Which Gastric Polyps Require Biopsy, Removal or Surveillance?

Answer in brief: Management depends on polyp type, size, appearance and background mucosa. Gastric adenomas generally require complete endoscopic removal. Hyperplastic polyps should prompt assessment for H. pylori and background gastritis and are often removed when large, symptomatic or atypical. Typical small fundic-gland polyps in chronic PPI users are usually low risk, but atypical, large or numerous lesions warrant sampling and consideration of syndromic disease.

Start with morphology and background mucosa

A gastric polyp is not a diagnosis. At endoscopy, document location, number, size, surface pattern, ulceration and any associated atrophy or metaplasia. The surrounding mucosa often matters as much as the polyp itself because gastric neoplasia risk may reflect the field in which a lesion developed.

Fundic gland polyps

Sporadic fundic gland polyps are commonly associated with proton pump inhibitor exposure and are usually small, smooth and located in the body/fundus. Dysplasia is uncommon in typical sporadic lesions. Sample or remove lesions that are unusually large, irregular, ulcerated, antral, or otherwise atypical. Numerous polyps, young age or dysplasia should raise the possibility of a polyposis syndrome.

Hyperplastic polyps

Hyperplastic polyps are linked to chronic mucosal injury, including H. pylori gastritis and autoimmune gastritis. They carry a low but non-zero risk of dysplasia, particularly with increasing size. Biopsy the background mucosa, test for H. pylori, eradicate infection when present, and consider complete removal of larger or atypical lesions.

Gastric adenomas

Adenomas are premalignant epithelial neoplasms. Complete endoscopic resection is generally appropriate when technically feasible, followed by careful inspection and biopsies of the remaining stomach for atrophy, intestinal metaplasia and synchronous neoplasia. Dysplasia within a lesion should trigger high-quality resection and pathology review.

Surveillance follows the pathology

There is no single interval for every gastric polyp. Surveillance is driven by histology, completeness of resection, dysplasia, background premalignant change and patient risk. Avoid creating indefinite surveillance solely because a low-risk polyp was once found.

What trainees should remember

Identify the polyp type and the mucosal field in which it arose. Adenomas usually come out; hyperplastic polyps trigger evaluation of the underlying gastritis; typical small sporadic fundic-gland polyps are usually low risk.

Frequently asked questions

Should every fundic gland polyp be removed?

No. Typical small sporadic fundic gland polyps generally do not require removal simply because they are present.

Why biopsy the surrounding stomach?

Because atrophy, intestinal metaplasia and H. pylori may determine long-term cancer risk even after the polyp itself is removed.

References and further reading

1. Thomson ABR. Endoscopy and Diagnostic Imaging, Parts I-II. CAPstone Academic Publishers; 2012.

2. Thomson ABR. Practice Review in Gastroenterology. CAPstone Academic Publishers; 2014.

3. Morgan DR, et al. ACG Clinical Guideline: Diagnosis and Management of Gastric Premalignant Conditions. Am J Gastroenterol. 2025.

4. Chey WD, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024.