COLORECTAL POLYPS

DR.BATOOL ZEHRA RESIDENT WARD 3

Colon Polyps

The term polyp of the colon refers to a

protuberance into the lumen from the normally flat colonic mucosa.
Polyps are usually asymptomatic but may ulcerate and bleed, cause tenesmus if in the rectum, and, when very large, produce

intestinal obstruction.

Colon Polyps
Hyperplastic Hamartomatous Inflammatory Neoplastic

Normal colonic mucosa

Hyperplastic Polyps:
90% of all polyps.

Benign epithelial polyps.

Located in the rectosigmoid < 0.5 cm in size. May exhibit malignant potential in case of

hyperplastic polyposis syndrome.

Hyperplastic Polyps

Inflammatory pseudo-polyps
irregularly shaped islands of residual intact colonic

mucosa.
result from mucosal ulceration and regeneration that

occurs in inflammatory bowel disease (IBD).

multiple, often filiform. semipedunculated in areas of more active recent

inflammation, and have mucus adherent to their apices.

Pseudopolyps in IBD

Hamartomatous polyps
growths, like tumours found in organs as a result of

faulty development.
made up of a mixture of tissues. Peutz-Jegher Syndrome or Juvenile Polyposis Syndrome

are examples.

Juvenile Polyps

hamartomatous lesions

consist of a lamina propria and dilated cystic

glands rather than increased numbers of epithelial cells.

Peutz-Jeghers polyps

hamartomatous lesion.

glandular epithelium supported by smooth muscle cells that is contiguous with the muscularis mucosa.

Duodenal Peutz-Jeghers polyp

Adenomatous Polyps

approximately 10% of polyps.

Adenomas are by definition dysplastic and

thus have malignant potential.

Pathologic classification
Histology and size of colonic adenomas are major

determinants of malignant potential.

glandular architecture of adenomas is characterized as:

tubular villous, tubulovillous.

Tubular adenomas
more than 80% of colonic adenomas.

characterized by a network of branching adenomatous

epithelium.

To be classified as tubular, the adenoma should have a

tubular component at least 75%.

Villous adenomas
5 to 15%.

most commonly occur in rectal area.

tend to be nonpedunculated, velvety, or cauliflowerlike in

appearance.
characterized by glands that are long and extend straight

down from the surface to the center of the polyp.

To be classified as villous,should have 75% villous

component.

Vilous adenoma

Tubulovillous adenomas

5 to 15% of adenomas.

Have 26-75% villous component.

Polyp base
Sessile

base is attached to the colon wall

Pedunculated

mucosal stalk is interposed b/w polyp and colon.

NOTE:

Adenomas commonly found within raised lesions, 27 to 36% flat , 1% depressed.

Advanced pathologic risk factors

Risk factors in adenomas are:

>1 cm in diameter.

high-grade dysplasia. >25 percent villous histology. invasive cancer.

(Invasive malignancy is defined by a breach of the muscularis mucosa by neoplastic cells)

Clinical presentation:
Mostly asymptomatic.

In symptomatic symptoms, most common per rectal

bleeding.

Villous adenomas manifest as :

syndrome of severe diarrhea with massive fluid and electrolyte loss(hypokalemia).

Family history.

Examination:
Anemia Digital Rectal Examination:

Normal or Blood stained or rectal polyps

Investigations:
Air contrast barium enema:
detect larger colonic polyps but can miss small.

Capsule Endoscopy:
Van Gossum trial reported low sensitivity of capsule

endoscopy to colonoscopy

Stool DNA:
detect mutant DNA fom exfoliated tumor cells in stool but expensive

Investigations:
Sigmoidoscopy/Colonoscopy:
preferred test to detect colonic polyps, obtain biopsies,

and/or perform endoscopic resection.

Sensitivities for large colonic polyps in the 80-90% range

have been reported.

Risk factors for focal cancer within an individual adenoma

Villous histology.

Increasing polyp size.

High-grade dysplasia.

