European Journal of Cardiovascular Medicine

A polyp is a general term used in medicine to describe any growth that protrudes above the mucosa. Sessile and pedunculated, polyps are easily observed under both macroscopic and microscopic inspection. Pedunculated polyps are defined as polyps with an attached stalk, while sessile polyps are defined as blooms and leaves that grow straight from the stem without a stalk. [1]. Due to a diet high in fat, a lack of physical exercise, and a lower intake of fiber, the prevalence of gastrointestinal polyps has increased in the modern world. [2] Both neoplastic and non-neoplastic intestinal polyps are possible. They are prevalent in the large intestine, followed by the stomach and small intestine, and are primarily asymptomatic. [3]

About 90% of all mucosal polyps found in the large intestine are non-neoplastic and can be divided into hyperplastic, inflammatory, lymphoid, and hamartomatous polyps (fundi gland, juvenile polyp, and Perutz-Jigger polyp). Due to an increase in proton pump inhibitor intake, fundi gland polyps (FGPs), the most prevalent type of stomach polyps, make up 50–77% of all gastric polyps. Fundi gland polyps come in two varieties: familial and sporadic. While fundi gland polyps linked to familial adenomatous polyposis (FAP) have a 41% probability of dysplasia, sporadic FGPs have generally been considered benign lesions with no chance of malignant development. [4] The second most prevalent kind of stomach polyp linked to Helicobacter pylori (Pylori) infection is hyperplastic polyps. [5]

Adenomatous polyps are a type of neoplastic polyp. [3] The most prevalent neoplastic polyps in large bowls are adenomatous polyps. Tubular adenomas, villous adenomas, and tubulovillous adenomas are the three histologic forms of adenomatous polyps. Of these, only 5% are pure villous adenomas, 10% to 25% are tubulovillous, and 65% to 80% are tubular. Villous adenomas are the largest and most likely to be malignant of all the adenomatous polyps.

[5] Findings from colonoscopies and endoscopies are crucial for polyp diagnosis, monitoring, and treatment. The two main determinants of polyp malignancy development are polyp size and histological type. The likelihood of having high-grade dysplasia increases with the size of the polyp. In order to properly classify and define the etiology of gastrointestinal polyps, it is crucial to ascertain the history of these lesions as well as their anatomical placements, endoscopic appearance, and quantity.

Study design: Prospective and retrospective study

Period of study: Three years

Place of study: Department Pathology, Dayanand Medical College Ludhiana

Sample size:

Inclusion criteria:

• All the biopsies of gastrointestinal polyps

Exclusion criteria:

• Biopsies of Carcinoma, Lymphomas and Carcinoid presenting as
• Biopsies of pseudopolyps and inflammatory polyps

Statistical Analysis:

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests, which compare the means of independent or unpaired samples, were used to assess differences between groups. Paired t-tests, which account for the correlation between paired observations, offer greater power than unpaired tests. Chi-square tests (χ² tests) were employed to evaluate hypotheses where the sampling distribution of the test statistic follows a chi-squared distribution under the null hypothesis; Pearson's chi-squared test is often referred to simply asthe chi-squared test. For comparisons of unpaired proportions, either the chi-square test or Fisher’s exact test was used, depending on the context. To perform t-tests, the relevant formulae for test statistics, which either exactly follow or closely approximate a t-distribution under the null hypothesis, were applied, with specific degrees of freedom indicated for each test. P-values were determined from Student's t-distribution tables. A p-value ≤ 0.05 was considered statistically significant, leading to the rejection of the null hypothesis in favour of the alternative hypothesis.

Table 1: Distribution of gastrointestinal polyps according to site (n=319)

Table 2: Distribution of Upper gastrointestinal polyps according to histopathological diagnosis. (n=86)

Table 3: Distribution of upper gastrointestinal polyp according to site on the basis of histopathological diagnosis (n=86)

Table 4: Distribution of lower gastrointestinal polyps according to histopathological diagnosis (n=233)

Table 5: Adenomas with high grade dysplasia

Table 6: Adenomas associated with Adenocarcinoma in adjacent mucosa of colon

Figure 1: Adenomas associated with Adenocarcinoma in adjacent mucosa of colon

Distribution of gastrointestinal polyps according to site

Of the 319 cases, 233 (73.4%) had gastrointestinal polyps in various regions of the large intestine, 5 (1.5%) had them in the duodenum, and 81 (25.3%) had them in the stomach. The most prevalent kind of polyps were adenomatous, fundic gland, and hyperplastic.

Upper Gastrointestinal Polyps

UGI polyps occurred in 86 instances. There were 40 polyps in the stomach body, 36 in the stomach fundus, 5 in the stomach antrum, and 5 in the duodenum, according to the site. The most frequent site was the stomach body (46.5%). Nevertheless, no esophageal polyps were observed. The most common diagnosis was a fundic gland polyp, which accounted for 82.5% of cases, followed by a hyperplastic polyp (10.4%).

In both the stomach body (44.1%) and the stomach fundus (37.2%), fundic gland polyps were the most common histological type discovered. The stomach antrum had a higher prevalence of hyperplastic polyps (4.65%).

