para>JPS impose a higher risk of CRC, although juvenile polyps are not premalignant.
DIAGNOSIS
HISTORY
- Usually normal
- Generally asymptomatic
- Painless rectal bleeding, bright or dark red, mixed with stools, dripping, or on wiping
- Diarrhea or mucous stool
- Abdominal pain
- Constipation
- Chronic bleeding resulting in iron deficiency anemia
- McKittrick-Wheelock syndrome; large hypersecretory rectosigmoid villous adenoma, resulting in persistent severe diarrhea, electrolyte disorder, dehydration, and prerenal acute renal failure
- Social and family history
PHYSICAL EXAM
- Usually normal
- Rectal polyps noted as prolapsed or palpated on DRE
- FOBT by DRE is less effective than FOBT by stool passed spontaneously.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- CBC; anemia with chronic bleeding
- Basic metabolic panel; electrolyte disorder with hypersecretory adenomas
- Fecal occult blood test (FOBT), an insensitive screening test, as small polyps don't usually bleed, includes:
- Guaiac (gFOBT)-uses a chemical indicator with color change in presence of blood
- Immunochemical (iFOBT or fecal immunochemical test [FIT])-uses antibodies against human hemoglobin
- Stool DNA test is more sensitive and less specific than fecal immunochemical test (FIT).
Diagnostic Procedures/Other
- Colonoscopy is the gold standard test for detection of polyps and polypectomy. Not a perfect screening test, with increased miss rate with right-sided colon polyps, smaller polyp size, low quality of colon prep, less endoscopist experience
- Computed tomographic colonography (CTC) is less sensitive with flat polyps and requires excellent bowel preparation.
- Double-contrast barium enema
- Colon capsule endoscopy
- Enhanced optical technologies can potentially differentiate between neoplastic and non-neoplastic colonic lesions (4)[A].
- Enhanced optical technologies include:
- Narrowed spectrum endoscopy (narrow-band imaging [NBI])
- Image-enhanced endoscopy (i-scan)
- Fujinon intelligent chromoendoscopy (FICE)
- Confocal laser endomicroscopy (CLE)
- Patients with >10 colorectal adenomas should get genetic testing for APC and MUTYH (5)[C].
Test Interpretation
- Tubular adenoma
- Gross: tend to be polypoid
- Micro: dysplastic epithelium with a tubular architecture
- Villous adenoma:
- Gross: tend to be sessile
- Micro: dysplastic epithelium with fine finger-like projections
- Tubulovillous adenomas have a combination of tubular and villous architecture.
- Hyperplastic polyps are composed of hyperplastic colonic mucosa.
- Hamartomatous polyps include muscularis mucosa.
- Juvenile polyp
- Gross: pedunculated, smooth, red mass, 1 to 3 cm (2).
TREATMENT
SURGERY/OTHER PROCEDURES
- Colonic polypectomy; diagnostic, therapeutic
- Techniques are as follows:
- Snare polypectomy with electrocautery for pedunculated polyps
- Endoscopic mucosal resection for sessile polyps
- Endoscopic submucosal dissection
- Colorectal surgery; prophylactic in FAP and MAP and when there are numerous polyps or persistent bleeding (2,5)[C]:
- Total colectomy ileorectal anastomosis
- Proctocolectomy ileal pouch anal anatomosis
- Chemoprevention: NSAIDs and calcium may reduce incidence and recurrence of polyps in patients with FAP and MAP (3)[A].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow-up colonoscopy in:
- 10 years if no polyps or distal small hyperplastic polyps (<10 mm) (1)[B]
- 5 to 10 years if 1 to 2 small tubular adenomas (<10 mm) (1)[B]
- 3 years if 3 to 10 adenomas if any polyp ≥6 mm (1)[B] or if all polyps <6 mm (1)[C]
- <3 years if >10 adenomas (1)[B]
- 3 years if one or more adenomas ≥10 mm (1)[A]
- 3 years if one or more adenomas with villous features of any size or with HGD (1)[B]
- 5 years if sessile serrated polyp(s) <10 mm with no dysplasia (1)[C]
- 3 years if sessile serrated polyp(s) ≥10 mm or with dysplasia or traditional serrated adenoma (1)[C]
- 1 year if serrated polyposis syndrome (1)[B]
Patient Monitoring
- Colonoscopy for CRC screening starts at age 50 years and earlier for at-risk patients.
- Stop screening if life expectancy is <10 years.
- In CFAP and AFAP, screen for extracolonic manifestations: thyroid cancer, desmoid tumors, and gastroduodenal polyposis (every 6 months to 5 years) (5)[C]
- In families, lifetime screening is indicated in mutation carriers (5)[C]:
- In CFAP: with sigmoidoscopy or colonoscopy every 1 to 2 years starting at age of 10 to 11 years
- In AFAP and MAP: with colonoscopy every 1 to 2 years starting at age of 18 to 20 years
- After colorectal surgery, surveillance of the rectum (every 6 to 12 months) or pouch (every 6 months to 5 years) is indicated (5)[C].
