eMedicine Specialties > Gastroenterology > Colon

Villous Adenoma: Treatment & Medication

Author: Alnoor Ramji, MD, FRCPC, Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada
Coauthor(s): Eric M Yoshida, MD, MHSc, FRCPC, FACP, Program Director of Adult Gastroenterology Training Program, Assistant Professor, Department of Medicine, Division of Gastroenterology, University of British Columbia
Contributor Information and Disclosures

Updated: Aug 29, 2009

Treatment

Medical Care

  • A full colonoscopy is the accepted procedure of choice in North America for screening or investigation of possible adenomas. If possible, remove all polyps at endoscopy. Send polyps to a pathologist to assess for histological type, grade of dysplasia, and presence of carcinoma. Record the gross morphology, location, and size of each polyp.
  • Perform a full colonoscopy if sigmoidoscopy reveals an adenoma. Of patients with rectosigmoid adenomas, 40-50% have additional proximal polyps. From the NPS data, patients with left-sided adenomas had a 2.9-fold risk of also having right-sided polyps compared to patients with no left-sided polyps. Patients with only a hyperplastic polyp in the rectosigmoid do not require full colonoscopy.
  • Cautery snare is recommended for removal of larger polyps. For large sessile polyps, for which the risk of perforation is higher, injection of 1 mL or more of saline into the submucosa directly under the polyp is a useful technique. This lifts the flat polyp away from the muscular layer, creating a stalklike effect. A couple of drops of methylene blue added to the saline also allows the operator to determine if a perforation has occurred in the muscle layer, which would be seen as a break in the layer. Smaller sessile polyps should be removed or biopsied and ablated with hot-biopsy forceps or a minisnare.
  • After removal of a large (>2 cm) sessile polyp or if the possibility exists of incomplete removal of a large adenoma, a follow-up colonoscopy usually should be performed within 3-4 months.
  • In the case of malignant polyps, no further treatment is necessary if certain conditions are met, as published by the AmericanCollege of Gastroenterology.
    • The polyp is considered to be completely excised by the endoscopist.
    • The polyp is fixed and sectioned so that it is possible to accurately determine the depth of invasion, grade of differentiation, and completeness of excision of the carcinoma.
    • The cancer is not poorly differentiated. 
    • No evidence exists of vascular or lymphatic involvement. 
    • The margin of the excision is not involved.
  • The role for nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors is unclear. No evidence indicates regression in patients who already have polyps who are treated with these agents, although NSAIDS may have a role in primary prophylaxis.

Surgical Care

  • Surgical resection of a colorectal polyp may be required, especially if the polyp is larger than 2-3 cm and is sessile (as villous adenomas often are). Also, polyps encompassing 2 colonic folds often require surgical consideration. In such situations, the colonic wall can be marked with India ink for localization of the bowel segment at surgery.
  • If benign, duodenal villous adenomas can be treated by local transduodenal resection, although recurrence is common and may be malignant. Consider pancreaticoduodenectomy for duodenal malignant villous adenomas and for villous tumors of the ampulla of Vater.

Consultations

  • A competent endoscopist should supervise care and follow-up.
  • Consultation with a surgeon may be required for resection of the polyp.

Diet

  • Dietary recommendations have been established to prevent colorectal cancer. Given the evidence for the adenoma-to-carcinoma sequence, these recommendations likely also apply to adenomas.
    • Fat intake: Limit total fat to 25-30% of energy intake. A fatty diet may increase biliary sterols, which are damaging.
    • Fruit and fiber intake: Increase fruit and fiber intake to 5 servings daily. Increased fiber dilutes luminal contents and decreases the contact between carcinogenic substances and the lumen. Fruits and vegetables also contain minerals and vitamins that may impede carcinogenesis.
    • Fiber intake: Ingest 20-30 g of fiber daily. In addition to the benefits of increased fruit and fiber intake, fiber may inhibit some harmful bacteria and prevent damaging effects of bile acids.
  • Dietary supplementation with 3 g of calcium carbonate is suggested based upon limited data.

Activity

  • Maintain normal body weight.
  • Exercise daily. Exercise helps decrease transit time and, therefore, the contact of harmful substances with the lumen.
  • Avoid smoking and excessive consumption of alcohol.

Medication

The literature supports the use of NSAIDs in FAP syndrome, with regression of polyps already present. It has been demonstrated that COX-2 is up-regulated 2-50 times in most (85-90%) adenocarcinomas. The role for NSAIDs (including the newer COX-2 inhibitors) in nonfamilial adenomatous lesions is unclear. For sporadic polyps, NSAID use has not been proven to cause regression in already developed polyps, although evidence suggests a decreased incidence of polyps in persons already taking NSAIDs. Therefore, a potential role exists for NSAIDs as primary prophylaxis.