Fundic Gland Polyps

The prevalence of fundic gland polyps was higher in the 61–70 age group (28.2%), with a mean age of 55.7 years. The number of fundic gland polyps was greater in females. (Figure1)

Hyperplastic Polyp

Nine instances (10.4%) of hyperplastic polyps in the upper gastrointestinal tract were found in the current investigation. The mean age was 73.2 years, with a M: F ratio of 1.3:1, and the age range was 61–70 years. The most frequent location was the stomach antrum, which was followed by the stomach body and fundus. (Figure 2)

Lower Gastrointestinal (GI) Polyps

The number of lower GI polyp patients was 233. After the rectum, ascending colon, transverse colon, descending colon, caecum, ileocaecal area, and anal verge, intestinal polyps most frequently affected the sigmoid colon (30.4%).

The most prevalent histological type, accounting for 79.4% of lower gastrointestinal polyps, was adenomas, which were followed by juvenile polyps (16.7%). (Table IV)

Adenoma

The mean age of the patients was 60.5 years, with a range of 28 to 92 years. Patients between the ages of 51 and 60 made up the largest group. With a male to female ratio of 3.4:1, adenomas were more prevalent in males (77.2%) than in females. The sigmoid colon has the highest prevalence of adenomas (34%) followed by ascending colon (15.1%).

Histological types of Adenomas

Adenomas were separated according to their villous component in the current investigation. The diagnosis of tubular adenoma was made for adenomas with a villous component of less than 25%, tubulovillous adenomas for those with a villous component of 25-75%, and villous adenoma for those with a villous component of greater than 75%. Consequently, tubular adenomas accounted for the majority of 185 adenomas (83.7%), followed by tubulovillous (13.5%) and villous adenomas (2.7%).

Tubular Adenomas:

Twenty percent of tubular adenomas are found in the rectum and small intestine, and forty percent are found in the right and left colon.

Villous Adenomas:

Larger adenomas known as villous adenomas are linked to severe dysplasia. Although it can occur anywhere in the colon, it most frequently appears in the rectum and rectosigmoid area. Nevertheless, it is infrequently seen in the Vater's ampulla and small intestine (5). Sessile in nature, they resemble velvety or cauliflower-like projections.

Tubulovillous adenoma: Adenomas composed of both tubular and villous structures, each comprising more than 25% of tumour.

High grade dysplasia was seen in 80% of villous adenoma cases, 48% of tubulovillous adenoma cases, and 3.8% of tubular adenomas in the current investigation.

According to Table VI, adenocarcinoma well differentiated in the surrounding colon mucosa is linked to 20% of instances of villous adenoma, 12% of cases of tubulovillous adenomas, and 0.6% of cases of tubular adenomas in the current study. These cancers penetrate all the way up to the serosa in the intestinal wall. Constipation, abdominal pain, and rectal bleeding are all signs of intestinal blockage that these patients present with.

According to our research, two out of every five cases of villous adenomas and one out of every twenty-five cases of tubulovillous adenoma develop intramucosal cancer.

Five known cases of inflammatory bowel disease, where tubular adenomas were the most prevalent polyp to emerge, and one unusual case of carcinoma ovary, where Peutz Jeghers polyp developed in the colon, were included in the current study.

Juvenile polyp

Juvenile polyps most frequently afflicted children aged 0–10 years, accounting for 46.2% of all cases, with a mean presentation age of 18.6 years. With a male to female ratio of 1.8:1, male predominance was seen. The rectum was where juvenile polyps were most frequently found (66.6%).

Peutz-Jegher polyp

Out of the 233 cases of lower gastrointestinal tract polyps identified in this investigation, only 3 (1.3%) cases of Peutz-Jegher polyp were identified. With a mean age of 29, the most prevalent age group was 31–40 years old (66.7%), and it was only seen in females (100%) and the ileocaecal area (100%).

We found that the large intestine (73.4%) had the highest frequency of polyps, followed by the stomach (25.3%) and duodenum (1.5%). These results were consistent with Gurung P et al.'s, who discovered that gastrointestinal polyps frequently impacted the large intestine in 83.6% and 93.42% of cases, respectively. [3,]

Upper gastrointestinal polyps

The most frequent location for upper gastrointestinal polyps was the gastric body, however they were observed in other areas of the stomach and duodenum as well. Fundic gland polyps (82.5%) were the most prevalent of the 86 upper gastrointestinal polyp cases in the current study. This was in line with research by Stotle M et al., which discovered that fundic gland polyps were the most prevalent polyp, accounting for 47%, 77%, and 65% of the cases, respectively. [6,] Hyperplastic polyps were the second most prevalent histological type in our analysis, however Ari A et al.'s investigation found that they were the most common (50%) and primarily located in the antrum. [7] Given that the study was conducted in Turkey, geographic location could be a contributing cause to this discrepancy. In their local community, they also reported a high prevalence of H. Pylori infection and chronic gastritis, both of which are linked to hyperplastic polyps. However, fundi gland polyps have a causal relationship with proton pump inhibitors and are rarely linked to Pylori infection. According to research by Markowski AR et al., the stomach body was the most frequently found location for fundic gland polyps, confirming that this was the preferred site [8].

