AGA Clinical Practice Update on Management of Gastric Polyps: Expert Review.

[DESCRIPTION] This Clinical Practice Update (CPU) expert review will advise clinicians on the diagnosis and management of gastric mucosal polyps. Gastric polyps are raised epithelial lesions of the gastric mucosa that can arise from various mucosal alterations and perturbations, including mucosal hyperplasia, adenoma, fundic gland proliferation, and enterochromaffin-like cell proliferation. Current guidance on the management of gastric polyps remains limited. This CPU provides a framework for understanding the natural history and epidemiology of gastric polyps and advises on best practices for the endoscopic detection and classification of gastric polyps, the endoscopic resection of gastric polyps, and endoscopic surveillance following resection. Because gastric polyps often occur within a field of altered gastric mucosa (eg, mucosal atrophy, pseudo-pyloric and intestinal metaplasia), we will advise on best practices for the sampling and surveillance of mucosal pathology giving rise to gastric polyps. This CPU is intended to complement other documents issued by the American Gastroenterological Association (AGA) Institute on gastric neoplastic and pre-neoplastic lesions, including the clinical practice guidelines on management of gastric intestinal metaplasia, as well as AGA CPUs on atrophic gastritis, high-quality upper endoscopy, and screening and surveillance of individuals at increased risk for gastric cancer.

[METHODS] This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these BPA statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE STATEMENTS BPA 1: Gastric polyps are frequently identified during upper endoscopy exams and include different histologic subtypes, such as fundic gland polyps (FGPs), gastric hyperplastic polyps (GHPs), hamartomatous polyps, gastric adenomas (GAs), pyloric gland adenomas, oxyntic gland adenomas, and gastric neuroendocrine tumors (G-NETs). BPA 2: Clinicians should be aware that different types of gastric polyps may coexist in the same person. BPA 3: Clinicians should be aware that different types of gastric polyps are associated with varying spectra of histopathologic abnormalities in the surrounding gastric mucosa, which may aid in their identification and diagnosis. BPA 4: Systematic endoscopic examination of the polyps and the surrounding gastric mucosa is essential in assessing the underlying gastric mucosa pathology (eg, Helicobacter pylori gastritis, autoimmune gastritis, gastric intestinal metaplasia [GIM]) and determining subsequent management: biopsies of the polyps, biopsies of the surrounding mucosa, and resection of the polyps. BPA 5: All patients with adenomatous or hyperplastic gastric polyps should be tested and treated if positive for H pylori infection. BPA 6: Patients who are using proton pump inhibitors (PPIs) for valid reasons do not need to discontinue these medications in the presence of documented fundic gland hyperplasia-related gastric polyps. BPA 7: Clinicians should be aware that different histological types of gastric polyps have unique/characteristic topographical features, endoscopic features, and size. BPA 8: Endoscopic evaluation of patients with gastric polyps should include complete inspection with high-definition white-light and enhanced imaging, such as virtual chromoendoscopy. Endoscopists should recognize and photo-document the endoscopic features of gastric polyps as well as the surrounding gastric mucosal abnormalities. BPA 9: Clinicians should be aware that endoscopic resection of the polyps includes traditional techniques (snare and biopsy forceps, mucosal resection) or endoscopic submucosal dissection. BPA 10: In the presence of numerous gastric polyps of varied sizes, the largest polyps should be resected when possible, and the smaller polyps sampled or resected. BPA 11: Suspected abnormalities in the surrounding mucosa, such as GIM or atrophic gastritis, should undergo targeted biopsies according to the existing protocols. BPA 12: Surveillance plans in patients with gastric polyps should be formulated based on the histopathological type of the polyps and the surrounding gastric mucosa. BPA 13: When a dysplastic lesion in the polyp is confirmed and resected completely, a follow-up surveillance endoscopy should be completed in 1 year for patients with low-grade dysplasia polyps and 6 months for patients with high-grade dysplasia polyps. If the polyp is biopsied or resection is incomplete, follow-up endoscopy is advised within 3 months for high-grade dysplasia and 6 months for low-grade dysplasia. BPA 14: Endoscopic surveillance is advised in patients with gastric polyps when the histopathology of adjacent mucosa confirms GIM and/or atrophic gastritis.