A 64-year-old woman with chronic gastritis due to long-standing Helicobacter pylori infection presents with iron deficiency anemia. Upper endoscopy reveals the findings shown in the diagram. The structures marked **A** are multiple small (0.5–1.5 cm) sessile smooth polyps scattered across the gastric body and antrum on a background of atrophic mucosa. Biopsies confirm elongated, tortuous, dilated foveolar glands with edematous lamina propria. Which of the following is the most appropriate INITIAL management step for these polyps?
A. Surveillance endoscopy at 3-monthly intervals due to high malignancy risk
B. H. pylori eradication therapy (clarithromycin-based triple therapy or bismuth quadruple therapy)
C. Immediate endoscopic polypectomy of all polyps >0.5 cm
D. Proton pump inhibitor monotherapy to suppress acid and promote polyp regression
Explanation
Why H. pylori eradication therapy is right
Hyperplastic polyps (marked A) are the most common type of gastric polyp (~75% in H. pylori-endemic regions) and arise as a regenerative response to mucosal injury from chronic H. pylori gastritis. The clinical anchor emphasizes that H. pylori eradication is the cornerstone of initial management, leading to regression of up to 70% of small hyperplastic polyps within 12 months. In this patient with confirmed H. pylori-associated chronic gastritis and multiple small hyperplastic polyps, eradication therapy (clarithromycin-based triple therapy or bismuth quadruple for resistant strains) addresses the underlying pathogenic driver and is the standard first-line approach per WHO Digestive 5e and AGA Gastric Polyps Guidelines 2021.
Why each distractor is wrong
Immediate endoscopic polypectomy of all polyps >0.5 cm: While polypectomy is indicated for polyps >0.5–1 cm that are symptomatic, have dysplasia, or are solitary lesions where adenoma cannot be excluded, it is NOT the initial step in asymptomatic multiple hyperplastic polyps. Eradication is attempted first because many small hyperplastic polyps regress spontaneously after H. pylori clearance, making polypectomy unnecessary.
Surveillance endoscopy at 3-monthly intervals due to high malignancy risk: Hyperplastic polyps have low malignant potential (<2% overall). While surveillance is warranted after polypectomy or in the presence of significant atrophy/intestinal metaplasia (OLGA III/IV), routine 3-monthly surveillance is excessive and not recommended for small uncomplicated hyperplastic polyps, especially before attempting eradication.
Proton pump inhibitor monotherapy to suppress acid and promote polyp regression: PPIs alone do not address the underlying H. pylori infection and are not standard monotherapy for hyperplastic polyps. While PPIs may be used as part of eradication regimens, they are not the primary management strategy and do not reliably promote regression of H. pylori-associated hyperplastic polyps without eradication.
High-YieldNEET PG
Hyperplastic polyps in H. pylori gastritis regress in ~70% of cases after eradication therapy within 12 months—always eradicate first before considering polypectomy in asymptomatic small multiple polyps.
WHO Digestive 5e; AGA Gastric Polyps Guidelines 2021
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