Synopsis
Characterise colorectal polyps accurately, secure complete and safe excision, interpret pathology and procedural quality together, and apply UK post-polypectomy surveillance without unnecessary colonoscopy.
- A polyp is a morphological finding, not a final diagnosis. Management depends on size, site, morphology, optical pattern, histology, number and confidence of complete removal.
- Premalignant colorectal polyps include conventional adenomas and serrated lesions; small distal hyperplastic polyps generally carry different risk from proximal dysplastic serrated disease.
- Suspected deep submucosal invasion should be photographed, described, biopsied selectively and referred for colorectal multidisciplinary planning rather than fragmented piecemeal removal.
- A large non-pedunculated lesion without clear deep invasion should be assessed by an endoscopist skilled in advanced resection before surgery is assumed necessary.
- The BSG high-risk criteria are either at least two premalignant polyps with one advanced polyp, or at least five premalignant polyps; this group receives a one-off colonoscopy at three years.
- An advanced polyp for these criteria is a serrated polyp at least 10 mm or with any dysplasia, or an adenoma at least 10 mm or with high-grade dysplasia.
- Piecemeal endoscopic mucosal resection of a lesion at least 20 mm needs an early site check, usually at two to six months, and a further check around eighteen months under BSG guidance.
- Surveillance recommendations assume a high-quality complete baseline colonoscopy and credible excision; poor preparation, an incomplete examination or uncertain margins first requires completion or site assessment.
Key red flags
Ulceration, induration, convergence, depressed morphology, disrupted vascular pattern or convincing non-lifting raises submucosal cancer and should prevent casual piecemeal resection.
Immediate or delayed bleeding, escalating abdominal pain, fever, tachycardia or peritonism after resection raises haemorrhage, perforation or electrocoagulation syndrome and needs acute reassessment.
Investigation priorities
Detect synchronous lesions, document caecal completion and bowel preparation, and permit complete optical characterisation and resection.
Management branches
A colorectal polyp is identified during screening or symptomatic investigation.
- Record exact segment, calibrated size, morphology and optical pattern, photograph the lesion and inspect for synchronous disease before choosing treatment.
- Remove a lesion with an evidence-based technique within competence, retrieving tissue and documenting en-bloc versus piecemeal excision and confidence of completeness.
- For a large non-pedunculated lesion or possible superficial cancer, seek advanced endoscopy review; for likely deep invasion, avoid destructive fragmentation and refer to colorectal MDT.
- Place a tattoo only when useful for later localisation and at an appropriate distance and orientation, recording it precisely so it does not compromise subsequent resection.