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Polyps

Complete Fiberoptic Colonoscopy: Polyps (procedure)

Polyps are abnormal growths that project from a broad base or slender stalk found in any organ with blood vessels.


Presentation

Polyps are asymptomatic most times. They are usually an incidental finding. Colorectal polyps present with a slow and occult bleeding in the rectum; the CBC reveals an iron deficiency anemia. When a large polyp obstructs the colon the patient may experience abdominal pain, nausea, and vomiting demanding an emergency surgical polypectomy. A polyp may also present as change in bowel habits like prolonged constipation or diarrhea.
A nasal polyp typically manifests itself with obstruction, stuffiness, runny nose, post nasal discharge, breathing from the mouth, snoring, and decreased sense of smell.
The symptoms of cervical polyps are any abnormal vaginal bleeding, like bleeding between menses, post coital bleeding or post menopausal bleeding. Uterine polyps usually present with a heavy menstrual flow, irregular periods, and infertility.

Hoarseness
  • Symptoms of vocal cord nodules, polyps, and granulomas include chronic hoarseness and a breathy voice, which tend to develop over days to weeks.[merckmanuals.com]
  • Vocal cord nodules are the most common cause of chronic (long-term) hoarseness in children.[gosh.nhs.uk]
  • These include: hoarseness breathiness a "rough" voice a "scratchy" voice a harsh-sounding voice shooting pain from ear to ear feeling like you have a "lump in your throat" neck pain less ability to change your pitch voice and body tiredness Causes of[asha.org]
Rectal Bleeding
  • They should be given diagnostic consideration in patients presenting with symptoms of rectal bleeding, tenesmus, and altered bowel habits. 2013. KEYWORDS: Adolescent; Cloacogenic polyps; Rectal bleeding[ncbi.nlm.nih.gov]
  • Predictive value of rectal bleeding in screening for rectal and sigmoid polyps. Br Med J 290:1546, 1985 Wegener, M. Colorectal adenomas. Distribution, incidence of malignant transformation, and rate of recurrence.[drmcdougall.com]
  • Most colonic polyps cause no symptoms, but they may cause rectal bleeding, mucus in stools, abdominal pain and rarely diarrhoea or constipation.[nice.org.uk]

Workup

Polyps are usually diagnosed during investigations being done for some other purpose. The basic test for a colorectal polyp is a fecal occult blood test to detect bleeding, but flexible sigmoidoscopy, virtual colonoscopy or a minimally invasive CT scan may also be done. A colonoscopy is advisable for resection or for a biopsy being done to rule out malignancy. Capsule colonoscopy has 88% sensitivity and 82% specificity and can be carried out for patients who cannot undergo colonoscopy. [6] Nasal polyps are diagnosed with the help of a nasal endoscopy, CT scan, and MRI. Children found to have nasal polyps should definitely undergo a sweat test to rule out cystic fibrosis. Cervical polyp is a finding on pelvic examination and can be confirmed with biopsy (that is also considered the best way to detect the nature of any polyp). Uterine polyps are usually found in a transvaginal ultrasound or during a hysteroscopy. [7] 

Treatment

Colorectal polyps are best treated with surgical removal due to the chances of development of cancer. Most of the times a colonoscopic resection of the polyp is done and it is sent for histopathology in order to determine its type. The histopathology report also determines the follow up plan. While polypectomy is the first line treatment, it is seen that non-steroidal anti-inflammatory drugs (NSAID) can reduce the number and size of polyps. [8] However, colonic resection may be required if there are multiple polyps or large sessile polyps.
The first line treatment of nasal polyps to reduce size is corticosteroid nasal sprays like fluticasone, budesonide, triamcinalone, and beclomethasone. [9] Oral corticosteroids like prednisone as a 1 week dose tapering can also help. Large polyps can only be treated with endoscopic surgical removal which is usually an outpatient procedure.
Cervical polyps need removal only when they are very large or bleed. A small outpatient procedure, cervical polyps can be easily removed with a small and gentle twisting or electrocautery. Small uterine polyps which can be safely left untreated as they regress on their own. Certain hormonal medications like progestin or gonadotropin releasing hormone agonists may help but is a short term solution. Surgical removal is advised when severe symptoms appear.

Prognosis

Most of the polyps are usually benign and only few turn cancerous. Colorectal polyps start as small and benign lesions and as they get larger their potential to turn malignant increases. Serrated polyps, usually found in the caecum and the ascending colon, possess a high malignant potential. Polyps grow slowly and cancer development occurs approximately 10 years after the formation of a small polyp. [5] Nasal polyps are never cancerous and carry a very high recurrence rate after post surgical removal. Most cervical polyps are non-cancerous and do not grow back. Endometrial polyps are usually benign and only 0.5% contain adenocarcinoma cells. The rate of development into a malignancy is much higher in postmenopausal women with an endometrial polyp.

Etiology

Polyps become common with age. The definite cause of polyps is still not clear. A particular mutation seems to trigger an unregulated growth of the cells of the mucous membranes causing the formation of a mass. However, there are definitely certain risk factors associated with the formation of polyps. Colorectal polyps are common in people with a family history of polyps or colonic cancer, tobacco and alcohol users, people who are overweight, and in those following a diet rich in fat and low in fiber [1]. Polyps of the nose and sinuses are linked with chronic inflammation of the air passages as in allergic rhinitis and asthma. Cervical and uterine polyps are related to increased estrogen levels, chronic inflammation, and maybe infection.

