Profile of Colorectal Polyps in Colonoscopies

Abstract

Introduction

Colorectal cancer (CRC) is a global public health concern, ranking third among the most common cancer types in Brazil. Colorectal polyps play a crucial role in CRC prevention when identified and removed during colonoscopy.

Objective

This study aims to analyze the profile of patients with colorectal polyps at a reference clinic in the southernmost region of Santa Catarina, during the period from January to June 2023.

Methods

A cross-sectional, descriptive study was conducted, with analysis of secondary data from medical records, followed by statistical analyses to describe the sample and evaluate associations between variables.

Results

A total of 206 colonoscopic exams were analyzed, revealing a female predominance, with the predominant age group between 45 and 75 years old and the predominant location in the sigmoid colon. Most polyps were small and sessile, primarily removed by biopsy forceps.

Conclusion

The study provided important insights into the profile of patients with colorectal polyps in the study region, highlighting epidemiological patterns and challenges in the removal of these lesions. The findings underscore the importance of more effective prevention and treatment strategies.

 

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Keywords

colorectal neoplasms - colonic polyps - colonoscopy - triage

Introduction

Colorectal cancer (CRC) refers to tumors that develop in the large intestine (colon) and rectum.[1] This condition is recognized as a significant public health issue worldwide.[2] In Brazil, CRC ranks third among the most common types of cancer, excluding non-melanoma skin tumors.[3] The National Cancer Institute (INCA) estimates that between 2023 and 2025, there will be 45,630 new cases of colorectal cancer per year in Brazil, representing an estimated incidence rate of 21.10 cases per 100,000 inhabitants.[3]

The progression of colorectal cancer varies and is influenced by the complex interaction between genetic and environmental factors.[4] The primary pathway of development, responsible for ∼75% of cases, is known as the adenoma-carcinoma sequence, in which adenomatous polyps become malignant.[1] [5] The development mechanism of the remaining CRC cases is not yet fully understood.[6]

Colorectal polyps, which are protrusions in the mucosa of the colon and rectum, play a crucial role in CRC prevention when identified and removed early through polypectomy during colonoscopy.[4] [7] This approach interrupts the adenoma-carcinoma sequence by detecting lesions early, reducing the incidence, morbidity, and mortality of the disease.[8] This highlights that colonoscopy not only provides a diagnosis but also plays an essential therapeutic role.[4]

Colonoscopy is highly preferred as a diagnostic method and is often considered the gold standard. Its advantage lies in its ability to examine the entire large intestine and perform the removal or biopsy of polyps, including those with advanced or non-advanced neoplasia.[7] [8]

Considering the importance of early lesion identification for CRC treatment and prevention, this study aims to analyze the profile of patients with colorectal polyps who underwent colonoscopy at a reference clinic in the south region of Santa Catarina from January to June 2023. This research contributes to a better understanding of the local epidemiology of these lesions and identifies relevant clinical and morphological characteristics. The findings may help improve colorectal cancer screening and prevention strategies while assisting in identifying specific at-risk groups. The study's methodological rigor, including compliance with the STROBE protocol and ethical approval, ensures its clinical and scientific credibility and usefulness.

 

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Methods

A cross-sectional, descriptive study was conducted with the collection of secondary data to analyze the profile of patients with colorectal polyps detected in colonoscopies, following the steps recommended by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) protocol. All procedures were approved by the Research Ethics Committee (CEP) of the Federal University of Santa Catarina (UFSC), according to the Ethical Appreciation Presentation Certificate (CAAE) N°. 73561923.6.0000.012.

The analyzed data were obtained from medical records of a reference clinic located in the south region of Santa Catarina, concerning examinations performed between January and June 2023. Inclusion criteria considered patients over 18 years of age, of both sexes, who underwent a complete colonoscopy within the selected period. Cases were excluded from the sample if colonoscopy reports were incomplete or inconclusive due to technical reasons, inadequate bowel preparation, colon obstruction, intestinal loop obstruction, a history of previous colorectal cancer, or if they involved patients under 18 years old, those whose clinical data could not be retrieved from medical records or had missing data, and exams in which no polyps were detected.

