What is the recommended management for a patient with a hyperplastic polyp, considering their medical history and risk of colorectal cancer?

Management of Hyperplastic Polyps

For small hyperplastic polyps (<10 mm) in the rectum or sigmoid colon, return to routine average-risk screening with colonoscopy in 10 years, as these carry no increased colorectal cancer risk. 1, 2

Risk Stratification by Location, Size, and Number

Low-Risk Hyperplastic Polyps (No Intensified Surveillance)

• ≤20 hyperplastic polyps in the rectum or sigmoid colon that are <10 mm: Follow-up colonoscopy in 10 years (strong recommendation, moderate quality evidence) 1
• ≤20 hyperplastic polyps proximal to the sigmoid colon that are <10 mm: Follow-up colonoscopy in 10 years (weak recommendation, very low quality evidence) 1
• These patients should be managed as average-risk individuals with no intensified surveillance 1, 2

High-Risk Hyperplastic Polyps (Require Intensified Surveillance)

• Hyperplastic polyps ≥10 mm: Follow-up colonoscopy in 3-5 years (weak recommendation, very low quality evidence) 1
• Large (≥1 cm), sessile, proximally located hyperplastic polyps with atypical architectural features: Complete removal is mandatory and warrant surveillance similar to adenomas, as they can progress to microsatellite instability colorectal cancer through the serrated pathway 1, 2
• The 3-year interval is favored if there are concerns about complete excision, bowel preparation quality, or local consistency in distinguishing sessile serrated polyps from hyperplastic polyps; the 5-year interval is appropriate when confidence is high in these areas 1

Hyperplastic Polyposis Syndrome

All endoscopists must remain vigilant for hyperplastic polyposis syndrome, which carries a significantly elevated colorectal cancer risk of approximately 54%. 3

Diagnostic Criteria (Any One of the Following):

• At least 5 hyperplastic polyps proximal to the sigmoid colon, with 2 being >1 cm in diameter 1, 2
• Any number of hyperplastic polyps proximal to the sigmoid colon in a patient with a first-degree relative with hyperplastic polyposis 1, 2
• More than 30 hyperplastic polyps of any size distributed throughout the colon 1, 2

Management Considerations:

• Patients meeting these criteria have a markedly increased colorectal cancer risk and require specialized management beyond standard surveillance intervals 1, 2
• Research demonstrates that 54% of hyperplastic polyposis patients developed colorectal cancer during follow-up, with 84% of cancers occurring in the proximal colon 4, 3
• The syndrome is predominantly found in individuals of European ancestry 4
• Optimal management protocols remain under investigation, but frequent colonoscopic surveillance is essential 1

Critical Clinical Pearls

Complete Polyp Removal

• Ensure complete excision of all hyperplastic polyps ≥10 mm, particularly those in the proximal colon, as incomplete removal increases cancer risk. 2, 5
• Document polyp characteristics clearly: size, location, number, and morphology in the pathology report to guide surveillance decisions 2

High-Risk Features Requiring Immediate Attention:

• Large solitary hyperplastic polyps in the right colon warrant particular attention as they carry higher malignancy risk 2
• Atypical architectural and cytologic features, sessile morphology, and proximal location suggest variants that may evolve into serrated adenomas 1
• These variants are linked to sporadic microsatellite instability adenocarcinoma through acquired mismatch repair deficiency 1

Common Pitfalls to Avoid:

• Do not intensify surveillance for small distal hyperplastic polyps (<10 mm in rectosigmoid), as this leads to unnecessary procedures without mortality or morbidity benefit. 2, 5
• Failing to recognize hyperplastic polyposis syndrome can have dire consequences given the 54% cancer risk 3
• Not evaluating the entire colon when large or proximal hyperplastic polyps are found can miss synchronous neoplasia 2, 5

Quality Control Requirements

All recommendations assume: 1

• Examination complete to cecum
• Bowel preparation adequate to detect lesions >5 mm in size
• High confidence of complete resection

These recommendations do not apply to individuals with hereditary CRC syndromes, inflammatory bowel disease, personal history of CRC, or family history of CRC, where shorter intervals may be warranted 1