Colonic polyps

Last updated: September 29, 2023

Summarytoggle arrow icon

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., adenoma-carcinoma sequence) 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.

Epidemiologytoggle arrow icon

References: [2]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

The exact etiology is unknown. Risk factors include the following: [1]

Classificationtoggle arrow icon

Macroscopic classification of colonic polyps

Histologic classification of colonic polyps

Histologic classification of colonic polyps [3][4][5]
Histological type Subtypes Characteristics Malignant potential
Inflammatory polyps (pseudopolyps)
  • Low malignant potential
Mucosal polyps
  • Benign (no clinical significance)
  • Typically small < 5 mm
  • Mostly appear like normal mucosa
Submucosal polyps

Hyperplastic polyps

  • Most common type of nonneoplastic polyp among those with low malignant potential
  • Small (< 5 mm)
  • Common in the distal colon (rectosigmoid)
  • Might transform to serrated polyps
  • Histology: hyperplasia of normal cellular components with a sawtooth/serrated pattern of crypt epithelium
Hamartomatous polyps [6]
  • Low for solitary polyps
  • Increased risk of colonic and extra-colonic malignancies when associated with syndromes
Serrated polyps

Sessile serrated polyps

  • Moderate malignant potential (∼ 5%) [7]

Traditional serrated adenoma

Adenomatous polyps

Tubular adenoma

  • Frequency: 65–80% [3]
  • Location: anywhere in the colon
  • Histology: proliferating cells forming tubules

Tubulovillous adenoma

  • Frequency: 10–25% [3]
  • Histology: a mixture of tubular and villous histological picture

Villous adenoma

The majority of colon carcinomas develop from adenomas (adenoma‑carcinoma sequence). However, only ∼ 5% of adenomas develop into colon cancers.

Villous adenomas are villains because they have the highest malignant potential.

Clinical featurestoggle arrow icon

Subtypes and variantstoggle arrow icon

Hereditary polyposis syndromes [8][9][10]

At-risk family members who decline genetic testing should undergo the same endoscopic surveillance as individuals with known mutations. [8]

Adenomatous polyposis syndromes [8][9][10]

Overview of adenomatous polyposis syndromes [8][9][10]
Syndrome Characteristic features Diagnostic findings Management [9]
Familial adenomatous polyposis (FAP) [9][10][12]
Attenuated FAP
  • Surveillance
    • Similar to FAP
    • Delayed onset of screening colonoscopies: every 1–2 years starting at 18–20 years of age [9]
  • Treatment

MUTYH-associated polyposis [10]

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. [8][9][10]

Counsel patients on the course of polyposis syndromes and the need for adherence to surveillance protocols. [8]

The Turban covers the head: Turcot syndrome is associated with malignant brain tumors.

Hamartomatous polyposis syndromes [9][10]

Hamartomatous polyposis syndromes [9][10]

Syndrome Characteristic features Diagnostic findings Management

Peutz-Jeghers syndrome (PJS)

Juvenile polyposis syndrome (JPS) [9]

Cowden syndrome (most common PTEN hamartoma tumor syndrome) [15]

  • Surveillance
    • Coloscopy and EGD: every 2 years starting at 15 years of age [9][10]
    • Screen for associated cancers. [9]
  • Treatment

25% of patients with hamartomatous polyposis syndromes have no family history (i.e., de novo mutation), and ≥ 10% of patients have negative genetic testing. [10]

Nonhereditary polyposis syndromes

Serrated polyposis syndrome [5][9][18]

Cronkhite-Canada syndrome [19][20]

Managementtoggle arrow icon


Polyps are often identified as an incidental finding on workup for other conditions.

Patients with red flags for colon cancer or positive colorectal cancer screening tests (e.g., fecal occult blood testing) should undergo diagnostics for colorectal cancer.

Colonoscopy [24][25]

Colonoscopy facilitates simultaneous diagnosis and management of most polyps; suspected malignant colorectal polyps should be biopsied and referred to surgery.

Recommended removal techniques for low and high-risk colonic polyps [24][26][27]
Suspected polyp type Characteristic features Recommended excision technique

Patients with hereditary polyposis syndromes with multiple polyps that cannot be managed endoscopically should also be referred for surgery.

Endoscopic colon polypectomy [24][25]


  • Snare polypectomy
    • A thin wire snare encircles the polyp including a surrounding margin of healthy tissue.
    • The snare is then retracted, which causes it to tighten and cut through the encircled tissue.
    • Can be performed with electrocautery (i.e., hot snare) or without (i.e., cold snare)
  • Endoscopic mucosal resection
    • The submucosa under the polyp is injected to lift the polyp away from the deeper mucosa.
    • A snare procedure is then performed to excise the polyp.

Complications [24][25][28]

Surgical resection [24][25][30]

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. [24]

Follow-up [31][32]

The guidance in this section is for patients with no additional risk factors. For individuals at high risk of CRC, follow colorectal cancer screening in high-risk individuals. For individuals with hereditary polyposis syndromes, follow condition-specific screening procedures (see “Subtypes and variants”).

Surveillance after colon polypectomy [31][32]
Risk category Recommended interval to repeat colonoscopy

Very low risk

  • 10 years


  • 7–10 years
Intermediate risk
  • 3–5 years


  • 3 years

Very high risk: > 10 adenomas

  • 1 year [9]

Follow-up should be tailored to the histology of the colonic polyp and the patient's risk factors for colorectal cancer.

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Referencestoggle arrow icon

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