The analyzed variables included sex, age, indication for the procedure, bowel preparation quality (according to the Boston Bowel Preparation Scale - BBPS),[9] polyp morphology, as well as polyp size, number, topographic distribution, and method of extraction. The reasons for the procedure were categorized as screening for colorectal cancer, anemia, polypectomy, positive fecal occult blood test (FOBT), hematochezia, lesion surveillance, abdominal pain or distension, diarrhea, constipation, weight loss, altered bowel habits, and “others.” The “others” category included the following indications: presence of hemorrhoids, pain during defecation, evaluation of ulcerative colitis, assessment of cecal blurring, family history of colon cancer, and rectal pain. Indications were categorized this way to group those with lower statistical relevance.

The topographic categories used were cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum. Similarly, bowel preparation quality according to BBPS was divided into good preparation and unsatisfactory preparation. For epidemiological comparison purposes, the population was divided into three age groups: under 45 years old, between 45 and 75 years old, and over 75 years old. Polyp morphology was classified according to the Paris Classification for polypoid lesions (sessile, subpedunculated, and pedunculated polyps).[10] Polyp size was categorized as small (<5 mm), medium (5–20 mm), and large (>20 mm).[2] The number of polyps was divided into 1, 2, 3, 4, and 5 or more lesions detected in the same examination. The extraction method was classified as biopsy forceps, diathermy loop, and cases where polyps were not removed.

Initially, a description of the sample was performed according to the sociodemographic and clinical characteristics of the patients, using absolute and relative frequencies for categorical variables and means and standard deviations (SD) for numerical variables. Additionally, using the same parameters, the main indications for the examination were described. Furthermore, the association between the number of lesions and independent variables was tested. Considering the number of polyps as the unit of analysis, their morphology was described according to topography, size, and extraction type. To test these associations, Pearson's Chi-square test was used, and when appropriate, Fisher's exact test. The analyses were performed using statistical software Stata 16.1.

 

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Results

During the analyzed period, a total of 667 colonoscopies were performed, of which 206 were selected after applying the eligibility criteria. Among the selected examinations, the majority were performed on female patients (58.7%). The mean age of the patients was 60.5 years, ranging from 32 to 90 years. Most colonoscopic examinations were conducted in patients aged between 45 and 75 years (83.0%), followed by patients under 45 years old (9.2%). The complete data can be observed in [Table 1].

Table 1 Sample description

Variables	n	%
Sex
Male	85	41,3
Female	121	58,7
Age (years) (mean/ standard deviation)
< 45	19	9,2
45 to 75	171	83,0
> 75	16	7,8
Bowel preparation (Boston)
Good	190	92,2
Unsatisfactory	16	7,8
Indication
Screening	123	59,7
Other	83	40,3
Number of lesions
1	111	54,0
2	52	25,2
3	20	9,7
4	10	4,8
5 or more	13	6,3

Source: prepared by the authors.

Regarding bowel preparation, according to the Boston scale, 92.2% of the examinations showed adequate preparation for the procedure. As for the indications for performing the exam, the majority were for colorectal cancer screening (59.7%) ([Table 1]). Other indications included, in second place, constipation (5,8%). The third most common indication was hematochezia (4,4%). The remaining indications are detailed in [Table 2].

Table 2 Description of colonoscopy indication

Indication	n	%
Screening	123	59,7
Anemia	8	3,9
Polypectomy	8	3,9
Positive Fecal Occult Blood Test (FBS)	6	2,9
Hematochezia	9	4,4
Monitoring of lesions	8	3,9
Abdominal pain or distensions	8	3,9
Diarrhea	7	3,4
Constipation	12	5,8
Weight loss	2	0,9
Change in bowel habits	3	1,5
Others	12	5,8

Source: prepared by the authors.

Regarding the number of lesions identified in a single colonoscopic examination, many cases presented a single polyp (54.0%).

It was observed that 10.6% of men had 5 or more lesions, while only 3.3% of women presented this quantity. However, there was no statistically significant difference in the total number of lesions found between sexes (p = 0.057).

