Management of Serrated Colon Polyps

Risk Stratification and Initial Management

Small distal hyperplastic polyps (≤20 HPs in rectum/sigmoid <10 mm) require no surveillance beyond routine 10-year screening intervals, as recommended by the American Gastroenterological Association, based on evidence from Gastroenterology 1, 2
Small proximal hyperplastic polyps (≤20 HPs proximal to sigmoid <10 mm) also warrant 10-year intervals, though this recommendation is based on very low-quality evidence from Gastroenterology 1, 2
Small hyperplastic polyps or SSPs <10 mm without dysplasia have no clear indication for colonoscopic surveillance unless they meet criteria for SPS, according to the British Society of Gastroenterology 3, 4
Sessile serrated polyps (SSPs) ≥10 mm or any SSP with dysplasia warrant 3-year surveillance colonoscopy, as recommended by the American College of Gastroenterology 1, 2, 3
Traditional serrated adenomas (TSAs) require 3-year surveillance, based on guidelines from the American Gastroenterological Association 1, 2
3-4 SSPs <10 mm require 3-5 year surveillance, according to the European Society of Gastrointestinal Endoscopy 1, 2
5-10 SSPs <10 mm require 3-year surveillance, as recommended by the American Society for Gastrointestinal Endoscopy 1, 2
Large hyperplastic polyps ≥10 mm require 3-5 year surveillance, based on evidence from Gastroenterology 1, 2

Patients with SPS require intensive 1-2 yearly colonoscopic surveillance due to elevated colorectal cancer risk, as recommended by the British Society of Gastroenterology 5, 6, 7, 8, 4, 9
Surgery should be considered when lesions are not amenable to colonoscopic resection due to size, site, or number, according to the American College of Surgeons 5, 6, 7, 10, 3, 8, 4, 9
Endoscopic management may be appropriate if polyps are manageable in size, location, and number, the patient is willing, and appropriate endoscopic expertise is available, as recommended by the European Society of Gastrointestinal Endoscopy 5, 6, 7, 8, 4, 9
All patients with SPS should be referred to clinical genetics services or a polyposis registry where resources allow, according to the National Comprehensive Cancer Network 5, 6, 7, 10, 3, 8, 4, 9

Endoscopists should aim for a proximal serrated polyp detection rate >5%, as recommended by the American Society for Gastrointestinal Endoscopy 10, 3
Clinicians must acquire knowledge and skills to recognize and differentiate serrated lesion types, as these lesions have distinct endoscopic appearances and are more difficult to detect than conventional adenomas on average, according to the American College of Gastroenterology 10, 3