Management Plan
COLONOSCOPIC REMOVAL
Solitary pedunculated polyp . polypectomy & biopsy

Large suspicious polyp.. polypectomy & biopsy

with injection of indian ink dye

Multiple polyps. polypectomy & biopsy

followed by assesment for familial syndromes

Histopathology
Hamartomatous Polyp

Single..Surveillence MultipleAssesment for PJS / JPS

Hyperplastic Polyp
SingleSurveillence Multiple.Assesment for HPS

Adenomatous Polyp
SingleSurveillence Multiple.Assesment for HNPCC / FAP

Surveillance
Small hyperplastic polyps
Adenomatous polyps
only 1 or 2

colonoscopy 10 yearly

small (<1 cm) tubular adenomas only low-grade dysplasia

5 yearly

multiple (3-10) adenomas, adenoma > 1 cm, adenoma with villous features, high-grade dysplasia

3 yearly

Surveillance
Adenomatous Polyps:
Patients who have
more than 10 adenomas at 1 examination

Examine at a shorter interval (less than 3 yearly) Evaluation of an underlying familial syndrome

Peutz Jeghers Syndrome

also known as hereditary intestinal polyposis syndrome

autosomal dominant genetic disease.

increased risk of both gastrointestinal (gastric, small

bowel, colon, pancreas) and nongastrointestinal cancers

cumulative cancer risk of about 50 percent by age 60.

Frequency of Carcinoma in PJS

Diagnostic Criteria of PJS:

The main criteria for clinical diagnosis are: Family history Mucocutaneous lesions
patches of hyperpigmentation in mouth,hands and feet.

oral pigmentations are the first on the body to appear. The mucosa of the lower lip is almost invariably involved.

Hamartomatous polyps

in the gastrointestinal tract.

Management of PJS:
GIT manifestation
(bleeding,intussusception)
Laporotomy and segmental resection or Laporotomy,intraop endoscopy and push enteroscopy

Closed surveillence for extraintestinal cancers

Juvenile Polyposis Syndrome

DIAGNOSTIC CRITERIA:

presence of more than five polyps in the colon or rectum

numerous juvenile polyps throughout intestine

any number of juvenile polyps with a family history

NOTE: increased risk of colon cancer.

Management of JPS:
Local disease without symptoms
Endoscopic Surveillance (1-3 yearly)

Diffuse disease with symptoms

Total Abdominal Colectomy with Ileorectal Anastomosis

Hyperplastic polyposis syndrome

characterized by
multiple,large proximal hyperplastic polyps

occasionally, smaller serrated adenomas.

mixed hyperplastic / adenomatous polyps.

WHO Diagnostic criteria for HPS:

5 hyperplastic polyps proximal to the sigmoid colon, of

which two are greater than 1 cm in diameter.

Any number of hyperplastic polyps proximal to the

sigmoid colon in an individual with first degree relative.

Greater than 30 hyperplastic polyps distributed

throughout the colon.

Management of HPS:

Asymptomatic

Closed Surveillance

Suspicion of Malignancy

Total Abdominal Colectomy with IleoAnal Pouch

Familial Adenomatous Polyposis

Diagnostic Criteria:
100 adenomatous polyps in colorectum Family history of FAP or colon cancer APC gene mutation Note:
associated with osteomas, sebaceous cyst ,dermoid cyst called gardner syndrome.

Familial adenomatous polyposis

Familial adenomatous polyposis

Management of FAP:
Familial Adenomatous Polyposis

Total Proctocolctomy with Ileostomy Total Proctocolctomy with illeal pouch anal anstomosis

Total abdominal Colectomy with Illeorectal anastomosis

Screening:
Hereditary nonpolyposis colorectal cancer:
Colonoscopy every one to two years

beginning at age 20 to 25,

10 years earlier than the youngest age of colon cancer.

Familial Adenomatous Polyposis:

Colonoscopy every 12 months. starting at around age 10 to 12 and continuing until age 35 to 40 if negative.

Hereditary Nonpolyposis Colorectal Cancer(HNPCC)

characterized by:
early-onset CRC. predominance of lesions proximal to the splenic flexure

(60% to 70% of cases).

benign and malignant extracolonic tumors.
Note:extracolonic tumors includes ovarian,uterine,ureter,pelvic tumors

Hereditary nonpolyposis colorectal cancer (HNPCC)

Management of HNPCC HNPCC

Total abdominal Colectomy with Ileorectal anastomosis

Total Proctocolctomy

with ileal pouch anal anastomosis

Segmental colon resection

Prevention:
Guidelines proposed by American College of

Gastroenterology (ACG):
A diet that is low in fat and high in fruits, vegetables, and fiber.

Maintenance of normal body weight through regular exercise and

caloric restriction.
Avoidance of smoking and excessive alcohol use, especially beer. Dietary supplementation with 3 g of Calcium Carbonate.

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