Fundic gland polyp

Our analysis of 71 fundic gland polyp cases revealed that, with a mean age of 55.7 years, they most frequently afflicted people between the ages of 61 and 70. With a male to female ratio of

1:2.5, female predominance was observed. These were consistent with the research presented in (Table VI)

Table VI: Comparison of Epidemiological profile of fundic gland polyp

Hyperplastic polyps

The second most common type of polyp was hyperplastic, which manifested at a mean age of 73.2 years, with a range of 62 to 86 years. In contrast to the age of presentation in our investigation, Ljubicic et al. discovered that the mean age of the hyperplastic polyps was ten years earlier in a younger age group, with a mean age of 56.7 years. [11] This may be the result of both the lack of a nationwide screening program and a lack of knowledge among Indians.

Lower gastrointestinal polyps

Adenomas accounted for 79.4% of the 233 cases of lower gastrointestinal polyps in the current investigation, making them the most common histological diagnosis. Our results concurred with research conducted by Gurung P et al. Mirzaie et al. also discovered that the most prevalent type of polyps were adenomatous ones. [2, 3] (Table VII)

Table VII : Comparison of incidence of lower gastrointestinal polyps with other studies

Adenoma

The mean age of patients with adenomas in our study was 60.5 years, with a range of 28 to 92 years. These findings were consistent with a study by Tony J et al. that found the mean age of adenomas to be 59.3 years and 57 years, respectively. [15] Adenomas were more frequently detected in the sigmoid colon (34%) in the current analysis of 185 cases, which was consistent with the findings of Eshghi MJ et al., who also reported that the sigmoid colon was the prevalent place (27.2%) in their investigation of 727 cases. [16]

Villous adenoma (2.7%), tubulovillous adenomas (13.5%), and tubular adenoma (83.7%) were the most prevalent histological types in our study. According to research by Tony J. et al. tubular adenoma was the most prevalent adenomatous polyp in connivance. [16]

Our study found that 3.8% of tubular adenomas, 48% of tubulovillous adenomas, and 80% of villous adenomas had high grade dysplasia. This was in line with a study by Valarini et al. that found that high grade dysplasia was present in 13.4% of tubular adenoma cases, 32% of tubulovillous adenoma cases, and 75% of villous adenomas. [17] Therefore, the villous component of adenomas is strongly correlated with a higher risk of malignancy, either as adenocarcinoma or high grade dysplasia.

Five individuals developed adenocarcinoma out of 185 cases of adenomatous polyps, and villous adenomas (20%) were the most common polyp in our study where a high percentage of adenocarcinoma developed. This study agreed with the Coleman HG. et al. study. Villous and tubulovillous adenomas were the most prevalent polyps in which adenocarcinoma arises, and in their study, 193 colorectal cancer cases were detected among 6,972 adenoma patients, reflecting an annual advancement rate of 0.43%. It comes to the conclusion that the probability of getting adenocarcinoma increases with villous architecture. [18]

Five cases of inflammatory bowel illness, which most frequently results in tubular adenoma, were identified in the current investigation. This result was consistent with a research by Loffeld, R. J., who discovered that the most prevalent polyp in patients with inflammatory bowel disease was tubular adenoma. It was an uncommon discovery, and it suggests that these people have adenocarcinoma earlier than the general population. [19]

One exceptional occurrence in our analysis was a lady who had Peutz Jeghers polyps in her colon and a known ovarian condition. For what reason is unknown.

Juvenile polyp

In our study, the most prevalent age group impacted by juvenile polyps was 2–10 years old (46.2%), with a male predominance (64.1%) and a male to female ratio of 1.8:1, which were consistent with Fox VL et al. discovered that males made up 64.1% of the juvenile polyps seen in the 3.7-8.8 age range. [20] In a similar vein, Anyanwu et al. discovered that adolescent polyps between the ages of 2.5 and 9 were prevalent in the 3–12 age range and were primarily observed in men. [21] Similar to the findings of Lee BG et al., juvenile polyps were frequently seen in the rectum (66.6%). [21]

Peutz- Jegher polyp

Only three Peutz-Jeghers polyp cases were found in our analysis of 233 cases of lower gastrointestinal polyps. Only one instance of Peutz-Jeghers polyp was discovered by Albasri et al. in their analysis of 224 colonic polyps and 124 colonic polyps, respectively. [15] This could be because Peutz-Jeghers polyps are uncommon colon polyps.

We concluded that many different types of lesions with different clinical implications seen throughout the histomorphological spectrum of gastrointestinal polyps. With unique histological characteristics, these polyps can be divided into several categories, such as inflammatory, adenomatous, and hyperplastic polyps. The need of early discovery and therapy is underscored by the increased risk of malignant transformation associated with adenomatous polyps, especially those exhibiting dysplasia. Hyperplastic polyps, on the other hand, typically have a low propensity for malignancy. Accurate diagnosis, classification, and risk stratification depend on a comprehensive histological investigation, which also directs the right course of therapy and surveillance tactics to stop the development of colorectal cancer.

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