No patient under 45 years old had more than 3 lesions, while 5.8% of patients between 45 and 75 years old and 18.7% of patients over 75 years old had 5 or more lesions. Patients between 45 and 75 years old had the highest percentage of examinations with 3 lesions, whereas patients over 75 years old had the highest percentage of examinations with 4 lesions and with 5 or more lesions (p = 0.002). There was no statistically significant difference in the number of lesions concerning bowel preparation (p = 0.965) or the indication for the examination (p = 0.840) ([Table 3]).

Table 3 Characterization of the number of polyps

	Number of injuries
Variables	1	2	3	4	5 or more	p-value
Sex						0,057
Male	51,8	20,0	14,1	3,5	10,6
Female	55,3	29,0	6,6	5,8	3,3
Age (years)						0,002
< 45	73,7	21,0	5,3	0,0	0,0
45 to 75	53,2	27,0	10,5	3,5	5,8
> 75	37,5	12,5	6,3	25,0	18,7
Bowel preparation						0,965
Good	54,2	24,7	10,0	4,8	6,3
Unsatisfactory	50,2	31,2	6,2	6,2	6,2
Indication						0,840
Screening	56,1	23,6	8,9	5,7	5,7
Others	50,6	27,7	10,9	3,6	7,2

Source: prepared by the authors.

[Table 4] presents the relationship between polyp morphology, distribution, size, and extraction method, with a total of 408 polyps identified during the analysis.

Table 4 Distribution of polyps

	n (%)	Sessile (%)	Subpediculated (%)	Pediculated (%)	P-value
Location					0,002
Cecum	26 (6,4)	100	0	0
Ascending Colon	85 (20,8)	88,2	5,9	5,9
Transverse Colon	49 (12,0)	85,7	8,2	6,1
Descending Colon	59 (14,5)	88,2	6,8	5,0
Sigmoid Colon	99 (24,2)	68,7	13,1	18,2
Rectum	90 (22,1)	78,9	4,4	16,7
Size					<0.001
Small	209 (71,1)	97,2	1,4	1,4
Medium	101 (24,7)	49,5	25,7	24,8
Large	17 (4,2)	11,8	0,0	88,2
Extration					<0.001
Biopsy clamp	307 (75,2)	97,4	1,9	0,7
Diathermic loop	64 (15,7)	35,9	32,8	21,3
Not extracted	37 (9,1)	32,4	8,1	59,5
TOTAL	n = 408	n = 334	n = 30	n = 44

Source: prepared by the authors.

Regarding location, there was considerable variability across different segments of the colon. The sigmoid colon was the most frequent site for polyp identification (24.2%), followed by the rectum (22,1%) and the ascending colon (20,8%). In the cecum, all identified polyps were classified as sessile, representing 100% of the total. This morphology predominated throughout the colon and rectum. The highest proportion of subpedunculated and pedunculated polyps was found in the sigmoid colon, with 13.1% and 18.2%, respectively. In the rectum, the second highest proportion was of pedunculated polyps (16.7%), while in the transverse colon, it was subpedunculated polyps (8.2%).

Regarding polyp size, the majority were classified as small (71.1%). Among small and medium-sized polyps, sessile morphology was predominant, representing 97.2% and 49.5%, respectively. No large polyps were classified as subpedunculated. Among large polyps, the majority were pedunculated (88.2%).

The analysis of extraction methods revealed that biopsy forceps were the most used method (75.2%), followed by diathermic loop (15.7%). Both extraction methods were predominantly employed for the removal of sessile polyps, representing 97.4% and 35.9%, respectively. Notably, 59.5% of pedunculated polyps were not removed.

 

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Discussion

Colonoscopy is widely recognized for its high sensitivity in detecting cancer and precancerous lesions, enabling simultaneous diagnosis and treatment.[11] Colonoscopic polypectomy plays a crucial role in reducing colorectal cancer incidence, reinforcing the adenoma-carcinoma sequence theory, as demonstrated in prior studies.[12] [13]

Our analysis revealed that many patients diagnosed with colorectal polyps were women, comprising 58.7% of the sample. While statistical significance was not observed, the literature suggests a slight female predominance in similar studies[1] [5] [8] [14] [15] [16] [17] Data from the National Cancer Institute's 2023 census projected 21,970 new cases among men and 23,660 among women, with estimated risks of 20.78 and 21.41 new cases per 100,000 individuals, respectively.[3]

Despite this, the absolute difference between sexes in our sample was 36 individuals (17.4%), suggesting that prevention campaigns may increase awareness among men regarding early detection. However, women continue to seek medical care more frequently, contributing to a higher diagnosis rate of colorectal polyps, even though men exhibit a greater lesion incidence.

