Synopsis
Classify gastric polyps accurately, assess the background mucosa and inherited context, remove lesions with meaningful neoplastic risk, and apply evidence-based surveillance to atrophy, intestinal metaplasia and dysplasia without over-scoping low-risk findings.
- The clinically useful gastric polyp assessment combines surface pattern, size, site, number, histology and background mucosa; the word polyp alone does not determine risk.
- Fundic-gland polyps are usually small, smooth and multiple in the fundus or body, often during PPI exposure, and sporadic lesions have very low malignant potential.
- Numerous fundic-gland polyps in a young person, dysplasia within one, an antral location or concomitant duodenal adenoma should prompt assessment for familial adenomatous polyposis.
- Hyperplastic polyps arise in an inflamed or atrophic stomach; test and eradicate H. pylori, inspect the surrounding mucosa and resect large, pedunculated, symptomatic or dysplastic lesions.
- Gastric adenomas carry important malignant and synchronous-neoplasia risk and should be completely resected through an expert pathway with careful examination of the entire stomach.
- Atrophy and intestinal metaplasia are premalignant fields rather than polyps; topographical biopsies establish whether disease is limited to the antrum or extends into the body.
- BSG recommends three-yearly surveillance for extensive gastric atrophy or intestinal metaplasia affecting both antrum and body in suitable patients, with selected exceptions and shared decision-making.
- Visible dysplasia should be staged for en-bloc endoscopic resection, while non-visible dysplasia requires expert pathology review and repeat high-quality enhanced examination to find a hidden lesion.
Key red flags
Dysplasia reported from apparently flat random biopsies may reflect a subtle missed lesion or interpretive uncertainty and should trigger expert pathology confirmation plus prompt enhanced repeat endoscopy.
Depression, spontaneous bleeding, ulceration, converging folds, irregular microvascular pattern or non-lifting raises invasive neoplasia concern and should stop casual snare removal in favour of expert staging.
Investigation priorities
Characterise every lesion and search systematically for synchronous neoplasia.
Management branches
One or more gastric polyps or a premalignant biopsy finding is identified at endoscopy.
- Record lesion morphology, size, number and location with photographs, and use enhanced imaging to identify depression, irregular pattern or a resection boundary.
- Obtain appropriate lesion tissue while sampling antrum and body background separately when hyperplastic, adenomatous, atrophic or metaplastic disease is possible.
- Reconcile optical diagnosis, pathology, H. pylori status, PPI exposure and family phenotype in a clear final plan rather than issuing an isolated histology result.