, 2

Initial Endoscopic Assessment

Document the following for every polyp:

• Number, size, location, and morphology of all polyps 1
• Evaluate the entire stomach and duodenum for synchronous neoplasia 1
• Assess background mucosa for H. pylori, gastric atrophy (GA), and gastric intestinal metaplasia (GIM) 1
• Use optical enhancement (NBI, i-Scan, or FICE) to improve diagnostic accuracy 1, 2

Gastric Polyp Management by Type

Fundic Gland Polyps (FGPs)

No resection needed for typical FGPs <1 cm:

• Diagnosis can be made endoscopically: multiple, pale/translucent polyps in fundus/corpus with lacy blood vessels and fine grey dot pattern 3
• Biopsy only if atypical features present 3
• No surveillance required except in familial adenomatous polyposis (FAP) patients 1, 3

Resect FGPs if:

• Size >1 cm (1.9% dysplasia risk, 1.9% cancer risk) 1, 3
• Antral location 1
• Ulceration or unusual appearance 1, 3
• Age <40 years with >20 polyps (exclude FAP) 1

Re-evaluate PPI appropriateness in all FGP patients, as these polyps are associated with long-term PPI use and may regress when PPIs are stopped. 1, 3

Hyperplastic Polyps

Test and treat H. pylori before resection:

• Up to 70% regress after H. pylori eradication 1
• Repeat endoscopy 3-6 months after eradication 1

Resect hyperplastic polyps if:

• Size >1 cm (1.9-19% dysplasia risk) 1
• Size >3 cm (always resect regardless of H. pylori status due to high cancer risk) 1
• Pedunculated morphology 1
• Symptomatic (bleeding, obstruction) 1

Surveillance endoscopy is required if dysplasia, GA, or GIM is present, with intervals determined by the stage of chronic atrophic gastritis. 1

Adenomatous Polyps (Gastric Adenomas)

All gastric adenomas must be resected due to significant cancer risk:

• 30% have synchronous gastric adenocarcinoma 1
• 50% of adenomas >2 cm contain foci of adenocarcinoma 1

Resection technique:

• Endoscopic submucosal dissection (ESD) preferred for sessile polyps ≥15 mm (reduces recurrence vs EMR and allows en bloc excision) 1, 2
• EMR acceptable for smaller pedunculated lesions 1

Post-resection surveillance:

• Follow-up gastroscopy at 6-12 months after resection 1, 2
• Continue yearly surveillance thereafter, adjusted for number of polyps, size, and highest grade of dysplasia 1, 2

Duodenal Polyp Management

Duodenal adenomas have malignant potential and warrant endoscopic resection:

• Villous adenomas have high malignancy incidence and require excision 4
• Pedunculated duodenal polyps can be safely removed with endoscopic snare excision 4
• Non-ampullary and ampullary adenomas should be resected, though the duodenum's thin walls and narrow lumen increase procedural complexity 5

Biopsy all duodenal polyps >1 cm, as tissue diagnosis cannot be reliably made endoscopically (except villous adenomas which show characteristic features). 4

Critical Pitfalls to Avoid

Do not assume small polyps are benign without proper characterization:

• Size >1 cm significantly increases dysplasia and cancer risk across all polyp types 1, 3
• Hyperplastic polyps can harbor dysplasia (1.9-19%) and have 6% risk of synchronous neoplastic lesions elsewhere 1

Always evaluate for FAP in patients with:

• 20 FGPs 1

• Age <40 years with multiple polyps 1
• Presence of duodenal adenomas 1

Do not perform surveillance for typical FGPs or polypoid foveolar hyperplasia without dysplasia, GA, or GIM—surveillance is not indicated and wastes resources. 1, 3, 6