In assessing sex and polyp count per examination, no statistically significant differences emerged.[2] However, men presented a higher frequency of multiple polyps, with five or more lesions in 10.6% of cases. These findings align with previous studies[2] indicating an increased prevalence of polyps with age, particularly after 50[2] [5] [8] [14] [18] ^, affecting nearly 25% of individuals over 75.[2] [11] In our cohort, spanning ages 32 to 90, 83% of polyp-positive cases were aged 45–75, with a mean age of 60.5 years.

Notably, a considerable proportion of polyp cases occurred in individuals under 45, reflecting a rising concern within the medical community regarding increased incidence in younger populations.[1] [4] [12] Wolf et al.[19] linked this trend to Western lifestyle factors, including alcohol and red meat consumption, obesity, smoking, low fiber intake, and physical inactivity.

Polyp count per colonoscopy varies among studies,[5] [14] with reports of synchronous polyps ranging from 18.9% to 37.4%.[14] In our sample, most examinations revealed a single lesion (54.0%). Further analysis showed that age correlated with lesion quantity; among patients over 75, 18.7% exhibited five or more lesions, while those under 45 had a maximum of three. The predominance of single-polyp findings in our study may be attributed to the younger demographic composition of our sample.

Bowel preparation quality significantly impacts lesion detection, and our study found that most patients had good preparation, with only 7.8% classified as inadequate. Proper cleansing enhances the detection of lesions over 5mm,[4] whereas inadequate preparation increases the risk of missed diagnoses, incomplete exams, and the need for repeat procedures.[4]

Regarding the indication for the examination, the results obtained in this study do not differ significantly from those found in the literature. Although the literature highlights intestinal bleeding (including rectal bleeding) as the main indication[8] [13] [17] our study revealed that the primary indication was screening, accounting for 59,7% of the cases. However, it is important to note that in our investigation, intestinal bleeding was still a significant indication, ranking third with 4,4% of the cases.

Moreover, the study was conducted in a private clinic, which may justify the higher number of examinations related to screening rather than specific complaints. In private healthcare settings, it is common for patients to have greater access to preventive and routine tests, which may lead to a predominance of screening indications compared to public settings, where examinations are more often sought due to specific symptoms.

Torres et al.[8] indicated that constipation ranked fifth in terms of indication frequency. However, our research found constipation to be the second most frequent indication, suggesting a difference in trends regarding reasons for undergoing the exam. This discrepancy may be attributed to the specific profile of patients residing in the southernmost region of Santa Catarina, their health and lifestyle patterns, and the fact that our study was carried out in a private clinic. Additionally, Santos et al.[16] reported anemia as one of the main indications for colonoscopy, which is consistent with the findings of our study, where it was the fourth most common indication.

Regarding topography, older studies revealed that the highest incidence of polyps occurred in the sigmoid colon and rectum[1] [5] [14] [16] [17] [19]. Our results showed that the sigmoid colon was the most frequent site for polyp identification (24,2%), followed by the rectum (22,1%) and the ascending colon (20,8%). Recent studies have observed an increasing trend in the occurrence of polypoid lesions in the right colon, which aligns with our findings[2] [7] [20] [21] [22]. These findings highlight the importance of a complete colonoscopy, avoiding limitations to the evaluation of the left colon, since approximately 23% of lesions may be located near the splenic flexure and could be missed if the evaluation is restricted[20].

