Colonic polyps are abnormal colonic mucosal overgrowths. They are most common in people over 50 years of age but can also be found in younger patients who have hereditary polyposis syndromes. Affected individuals are typically asymptomatic but may present with gastrointestinal (GI) bleeding, iron deficiency anemia, and/or mechanical bowel obstruction (e.g., due to intussusception). Colonic polyps are classified macroscopically as either pedunculated (i.e., with a stalk) or sessile (i.e., without a stalk). They are classified histologically as adenomatous (most common), hyperplastic, inflammatory, serrated, or hamartomatous. Colonoscopy, which enables direct visualization biopsy and removal of the polyp, is the first-line diagnostic and therapeutic modality. Polyp removal is recommended because, although this condition is typically benign, it may transform to colorectal cancer. Adenomas (e.g., ) have the highest malignancy potential (∼ 5%). Patients with polyps that are concerning for malignancy and/or a history of familial adenomatous polyposis syndrome often require surgical resection. Regular follow-up surveillance is required following the removal of the polyps.
- ∼ 30% of individuals > 50 years
- Incidence increases with age.
- Sex: ♂ > ♀
- Race: more common in Black populations 
Epidemiological data refers to the US, unless otherwise specified.
Macroscopic classification of colonic polyps
|Histologic classification of colonic polyps |
|Histological type||Subtypes||Characteristics||Malignant potential|
|Inflammatory polyps (pseudopolyps)|| |
|Mucosal polyps|| |
|Hamartomatous polyps |
|Serrated polyps|| |
Sessile serrated polyps
Traditional serrated adenoma
|Adenomatous polyps|| |
Villous adenomas are villains because they have the highest malignant potential.
Hereditary polyposis syndromes 
- Consist of adenomatous polyposis syndromes; and hamartomatous polyposis syndromes
- Associated with:
- After diagnostic confirmation of hereditary polyposis syndromes, the following are recommended: 
At-risk family members who decline genetic testing should undergo the same endoscopic surveillance as individuals with known mutations. 
Adenomatous polyposis syndromes 
|Overview of adenomatous polyposis syndromes |
|Syndrome||Characteristic features||Diagnostic findings||Management |
|Familial adenomatous polyposis (FAP) || || |
MUTYH-associated polyposis 
Colonoscopy, not sigmoidoscopy, is the first-line screening modality for individuals with attenuated FAP or MUTYH-associated polyposis because these conditions typically manifest with proximal colonic polyps. 
Counsel patients on the course of polyposis syndromes and the need for adherence to surveillance protocols. 
The Turban covers the head: Turcot syndrome is associated with malignant brain tumors.
Hamartomatous polyposis syndromes 
|Syndrome||Characteristic features||Diagnostic findings||Management|
Peutz-Jeghers syndrome (PJS)
|Juvenile polyposis syndrome (JPS) || || |
Cowden syndrome (most common PTEN hamartoma tumor syndrome) 
Nonhereditary polyposis syndromes
Serrated polyposis syndrome 
- Definition: a condition in which multiple serrated polyps form in the colon; associated with an increased risk of colon cancer
- Prevalence: ∼1:100,000 
- Diagnostic findings: serrated polyps throughout the colon 
- Management 
Cronkhite-Canada syndrome 
- Definition: an extremely rare form of nonhereditary hamartomatous polyposis; associated with an increased risk of colorectal cancer 
- Etiology: unclear; likely immune-mediated
- Clinical features: typically manifests in individuals ∼ 60 years of age 
- Diagnostic findings: numerous hamartomatous polyps; inflammatory changes within polyps
- Request for all patients with suspected polyps (e.g., positive family history, ):
- Send any samples for
- No concerning features: Further treatment is not required.
- Malignant features: Treat as colorectal cancer.
- Features of : Refer to gastroenterology and genetics. 
- Follow-up is required for all patients because of the increased risk of malignancy.
Polyps are often identified as an incidental finding on workup for other conditions.
Patients with or positive (e.g., ) should undergo .
- No polyps present
- Polyps present
|Recommended removal techniques for low and high-risk colonic polyps |
|Suspected polyp type||Characteristic features||Recommended excision technique|
Endoscopic colon polypectomy 
- Snare polypectomy
- Endoscopic mucosal resection
Postpolypectomy bleeding: lower gastrointestinal bleeding that occurs up to 30 days postpolypectomy 
- Risk factors include: 
- Prophylactic measures
- Bowel perforation
- Postpolypectomy coagulation syndrome
Surgical resection 
- Colon resection may be required for suspected ; or confirmed malignancy (see “Surgery for colorectal cancer”).
- may require ; surgical polyp removal (e.g., for large polyps) and/or colonic resection.
Refer patients with low-risk polyps that are difficult to remove (e.g., due to size and/or location) to an endoscopist with experience in advanced endoscopic removal techniques prior to referring to surgery. 
The guidance in this section is for patients with no additional risk factors. For individuals at high risk of CRC, follow . For individuals with hereditary polyposis syndromes, follow condition-specific screening procedures (see “Subtypes and variants”).
|Surveillance after colon polypectomy |
|Risk category||Recommended interval to repeat colonoscopy|
Very low risk
|Intermediate risk|| |
Very high risk: > 10 adenomas
Follow-up should be tailored to the and the patient's .
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