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Colorectal polyps

Background

Overview

Definition
Colorectal polyps are abnormal growths originating from the colonic or rectal mucosa. They can be classified into several types, including adenomatous, hyperplastic, serrated, hamartomatous, and inflammatory polyps, each with varying potential for malignant transformation.
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Pathophysiology
The development of colorectal polyps is a complex process involving the abnormal proliferation of epithelial cells in the colon or rectum. This can be driven by various genetic and epigenetic changes, such as chromosomal instability and MSI pathways, leading to the disruption of normal cell growth and differentiation processes. Some polyps, particularly adenomatous polyps, have the potential to progress to CRC through a process known as the adenoma-carcinoma sequence.
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Epidemiology
The prevalence of colorectal adenomas in individuals aged > 50 years is estimated at 20-60% in the US.
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Risk factors
Several factors have been associated with an increased risk of colorectal polyps, including age (> 40 years), male sex, a family history of CRC or polyps, certain genetic syndromes, IBD, and lifestyle factors such as smoking, obesity, and a diet high in red meat (for rectal polyps).
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Disease course
Most colorectal polyps are asymptomatic and are often detected incidentally during routine colonoscopies. Occasionally, large polyps can cause symptoms.
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Prognosis and risk of recurrence
The prognosis for patients with colorectal polyps is generally good, especially when the polyps are detected and removed early. Most polyps are benign and can be completely removed during a colonoscopy. However, some polyps can progress to CRC if left untreated, and the risk increases with the size and number of polyps. Adenomatous polyps are the most common type and have the highest risk of progressing to CRC, and polyps > 1 cm or with villous histology are more likely to be malignant.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of colorectal polyps are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2024), the European Society of Gastrointestinal Endoscopy (ESGE 2024), the US Multi-Society Task Force on Colorectal Cancer (USMSTF 2020), and the Association of Coloproctology of Great Britain and Ireland (ACPGBI/BSG 2015).
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Diagnostic procedures

Technical considerations for colonoscopy, general principles: as per AGA 2024 guidelines, use high-definition white-light and/or electronic chromoendoscopy for structured visual assessment with photodocumentation for all polyps detected during routine colonoscopy. Inspect colorectal polyps closely for features of submucosally invasive cancer.
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  • Technical considerations for colonoscopy (CO2 insufflation)

  • Technical considerations for colonoscopy (documentation and reporting)

Therapeutic procedures

Endoscopic resection, general principles: as per ESGE 2024 guidelines, perform resection of all polyps, excluding diminutive (≤ 5 mm) rectosigmoid polyps that are confidently predicted to be nonadenomatous.
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  • Endoscopic resection, technical considerations

  • Endoscopic resection, pedunculated polyps

  • Endoscopic resection, diminutive polyps

  • Endoscopic resection, small polyps

  • Endoscopic resection, flat and sessile polyps

  • Endoscopic resection, large nonpedunculated polyps (choice of procedure)

  • Endoscopic resection, large nonpedunculated polyps (submucosal injection)

  • Endoscopic resection, large nonpedunculated polyps (ablation therapy)

  • Endoscopic resection, large nonpedunculated polyps (clipping)

  • Endoscopic resection, large nonpedunculated polyps (tattooing)

  • Endoscopic resection, large nonpedunculated polyps (post-resection assessment)

Perioperative care

Preprocedural antibiotic prophylaxis
As per ESGE 2024 guidelines:
Avoid administering antibiotics routinely for conventional polypectomy or endoscopic mucosal resection in the colon.
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Consider administering prophylactic antibiotics for endoscopic mucosal resection in the distal rectum or anorectal junction, due to the direct lymphovascular drainage of the mucosa into the systemic circulation, bypassing the portosystemic circulation.
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  • Management of periprocedural bleeding

Surgical interventions

Indications for surgery: as per AGA 2024 guidelines, refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation.
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Follow-up and surveillance

Surveillance colonoscopy after polypectomy, general principles: as per USMSTF 2020 guidelines, perform repeat colonoscopy in 3 years in patients with ≥ 1 adenomas ≥ 10 mm completely removed at high-quality examination.
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  • Surveillance colonoscopy after polypectomy (tubular adenoma)

  • Surveillance colonoscopy after polypectomy (hyperplastic polyps)

  • Surveillance colonoscopy after polypectomy (sessile serrated polyps)

  • Surveillance colonoscopy after polypectomy (high-grade dysplasia)

  • Management of recurrence