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Villous Adenoma Treatment & Management

  • Author: Alnoor Ramji, MD, FRCPC; Chief Editor: Julian Katz, MD  more...
Updated: Dec 16, 2014

Medical Care

See the list below:

  • 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 American College 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

See the list below:

  • 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.


See the list below:

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


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.

Limit total fat to 25-30% of energy intake. A fatty diet may increase biliary sterols, which are damaging.

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.

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.



See the list below:

  • 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.
Contributor Information and Disclosures

Alnoor Ramji, MD, FRCPC Department of Medicine, Division of Gastroenterology, University of British Columbia Faculty of Medicine, Canada

Alnoor Ramji, MD, FRCPC is a member of the following medical societies: Canadian Society of Internal Medicine

Disclosure: Nothing to disclose.


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 Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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 & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Manoop S Bhutani, MD Professor, Co-Director, Center for Endoscopic Research, Training and Innovation (CERTAIN), Director, Center for Endoscopic Ultrasound, Department of Medicine, Division of Gastroenterology, University of Texas Medical Branch; Director, Endoscopic Research and Development, The University of Texas MD Anderson Cancer Center

Manoop S Bhutani, MD 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, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

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Endoscopic view of a sessile polyp, which histology studies revealed to be a villous adenoma. Courtesy of H. Chaun, MD.
Endoscopic view of a sessile polyp histologically determined to be a villous adenoma. Courtesy of R. Enns, MD.
Endoscopic view of injection of saline into the base of a sessile polyp histologically determined to be a villous adenoma. This enables an easier polypectomy. Courtesy of R. Enns, MD.
Polypectomy with a snare around a sessile polyp base (villous adenoma) injected with saline. Courtesy of R. Enns, MD.
Histology of villous adenoma. Fingerlike projections stretching from the surface of a polyp downward with minimal branching. Courtesy of D. Owen, MD.
Histology of villous adenoma. Low-grade dysplasia with loss of mucin, prominent nucleoli, and hyperchromatic and elongated cells. Courtesy of D. Owen, MD.
Fecal occult blood testing. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University).
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