The American College of Gastroenterology (ACG) just released a clinical practice guideline, Diagnosis and Management of Adenomatous Colorectal Polyposis Syndromes. The guideline provides evidence-based recommendations regarding what patients should undergo risk assessment, how and when to perform germline genetic testing, and how to lower cancer risk with surgical, endoscopic, and chemoprevention strategies. Diagnosis and Management of Adenomatous Colorectal Polyposis Syndromes emphasizes the impact of presymptomatic diagnosis in patients in families with known pathogenic variants.

Today we have a look at the dozen recommendations included in the 2026 ACG adenomatous colorectal polyposis syndromes guideline. For the complete look at the following recommendations alongside their rationale and additional key concepts, view the full-text version.

Recommendations in the 2026 ACG Guideline Diagnosis and Management of Adenomatous Colorectal Polyposis Syndromes

Diagnosis

  • In individuals with ≥20 cumulative lifetime adenomatous colorectal polyps, we recommend multigene panel testing (MGPT) to evaluate for the presence of a germline pathogenic variant associated with an underlying hereditary adenomatous colorectal polyposis or cancer syndrome.
  • In individuals with 10–19 cumulative lifetime adenomatous colorectal polyps, we suggest MGPT to evaluate for the presence of a germline pathogenic variant associated with an underlying hereditary adenomatous colorectal polyposis or cancer syndrome.
  • In individuals with any of the following extracolonic features of FAP including desmoid tumors, cribriform morular carcinoma of the thyroid, bilateral and/or multifocal congenital hypertrophy of the retinal pigment epithelium, or hepatoblastoma, we recommend germline APC testing to evaluate for the presence of a germline pathogenic variant associated with FAP.

Colorectum: Surgery

  • We suggest total proctocolectomy with ileal pouch anal anastomosis over total colectomy with ileorectal anastomosis in individuals with FAP who have >20 rectal adenomas who require surgery, and who prioritize the marginal reduction in the risk of secondary proctectomy and rectal cancer over functional outcomes.
  • In individuals with rectal sparing FAP (≤20 rectal adenomas) who require surgery, we suggest total colectomy and ileorectal anastomosis over total proctocolectomy and ileal pouch anal anastomosis to improve quality of life after surgery.

Colorectum: Chemoprevention

  • We recommend against chemoprevention as a replacement for colectomy in patients with polyposis with an indication for surgery.
  • We suggest chemoprevention with sulindac 150 mg twice daily or celecoxib 400 mg twice daily be considered as an adjunct to endoscopic surveillance on a case-by-case basis to reduce polyp burden in the colon, rectum, or pouch; however, the impact on need for surgery or cancer risk is unclear.

Upper GI Tract: Endoscopy

  • In individuals with FAP, AFAP, and MAP, we suggest upper endoscopic surveillance, with visualization of the duodenal papilla, over no surveillance. Ongoing endoscopic surveillance is indicated, but the intervals are not well-defined.
  • In individuals with FAP, AFAP, and MAP, we suggest upper endoscopic surveillance of the duodenum at intervals based on the SS of duodenal polyposis: every 3–5 years for SS 0, every 3 years for SS I, every 2–3 years for SS II, every 6–12 months for SS III, and every 3–6 months for SS IV.
  • In individuals with duodenal adenomas >10 mm or any HGD, we suggest therapeutic intervention over surveillance alone. The decision between endoscopic and surgical resection should be individualized based on the duodenal and ampullary disease burden, patient preference, and access to an experienced therapeutic endoscopy team.
  • In individuals with adenomatous polyposis and an ampullary adenoma, without an indication for duodenectomy, we suggest endoscopic ampullectomy over surgical ampullectomy for the following indications: (i) ampullary adenoma ≥10 mm, (ii) ampullary adenoma with HGD, and (iii) ampullary adenoma associated with pancreatico-biliary symptoms, provided there is no intraductal extension > 10 mm.
  • In individuals with FAP, AFAP, MAP, and gastric polyposis, we suggest endoscopic resection of all antral polyps, proximal polypoid mounds, polyps ≥10 mm, gastric adenomas, and white mucosal patches.

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