Information about Approach to patient with colorectal polyp(s) by Dr Dhaval Mangukiya. Details of Approach to patient with colorectal polyp(s), Serrated neoplasia pathway, Management of small polyp(s), Management of large polyp(s), Pedunculated, Newer Makers, Surveillance, Surveillance of family members, Prevention of recurrence, References. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Approach to patient with
colorectal polyp(s)
Dr Dhaval Mangukiya
Dept. of Surgical Gastroenterology

2. • A colorectal polyp is defined as a protuberance into the
lumen from the normally flat colonic mucosa.
• The main importance of polyps is their well recognized
relationship to colorectal cancer. It now is generally
accepted that most (95%) colorectal cancers arise from
benign, neoplastic adenomatous polyps.
• Because most polyps are asymptomatic, they are
usually found incidentally or as the result of screening.
• Colonoscopy is the procedure of choice for diagnosing
colorectal polyps.

3. • Histologically, polyps are classified as neoplastic
or nonneoplastic.
• Nonneoplastic polyps have no malignant
potential and include hyperplastic polyps,
mucosal polyps, submucosal polyps and
inflammatory polyps.
• Neoplastic polyps have malignant potential and
are classified as serrated polyps, hamartomatous
polyps and adenomatous polyps.

5. Serrated neoplasia pathway
• This pathway is characterized by
hypermethylation of numerous genes (so-
called CpG Island Methylator Phenotype
[CIMP high]), and also have activating BRAF
mutations.

6. Management of small polyp(s)
• If a single small polyp (<1 cm) is encountered during
sigmoidoscopy/colonoscopy, it should be resected using
one of a number of different endoscopic techniques,
with or without electrocautery.
• If there are numerous small polyps, representative
biopsies should be obtained.
• Complete removal of all polyps by endoscopy or
surgery is required only for neoplastic polyps and
symptomatic non-neoplastic polyps.
• Current evidence supports the recommendation that a
hyperplastic polyp found during flexible sigmoidoscopy
is not, by itself, an indication for colonoscopy.

7. Management of large polyp(s)
• A patient who has had successful colonoscopic
excision of a large sessile polyp (>2 cm) usually
should undergo follow-up colonoscopy in 3–6
months to determine whether resection was
complete.
• If residual polyp is present, it should be resected
and the completeness of resection documented
within another 3–6-month interval.
• If complete resection is not possible after two or
three examinations, the good-risk patient should
usually be referred for surgical therapy.

8. • Non-neoplastic polyp – surveillance
• Adenomatous polyp & Noninvasive high grade
neoplasia {NHGN} – remove all polyps
colonoscopically. If not possible then consider
surgery
• Malignant polyp
Sessile – surgery
Exception to this rule is rectal sessile polyp with
stage T1, size <3cm, <30%of circumference
involvement, <8cm from anal verge.

9. Pedunculated –
• Favourable factors – colonoscopic removal
1. The cancer is not poorly differentiated.
2. There is no vascular or lymphatic involvement.
3. The margin of resection > 2 mm.
4. Depth of submucosal invasion is < 3 mm from
muscularis mucosae.
• Absence of favourable factors - surgery

11. Newer markers
• Metalloproteinase 7
• Vascular adhesion proteins
• Vascular endothelial growth factors and
• Cytokeratins.

12. Surveillance
• After a complete clearing colonoscopy has been
accomplished after an initial polypectomy, repeat
colonoscopy should be performed in 3 yrs for patients
at high risk for developing metachronous advanced
adenomas. This includes those who at baseline
examination have multiple (>2) adenomas, a large (>1
cm) adenoma, an adenoma with villous histology or
high-grade dysplasia, or have a family history of
colorectal cancer.
• Repeat colonoscopy should be performed in 5 yr for
most patients at low risk for developing advanced
adenomas. This are patients who do not have any of
above findings.

13. • In cases of NHGN and malignant polyp with
pedunculated morphology and favourable
histological criteria, it is recommended that a
colonoscopy be carried out after three
months. If this is normal, a further check up is
advised after one year, three years and five
years.

14. • If complete colonoscopy is not feasible, flexible
sigmoidoscopy followed by a double-contrast
barium enema is an acceptable alternative.
Follow-up surveillance should be individualized
according to the age and comorbidity of the
patient, and should be discontinued when it
seems unlikely that follow-up is capable of
prolonging quality of life.

15. Surveillance of family members
• Colonoscopic surveillance should be considered
for first degree relatives of adenoma patients,
particularly when the adenoma was advanced or
diagnosed before age 60 yr, or, in the case of
siblings, when a parent also had colorectal cancer
diagnosed at any age. When indicated,
surveillance should be initiated 5 yr younger than
the age of initial adenoma diagnosis, or at age 40
yr (whichever occurs first), and then at intervals
of 3–5 yr, depending on findings.

17. Prevention of recurrence
• A diet that is low in fat and high in fruits, vegetables, and
fiber is recommended.
• Normal body weight should be maintained, and smoking
and excessive alcohol use should be avoided.
• Daily dietary supplementation with 3 g of calcium
carbonate may reduce the recurrence of adenomas.
• Other chemopreventive measures (i.e., supplementation
with aspirin and other nonsteroidal anti-inflammatory
drugs (NSAIDs), selenium, or folic acid), supported by
indirect data, cannot yet be recommended pending the
results of ongoing clinical trials showing both efficacy and a
good risk– benefit ratio.

18. References
• Bond JH. Polyp Guideline: Diagnosis, Treatment, and
Surveillance for Patients With Colorectal Polyps. AJG
2000;95(11):3053-3063
• Snover DC. Update on the serrated pathway to colorectal
carcinoma. doi:10.1016/j.humpath.2010.06.002
• Bujanda L, et al. Malignant colorectal polyps. World J
Gastroenterol. 2010 July;16(25):3103–3111
• Yang DH, et al. Korean Guidelines for Postpolypectomy
Colonoscopy Surveillance. Clin Endosc. 2012 March; 45(1):
44–61.
• Brooks DD, et al. Colonoscopy Surveillance After
Polypectomy and Colorectal Cancer Resection. Am Fam
Physician. 2008 Apr 1;77(7):995-1002