In patients who have had a history of colon cancer, patients undergoing therapy with aspirin at 325 mg daily have fewer polyps than those on placebo. In patients with a history of a colonic polyp, low-dose aspirin (81 mg) may have some benefit in decreased adenoma recurrence.6

Studies with celecoxib have shown some regression in polyps in those patients with FAP. However, the routine use of COX-2 inhibitors for this indication may not be reasonable, especially in consideration of the recent documentation on cardiovascular toxicity/contraindications.

Nonsteroidal anti-inflammatory drugs

Mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions, also may exist.


Sulindac (Clinoril)

Sulfoxide NSAID that is metabolized to the anti-inflammatory sulfide metabolite and a sulfone metabolite. Sulfide metabolite is now known to have apoptotic activity on colonic epithelial cells and is presumed to be responsible for regression of adenomatous polyps. Primary route of excretion is via urine as both sulindac and its sulfone metabolite.

Adult

150 mg PO bid; not to exceed 400 mg/d

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; GI tract bleed; renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low WBC counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs; caution in anticoagulation defects or patients who are receiving anticoagulant therapy

More on Villous Adenoma

Overview: Villous Adenoma
Differential Diagnoses & Workup: Villous Adenoma
Treatment & Medication: Villous Adenoma
Follow-up: Villous Adenoma
Multimedia: Villous Adenoma
References
Further Reading
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References

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Further Reading

Clinical guidelines

Guidelines for colonoscopy surveillance after polypectomy: A consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
American Cancer Society - Disease Specific Society
American Gastroenterological Association Institute - Medical Specialty Society.  2006 May.  17 pages.  NGC:006080

Surveillance and management of groups at increased risk of colorectal cancer.
New Zealand Guidelines Group - Private Nonprofit Organization.  2004 May.  84 pages.  NGC:003655

Quality indicators for colonoscopy.
American College of Gastroenterology - Medical Specialty Society
American Society for Gastrointestinal Endoscopy - Medical Specialty Society.  2006 Apr.  13 pages.  NGC:004969

Colorectal cancer screening.
Institute for Clinical Systems Improvement - Private Nonprofit Organization.  1995 May (revised 2008 Jun).  27 pages.  NGC:006580

Routine aspirin and non-steroidal anti-inflammatory drug (NSAID) prophylaxis for colorectal cancer prevention.
United States Preventive Services Task Force - Independent Expert Panel.  2007 Mar.  5 pages.  NGC:005452

Clinical trials

Randomised Trial of NBI for Adenoma Detection

Selenium in Treating Patients With Adenomatous Colorectal Polyps

A Prospective, Single Blinded Study for Predicting Colon Polyp Histology With Narrow Band Imaging (NBI)

Chemoprevention of Colorectal Adenomas

Prevention of Progression of Duodenal Adenomas in Patients With Familial Adenomatous Polyposis (PreDuoFAP)


Related eMedicine topics

 Pancreas, Mucinous Cystic Neoplasm

Papillary Tumors

Neoplasms of the Endocrine Pancreas

Colon, Polyps

Hereditary Colorectal Cancer

Colon Cancer, Adenocarcinoma

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Keywords

villous adenoma, tubulovillous adenoma, adenomatous polyps, colonic tumor, colonic neoplasm, papillary adenoma, malignancy, tubular adenoma, tubulovillous adenoma, tubulo-villous adenoma, colonoscopy, adenocarcinomas, rectal cancer, colon cancer, colonic villous adenomas

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Contributor Information and Disclosures

Author

Alnoor Ramji, MD, FRCPC, Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada
Alnoor Ramji, MD, FRCPC is a member of the following medical societies: Canadian Society of Internal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Eric M Yoshida, MD, MHSc, FRCPC, FACP, Program Director of Adult Gastroenterology Training Program, Assistant Professor, Department of Medicine, Division of Gastroenterology, University of British Columbia
Disclosure: Nothing to disclose.

Medical Editor

Manoop S Bhutani, MD, FACG, FACP, Professor, Department of Medicine, Division of Gastroenterology, Director, Center for Endoscopic Ultrasound, Co-Director, Center for Endoscopic Research, Training and Innovation, University of Texas Medical Branch at Galveston
Manoop S Bhutani, MD, FACG, FACP is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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