Most lesions in our study were sessile, corroborating previous findings.[5] [7] [14] [18] Regarding morphology and topographic distribution, we observed that in the cecum, 100% of the polyps were sessile, with this morphology also being predominant throughout the colon and rectum. In the sigmoid colon, although sessile polyps prevailed, 13.1% were subpedunculated, and 18.2% were pedunculated. In the rectum, sessile polyps were the most frequent, followed by pedunculated ones (16.7%). Authors such as Manzione et al.[14] also observed a predominance of sessile polyps in the sigmoid colon and rectum.[5] [14] [17]

Pedunculated polyps were most frequently found in the sigmoid colon, followed by the rectum, while subpedunculated polyps were predominantly located in the sigmoid colon and, subsequently, in the transverse colon. These findings are important because distal polyps are closely associated with advanced proximal neoplasia.[14]

The majority of polyps identified in this study were small in size (71.1%), which is consistent with reports in the literature.[14] [18] Both small and medium-sized polyps were predominantly sessile, representing 97.2% and 49.5%, respectively, which is in agreement with findings from other studies.[7] [18] These findings suggest a potential correlation between polyp size and the degree of dysplasia, indicating that even small polyps may present significant dysplasia.[14]

Regarding large polyps, most were pedunculated (88.2%), and no large polyps were classified as subpedunculated. Gomes et al.5 also observed an association between polyp size and the likelihood of being an adenomatous polyp, suggesting that the larger the polyp, the higher the probability of it being an adenoma.

At the clinic studied, 9.1% of the total sample of polyps were not removed, with the majority of these being pedunculated (59.5%). This may be attributed to the clinic's role as a referral center for patients from the public healthcare system (SUS). In some cases, patients need to be referred to larger centers with more complex and costly equipment, especially for the removal of pedunculated and large polyps.[5]

Additionally, some polyps were not removed due to financial constraints among private patients, lack of authorization for resection from the patient or family members, the need for additional examinations, or the necessity of suspending anticoagulant medications before the procedure.

It is important to emphasize that there is a consensus recommending polypectomies for all symptomatic patients with polyps, regardless of morphology, if removal is technically feasible,[5] [18] except for polyps with hyperplastic characteristics.

The selection of the polyp removal method should be based on a thorough analysis of its size, morphology, and location.[17] In our study, biopsy forceps were the most frequently used instrument, accounting for 75.2% of removals, compared with electrocautery snare use, which represented 15.7%. This can be explained by the size of the lesions found in our study, as biopsy forceps are recommended for lesions up to 10mm,[24] in addition to the fact that most lesions identified were small or medium-sized sessile polyps. The extraction methods are in accordance with the guidelines of the Brazilian Society of Digestive Endoscopy (SOBED).

Although this was the first study to evaluate the profile of the population undergoing colonoscopy in our region and had a significant sample size, some inherent limitations must be acknowledged. One of them is the lack of access to histopathological results, which could enrich the understanding of the histological characteristics of the polyps, complementing the endoscopic findings.

A significant contribution of this study is highlighting a gap in scientific literature: the scarcity of studies directly relating polyp morphology to their specific location in the colon. This observation underscores the importance of our research in providing valuable insights into the distribution of colorectal polyps according to their morphological characteristics.

Furthermore, our results have potential implications not only for academic research but also for clinical practice and public health. This study contributes to a better understanding of the local population profile, enabling the observation of polyp migration to the right colon and correlating morphological types with lesion location.

Finally, when analyzing the influence of colorectal cancer awareness policies, we found that, although the female population was more prevalent, the absolute difference was only 36 women. This suggests that prevention campaigns are beginning to raise awareness among men, leading to an increased number of examinations and diagnoses in this population.

 

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Conclusion

The study analyzed the profile of patients with colorectal polyps at a reference clinic in the south of Santa Catarina, providing important insights. It was observed that the majority of those undergoing the examination were female, with the most common age group between 45 and 75 years, and the predominant location of polyps was in the sigmoid colon. Most of the polyps were small and sessile, primarily removed using biopsy forceps. However, pedunculated polyps were often not removed, possibly due to financial or technical barriers. While the study provides valuable information, the lack of access to histopathological results is a limitation. In conclusion, the study contributes to a better understanding of colorectal polyps in the local context and may guide more effective colorectal cancer prevention strategies in the region.

 

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Conflict of Interest

None.

• References

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Publication History

Received: 02 April 2025

Accepted: 22 May 2025

Article published online:
16 July 2025