What are the symptoms?

Patients may remain asymptomatic for a long time since it may take months to years for a polyp to reach a significant size or cause a problem. Most polyps are picked up as an incidental finding during a colonoscopy (endoscopy of large intestine) for various reasons like constipation, diarrhea, bleeding per rectum, abdominal pain or as part of health check up in asymptomatic patient especially after age of 50 years (incidental finding).

Large polyps may present with frank bleeding in stools, anemia due to chronic low grade blood loss in stools (occult blood in stools when stool is tested during investigations for anemia) or rarely constipation & abdominal pain. This is common to all age groups. Patients with polyposis syndromes can present with these complaints in their teens too. These patients are at a high risk to develop colorectal cancers at young age.

Is screening for colorectal polyps advised?

Screening for colorectal polyps is not advised as a routine process in the population. Patients above 50 years & otherwise average risk for colorectal cancer are encouraged to undergo a screening colonoscopy for polyps / cancer at least once in 10 years. Apart from this these patients are encouraged to do stool test for blood once a year. If that is positive then a colonoscopy is advised.

Patients with known family history of polyposis are advised screening colonoscopy from a younger age, once in 1-2 years and polyps are picked up early even before symptoms start.

Patients with known inflammatory bowel disease (ulcerative colitis / Chrohn’s disease) are advised screening colonoscopy around 8-10 years from the time of diagnosis. Depending on findings the frequency varies from once in 1-3 years.

When should you suspect a possibility of colonic polyposis syndrome?

If there are multiple polyps (>20) especially at a younger age (before forty), one should rule out a polyposis syndrome. These patients may have more than 100 polyps and have a very high chance of developing cancer at a young age. Such a patient is carefully worked up (family history, genetic analysis, features of other organ system – thyroid/brain etcetera) for polyposis syndrome. If established then family members (especially 1st generation) at risk are also counseled and encouraged to undergo work up to rule out polyposis / similar syndrome in them.

Are polyps benign or cancerous?

Colonic polyps can be benign/noncancerous, malignant/cancerous or there could be a small focus of cancer in an otherwise benign polyp. Some of the benign polyps are at high risk to develop malignancy (potentially malignant) than others. The risk factors include large size, peculiar endoscopic features, specific histopathological features of the polyp and associated genetic changes.

What is done when a colonic/rectal polyp is diagnosed?

The most important question is whether the polyp is benign or cancerous. Once found it is important for the patient to know the risk posed for cancer by the polyp, treatment needed if any and the surveillance / follow up needed if any. This is done on colonoscopy and biopsy. For better prediction of nature of polyp (& treatment) one needs a high-end endoscopy system with in-built special technology (NBI, chromoendoscopy), skilled & experienced gastroenterologist/endoscopist & experienced GI pathologist.

Most small nonmalignant appearing polyps (decided on endoscopic features) are initially snared and then sample is sent for histopathology or biopsy is taken by large forceps removing the entire polyp. Snares are better way of removing small polyps rather than random pulling with forceps. Larger polyps and malignant appearing polyps (decided on endoscopy) are usually biopsied in the 1st step and treatment is done after histopathology report. Treatment may be done endoscopically or through a surgery.

What special investigations are required in patients suspected with polyposis syndromes?

Patients with personal and family history / clinical suspicion of polyposis need special genetic studies to assess familial/hereditary problems. This is especially true for younger patients (<40 years of age). These include mutation in APC gene, MUTyH mutation and some uncommon gene mutations. The tumor tissue is also subjected to IHC for MMR status.

Read more about colorectal polyps: www.gastrointestinalsurgeonmumbai.com/colorectal-polyps.html

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