How should a gastric polyp identified on endoscopy be evaluated and managed, including criteria for removal and recommended surveillance intervals?

Management of Gastric Polyps

All gastric polyps identified on endoscopy should be documented with number, size, location, and morphology, with all polyps except typical small fundic gland polyps requiring biopsy for histopathological assessment. 1

Initial Endoscopic Evaluation

When you encounter a gastric polyp, your first step is systematic documentation and characterization:

• Document the exact number (if ≤5 polyps) or describe as "multiple" (if >5), along with the size of the largest polyp, location, and morphology 1
• Obtain photographic documentation of all polyps or representative polyps if numerous 1
• Use enhanced imaging techniques (narrow-band imaging, i-Scan, or FICE) when there is diagnostic uncertainty after white light examination to improve diagnostic accuracy 1, 2, 3
• Assess the background gastric mucosa for gastric atrophy, gastric intestinal metaplasia, H. pylori infection, and synchronous neoplasia—this is particularly critical when adenomas or hyperplastic polyps are present 1, 3

Management by Polyp Type

Fundic Gland Polyps (FGPs)

FGPs are the most common gastric polyps (13-77% of all gastric polyps) and appear pale, smooth, glassy, and translucent with lacy blood vessels visible through the surface 1.

For typical FGPs <1 cm:

• No resection is required as they carry minimal malignancy risk 2, 3
• Biopsy confirmation should be obtained when the diagnosis is uncertain based on endoscopic appearance 1
• Re-evaluate PPI appropriateness, as FGPs are associated with long-term PPI use and may spontaneously regress when PPIs are discontinued 1, 3

For FGPs >1 cm or atypical features:

• Resection is mandatory because larger FGPs have a 1.9% risk of dysplasia and 1.9% risk of focal cancer 1, 2, 3
• Resect any FGP with antral location, ulceration, or unusual appearance 3

Critical pitfall: Always evaluate for familial adenomatous polyposis (FAP) in patients with >20 FGPs, age <40 years with multiple polyps, or presence of duodenal adenomas 3

Hyperplastic Polyps

These polyps appear smooth, red, dome-shaped with whitish exudates (fibrin) and prominent surface vascular patterns 1.

Before considering resection:

• Test and eradicate H. pylori first—up to 70% of hyperplastic polyps regress after H. pylori eradication 2, 3
• Re-evaluate after H. pylori treatment before proceeding with endoscopic therapy 1

Indications for resection:

• Size >1 cm (carries 1.9-19% dysplasia risk) 2, 3
• Pedunculated morphology 1
• Symptomatic polyps causing obstruction or bleeding 1, 3

Surveillance requirements:

• Surveillance endoscopy is required if dysplasia, gastric atrophy, or gastric intestinal metaplasia is present, with intervals determined by the stage of chronic atrophic gastritis 3

Adenomatous Polyps (Gastric Adenomas)

All gastric adenomas must be resected when clinically appropriate and safe to do so—this is non-negotiable given their significant malignant potential 1, 4.

The evidence supporting aggressive management is compelling:

• 30% of patients with gastric adenoma have synchronous gastric adenocarcinoma elsewhere in the stomach 4, 3
• 50% of adenomas >2 cm harbor foci of adenocarcinoma 4, 3

Resection technique:

• For sessile polyps ≥15 mm: Use endoscopic submucosal dissection (ESD) rather than endoscopic mucosal resection (EMR) because the probability of invasive neoplasia is high and ESD reduces recurrence risk 2, 4, 3
• For smaller polyps: Standard polypectomy techniques are acceptable 4

Post-resection surveillance:

• Mandatory follow-up gastroscopy at 6-12 months after complete endoscopic excision 1, 2, 4
• Annual surveillance gastroscopy thereafter, with frequency adjusted based on number of polyps, polyp size, highest grade of dysplasia, and stage of chronic atrophic gastritis in background mucosa 1, 2, 4

Critical Pitfalls to Avoid

• Never adopt a "wait and see" approach for gastric adenomas—they require definitive resection due to significant cancer risk 4
• Do not overlook synchronous lesions—30% of patients with adenomas harbor concurrent gastric adenocarcinoma elsewhere, necessitating meticulous examination of the entire stomach 4, 3
• Do not assume small polyps are benign without proper characterization—size >1 cm significantly increases dysplasia and cancer risk across all polyp types 3, 5
• For large sessile lesions ≥15 mm, do not use EMR—ESD is superior for reducing recurrence and ensuring complete resection 4, 3
• Do not confuse gastric adenomas with hyperplastic polyps—they have different management algorithms, including potential H. pylori eradication before resection for hyperplastic polyps 4

Biopsy Strategy

• All gastric polyps except typical small FGPs should be biopsied for histopathological assessment 1
• When multiple polyps are present, representative biopsies should be taken, as coexisting polyps are usually of the same histological type 1
• A single biopsy of a polyp is usually sufficient, with this approach being as accurate as polypectomy in 97.3% of cases 1
• However, be aware that forceps biopsy may miss dysplastic components—in one study, 2 of 3 polyps with carcinoma in situ were not identified by forceps biopsy alone 5