Medical Care
Some studies have demonstrated that medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) decreases the number and the size of colonic polyps. However, NSAIDs, such as sulindac, do not prevent cancer development. These drugs do not yet constitute established therapies or chemopreventives for colonic polyps.
One study suggests that aspirin may be beneficial in reducing the incidence of recurrent colonic polyps, particularly advanced colonic polyps in select patients with a high risk of colon cancer (and coronary artery disease) and an acceptably low risk of gastrointestinal bleeding or hemorrhagic stroke. [6]
Consultations
Obtain a Surgical consultation; this is critical in patients with multiple polyps, including patients with familial adenomatous polyposis (FAP). Explain and discuss the type and timing of surgery with the patient.
Diet and activity
A regular diet may be continued. The patient can consider calcium and folate supplements to decrease the risk of colonic polyp recurrence.
Activities may be maintained as tolerated.
Surgical Care
Polypectomy
In the case of a solitary pedunculated polyp, colonoscopic removal can be performed concurrently with the search for other lesions.
Removal of a solitary colonic polyp is usually curative for that lesion. However, a complete colonoscopic examination should be performed because the finding of a single adenomatous polyp confers an increased risk for the development of others. The rate of colonic polyp recurrence (discovered at follow-up colonoscopy) at 1-year postpolypectomy is small, and recurrence may in fact represent missed synchronous lesions. Repeat colonoscopy at 3-12 months is sometimes advocated if there is substantial doubt whether a colonic polyp has been completely resected and/or contains high-grade dysplasia. [24]
A systematic review and meta-analysis of the efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps found that cold snare polypectomy had a significantly shorter procedure time and a tendency toward less delayed bleeding compared to hot snare polypectomy. [25] A total of 8 studies comprising 1665 patients and 3195 polyps were evaluated.
Combined laparoscopic/colonoscopic polypectomy or endolaparoscopic polypectomy (ELP) may be a safe and effective alternative to segmental resection, particularly for colonic polyps not amenable to exclusively colonoscopic removal because of their location, size, or tortuosity of the colon. [26] In a retrospective study of 30 patients with benign colonic polyps, 22 (73%) underwent successful ELP surgery, 7 were converted to colonic mobilization and colotomy, and 1 was converted to laparoscopic colectomy. [26]
Higher risk (eg, large, aggressive appearing) polyps are often marked at the time of resection by injection of ink (“tattooing”). This method helps to locate the site again, either during colonoscopy or surgery, for follow-up examination, biopsy, or resection. [27] Resection of a large, flat or sessile lesion, particularly when it is removed in pieces, or a polyp with a focus of high-grade dysplasia or cancer is often followed by repeat endoscopy in 3 months to confirm complete excision.
Colonic resection
In the case of multiple intestinal polyps associated with FAP, colon resection remains the only feasible option. See the image below.
Familial adenomatous polyposis, total colectomy specimen. The colonic mucosa is studded with innumerable sessile and small pedunculated polyps, which involve the entire length of the specimen.
Colonic resection is also advocated for patients with long-standing ulcerative colitis who have developed high-grade dysplasia or a dysplasia-associated lesion or mass (DALM). [6]
Surgical resection may be advocated for large, sessile polyps that are difficult to remove or for advanced colonic polyps that recur despite adequate initial endoscopic treatment.
Several surgical options should be discussed with the patient, including total colectomy, subtotal colectomy with rectal sparing, or segmental resection.
Prevention
Currently, no definitive guidelines exist regarding the prevention of the development of colonic polyps. However, note the following:
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Calcium may be modestly protective.
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Fiber may also have some activity; the best evidence is for cereal fiber.
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Aspirin may be considered in select patients.
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Studies have demonstrated that a diet high in antioxidants has no impact on colonic polyp recurrence.
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In one study, supplementary folate was also found to have no benefit, although this conclusion bears the caveat that the tested population had substantial basal folate intake. Thus, some folate intake may be protective.
See the Guidelines section for colorectal cancer screening recommendations from the US Multi-Society Task Force (MSTF), which represents the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE).
Long-Term Monitoring
Surveillance colonoscopy for early detection of colorectal cancer is probably unnecessary in those with low-risk adenomas (ie, 1-2 adenomas < 10 mm in size), whereas patients with 3 or more adenomas or adenomas larger than 10 mm should undergo surveillance colonoscopy at 3 years after baseline. [28]
Most gastroenterologists advocate repeat colonoscopy 5 years following complete removal of a low-risk adenomatous polyp (as defined histologically). Colonoscopy is repeated in 3 years if the polyp has higher-risk features. Repeat colonoscopy may be advised in 3-12 months if the adequacy of polyp removal is a matter of substantial doubt. If no colonic polyps are found at the initial examination, follow-up colonoscopy at approximately 10-year intervals is recommended.
See the Guidelines section for colorectal cancer screening recommendations from the US Multi-Society Task Force (MSTF), which represents the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE).
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Familial adenomatous polyposis, total colectomy specimen. The colonic mucosa is studded with innumerable sessile and small pedunculated polyps, which involve the entire length of the specimen.
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Multiple large polyps in the colon. The polyp in the center of the image is situated on a stalk. (Endoscopic image).