Epidemiology

The incidence of colorectal polyps is low in young individuals belonging to the age group of 30 – 50 years. The incidence significantly increases in individuals above the age of 50. It has also been observed that patients with hyperplastic polyps and adenomas are at a higher risk of developing colorectal cancer. In addition, it has been observed that African Americans show a greater prevalence of proximal or right sided polyps with poor outcome if cancer develops. The incidence of nasal polyps is around 36% in aspirin intolerant patients, 7% in asthmatics, and about 20% in those with cystic fibrosis. [2] Nasal polyps are more common in young and middle age. The incidence of cervical polyps is higher in women who have had children and are in perimenopause, while is rare in pre menstrual girls and post menopausal women. Uterine polyps occur in around 10% of the women and are most common in women in their 40s and 50s. [3]

Sex distribution
Age distribution

Pathophysiology

In normal colonic mucosa, cellular proliferation is restricted to the lower half of the tube and the normal process of generation, maturation and cell death occurring in a normal fashion. An abnormality in the genes prevents the cells from maturing and dying leading to the accumulation of immature and genetically abnormal cells. The genetic basis of the adenoma-carcinoma sequence involves mutation of the DCC, k-ras, and p53 genes. [4] Endometrial or uterine polyps usually comprise glands and vascular tissue. They have a characteristic cytogenetic rearrangement in the high-mobility group (HMG) family of transcription factors.

Prevention

Colorectal polyps can be prevented to a great extent with regular investigations and careful examinations by a doctor. A colonoscopy done once a year in patients in the age groupof  50 – 75 years, those with a strong family history of colon cancer or in patients who have undergone polypectomy can be very useful. It has been observed that people following a diet full of vegetables, fruits, or rich in calcium and vitamin D are at a lower risk of developing adenomatous polyps and colon cancer. [10] Aspirin has also been found to reduce the risk of development of adenomatous polyps and colorectal cancer. [10] Nasal polyps cannot be prevented and a high recurrence rate has been observed even after surgical removal. Cervical polyps and uterine polyps are best prevented by regular examinations and screening investigations.

Summary

Polyps are abnormal growths found commonly in the colon, cervix or nose. They are usually benign but have the risk of developing into malignant growths which can be determined through biopsy.

Polyps treatment depends on the size, location, number and whether or not they are cancerous.

Patient Information

Polyps are abnormal growths that bulge out from the wall of any organ. These growths mostly occur in the large intestine, nasal passage and sinuses, the female reproductive organs like cervix and uterus, and urinary bladder. Polyps may occur as a single growth or as multiple projections. The diagnosis of polyps is usually done when the patient is being investigated for some other reason. The symptoms vary based on the location of the polyps . Mostly, bleeding from the anus, longstanding constipation or diarrhea, stuffy nose, nasal obstruction, abnormal vaginal bleeding, and heavy menses are the commonest symptoms. Usually polyps are benign, non-cancerous growths and do not require removal. Polyps occurring in the large intestine or rectum may turn cancerous after a period of time requiring urgent attention. A regular screening procedure with tests like colonoscopy as advised by a doctor is the best way to prevent complications. Nasal polyps are always non-cancerous and surgical removal does not prevent their recurrence. On the contrary, use of medicines like corticosteroids can reduce symptoms caused by polyps. Small cervical and uterine polyps do not require removal as they disappear on their own after a certain period of time. A nutritious diet full of leafy greens with avoidance of alcohol and tobacco along with regular examinations by a doctor can greatly prevent the formation of polyps.

References

Article

  1. Haque TR, Bradshaw PT, Crockett SD. Risk factors for serrated polyps of the colorectum. Dig Dis Sci. 2014 Dec;59(12):2874-89.
  2. Bavbek S, Dursun B, Dursun E, et al. The prevalence of aspirin hypersensitivity in patients with nasal polyposis and contributing factors. Am J Rhinol Allergy. 2011 Nov-Dec;25(6):411-5. doi: 10.2500/ajra.2011.25.3660.
  3. Casey PM, Gallenberg MM, Kastner TM, et al. Outcomes in women age 40 years and older with cytologically benign endometrial cells. Am J Obstet Gynecol. 2012 Nov;207(5):379.e1-6.
  4. Wiland HO 4th, Shadrach B, Allende D, et al. Morphologic and molecular characterization of traditional serrated adenomas of the distal colon and rectum.Am J Surg Pathol. 2014 Sep;38(9):1290-7.
  5. Cappell MS.From colonic polyps to colon cancer: pathophysiology, clinical presentation, screening and colonoscopic therapy.Minerva Gastroenterol Dietol. 2007 Dec;53(4):351-73.
  6. Romero-Vázquez J, Argüelles-Arias F, et al. Capsule endoscopy in patients refusing conventional endoscopy. World J Gastroenterol. 2014 Jun 21;20(23):7424-33.
  7. de Godoy Borges PC, Dias R, t al. Transvaginal ultrasonography and hysteroscopy as predictors of endometrial polyps in postmenopause.Womens Health (Lond Engl). 2015 Jan;11(1):29-33.
  8. Murff HJ, Shrubsole MJ, Chen Z, et al. Nonsteroidal anti-inflammatory drug use and risk of adenomatous and hyperplastic polyps. Cancer Prev Res (Phila). 2011 Nov;4(11):1799-807.
  9. Wang C, Lou H, Wang X, et al. Effect of budesonide transnasal nebulization in patients with eosinophilic chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol. 2014 Dec 4. pii: S0091-6749(14)01513-9.
  10. Miller EA, Keku TO, Satia JA, et al. Calcium, dietary, and lifestyle factors in the prevention of colorectal adenomas. Cancer. 2007 Feb 1;109(3):510-7.

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Last updated: 2019-07-11 22:52