Management of Small (<5mm) Gastric Polyps Scattered Throughout the Stomach Body
Document the number (or estimated number), location, and size of the largest polyp, obtain photographic documentation of representative polyps, and biopsy at least one polyp for histopathological diagnosis—do not assume these are benign based on size alone. 1
Initial Endoscopic Assessment
The British Society of Gastroenterology mandates specific documentation for all gastric polyps, regardless of size:
- Record the total number of polyps (or estimated number if too numerous to count precisely) 1
- Document the location of polyps throughout the stomach 1
- Measure and record the size of the largest polyp present 1
- Obtain photographic documentation of all polyps, or representative polyps if numerous 1
- Use enhanced endoscopic imaging (NBI, i-Scan, or FICE) when there is diagnostic uncertainty after white light examination 1, 2
Biopsy Strategy
All gastric polyps except those with classic fundic gland polyp (FGP) appearance require biopsy for histopathological assessment. 1
When Biopsy Can Be Deferred:
- Polyps with typical FGP appearance: pale, smooth, glassy, transparent or translucent, lighter or same color as surrounding mucosa, with lacy blood vessels visible through the surface and fine grey dots on the surface 1
- Located in the fundus and corpus (not antrum) 1
- All polyps <1 cm in size 1
When Biopsy is Mandatory:
- Any polyp that does not have classic FGP appearance 1
- Any polyp located in the antrum (FGPs should not be in the antrum) 1
- Any polyp >1 cm (1.9% dysplasia risk and 1.9% cancer risk even in FGPs) 1, 2
- Polyps with ulceration or atypical features 1
Management Based on Histopathology
If Fundic Gland Polyps (Most Common, 13-77% of gastric polyps):
- No resection required for typical FGPs <1 cm 1, 2
- Review PPI use and consider discontinuation if appropriate, as FGPs are associated with long-term PPI therapy and may spontaneously regress when PPIs are stopped 1, 2
- Screen for familial adenomatous polyposis (FAP) if: >20 polyps present, patient age <40 years, dysplastic-appearing polyps, or presence of duodenal adenomas 1, 2
- No surveillance endoscopy needed if typical FGPs without atypical features 1
If Hyperplastic Polyps (Second Most Common):
- Test and treat H. pylori before considering resection, as up to 70% of hyperplastic polyps regress after H. pylori eradication 2, 3
- Resect if: size >1 cm (1.9-19% dysplasia risk), pedunculated morphology, or causing symptoms (obstruction, bleeding) 1, 2
- Assess background mucosa for gastric atrophy, gastric intestinal metaplasia, H. pylori, and synchronous neoplasia 1
- Surveillance required if dysplasia, gastric atrophy, or intestinal metaplasia present in background mucosa 2, 3
If Adenomatous Polyps (12% of gastric polyps):
- All adenomas must be resected when clinically appropriate and safe, regardless of size 1, 4
- High malignant potential: 30% have synchronous gastric adenocarcinoma elsewhere, and 50% of adenomas >2 cm contain foci of adenocarcinoma 2, 4
- Carefully examine the entire stomach for synchronous neoplasia 1, 4
- Follow-up gastroscopy at 12 months after complete resection, then annual surveillance thereafter 1, 4
- Assess background mucosa for gastric atrophy, intestinal metaplasia, and H. pylori 1, 4
Critical Pitfalls to Avoid
- Never assume small polyps are benign without histopathological confirmation—size <5mm does not exclude dysplasia or malignancy 2, 5
- Do not ignore polyps in the antrum—FGPs should not occur in the antrum, and antral location suggests hyperplastic or adenomatous polyps requiring biopsy 1
- Always evaluate for FAP when >20 polyps are present, especially in patients <40 years old 1, 2
- Do not overlook synchronous lesions—30% of patients with adenomas harbor concurrent gastric adenocarcinoma elsewhere in the stomach 2, 4
- Biopsy the background mucosa when hyperplastic or adenomatous polyps are found, as 37% have intestinal metaplasia and 6% have synchronous or metachronous adenocarcinoma 3