- First-degree relatives of patients with JPS require screening by colonoscopy and upper endoscopy after age 12 (2)[C].
DIET
Low-fat, high-fiber diet has been recommended but with insufficient evidence.
PATIENT EDUCATION
Importance of colonoscopy as a screening tool for reduction of incidence of colorectal cancer
PROGNOSIS
- Regression or no change in size, more with small hyperplastic polyps and with patients on NSAIDs
- Recurrence: Juvenile polyps recur in 45% of children with multiple polyps and 17% of children with solitary polyps (2).
- Increase in size, more with large adenomas
- Progression to cancer
- Risk factors for colon cancer (6)[A]:
- Polyp pathology
- Adenomatous
- Serrated
- With high-grade dysplasia
- With >25% villous histology
- Polyp size >1 cm in diameter
- Polyps located in proximal colon
- More than three polyps
- Recurrence rates <10% postpolypectomy
COMPLICATIONS
- Polyps: progression to cancer
- Polypectomy: bleeding 2-11%, perforation 0-1%, higher with endoscopic submucosal dissection
- Colonoscopy: complications related to anesthesia and procedure itself
REFERENCES
11 Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143(3):844-857.22 Thakkar K, Fishman DS, Gilger MA. Colorectal polyps in childhood. Curr Opin Pediatr. 2012;24(5):632-637.33 Johnson CC, Hayes RB, Schoen RE, et al. Non-steroidal anti-inflammatory drug use and colorectal polyps in the prostate, lung, colorectal, and ovarian cancer screening trial. Am J Gastroenterol. 2010;105(12):2646-2655.44 Wanders LK, East JE, Uitentuis SE, et al. Diagnostic performance of narrowed spectrum endoscopy, autofluorescence imaging, and confocal laser endomicroscopy for optical diagnosis of colonic polyps: a meta-analysis. Lancet Oncol. 2013;14(13):1337-1347.55 Stoffel EM, Mangu PB, Limburg PJ. Hereditary colorectal cancer syndromes: American Society of Clinical Oncology clinical practice guideline endorsement of the familial risk-colorectal cancer: European Society for Medical Oncology clinical practice guidelines. J Oncol Pract. 2015;11(3):e437-e441.66 Gao Q, Tsoi KK, Hirai HW, et al. Serrated polyps and the risk of synchronous colorectal advanced neoplasia: a systematic review and meta-analysis. Am J Gastroenterol. 2015;110(4):501-509.
ADDITIONAL READING
- Ashraf I, Paracha SR, Arif M, et al. Digital rectal examination versus spontaneous passage of stool for fecal occult blood testing. South Med J. 2012;105(7):357-361.
- Brenner H, Hoffmeister M, Arndt V, et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst. 2010;102(2):89-95.
- Cooper K, Squires H, Carroll C, et al. Chemoprevention of colorectal cancer: systematic review and economic evaluation. Health Technol Assess. 2010;14(32):1-206.
- Farraye FA, Odze RD, Eaden J, et al. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010;138(2):738-745.
- Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med. 2014;370(14):1287-1297.
- Lee BG, Shin SH, Lee YA, et al. Juvenile polyp and colonoscopic polypectomy in childhood. Pediatr Gastroenterol Hepatol Nutr. 2012;15(4):250-255.
- Sonnenberg A, Genta RM. Low prevalence of colon polyps in chronic inflammatory conditions of the colon. Am J Gastroenterol. 2015;110(7):1056-1061.
- Summers RM. Polyp size measurement at CT colonography: what do we know and what do we need to know? Radiology. 2010;255(3):707-720.
SEE ALSO
Colorectal Cancer
CODES
ICD10
- K63.5 Polyp of colon
- D12.6 Benign neoplasm of colon, unspecified
- K51.40 Inflammatory polyps of colon without complications
- D12.5 Benign neoplasm of sigmoid colon
- D12.2 Benign neoplasm of ascending colon
- D12.3 Benign neoplasm of transverse colon
- D12.4 Benign neoplasm of descending colon
- D12.0 Benign neoplasm of cecum
- D12.1 Benign neoplasm of appendix
ICD9
211.3 Benign neoplasm of colon
SNOMED
- 68496003 Polyp of colon (disorder)
- 428054006 Adenomatous polyp of colon
- 13025001 Pseudopolyposis of colon
- 72900001 Familial multiple polyposis syndrome (disorder)
- 428472008 Polyp of sigmoid colon (disorder)
- 309084001 Villous adenoma of colon
CLINICAL PEARLS
- Progression from normal mucosa to polyp to carcinoma is a sequence that takes years to develop.
- Colonoscopy is the gold standard tool for diagnosis of polyps and reduction of CRC incidence.
- Small hyperplastic polyps should be biopsied to differentiate adenomatous and serrated polyps.
- Use of NSAIDs and calcium is associated with decreased incidence and recurrence of polyps.