Frequency of dysplasia in endoscopically resected pseudopolyps in inflammatory bowel diseases

Pseudopolyps have traditionally been considered sequelae of mucosal healing in inflammatory bowel diseases (IBDs). However, recent retrospective studies suggest that pseudopolyps may harbor dysplasia or obscure neoplastic lesions. This prospective study aimed to assess the frequency of dysplasia in pseudopolypoid lesions endoscopically resected in IBD patients and to identify potential predictors of dysplasia.

We analyzed pseudopolypoid lesions resected during colonoscopies performed between June 2023 and March 2025 in patients with colonic IBD at a single tertiary center. Lesions macroscopically classified as pseudopolyps and completely resected were histologically analyzed and categorized as inflammatory pseudopolyps, inflammatory pseudopolyps with foci of epithelial dysplasia, conventional adenomas, or IBD-associated dysplasia. Multivariable logistic regression was used to identify predictors of dysplasia.

Pseudopolyps were identified in 165 out of 910 patients undergoing colonoscopy (18.1%), and 124 lesions were resected in 98 patients. Dysplasia was detected in 15 lesions (12.1%), including conventional adenomas (53%, one with intramucosal carcinoma/high-grade dysplasia), IBD-associated dysplasia (20%), and hyperplastic lesions with dysplasia (27%). A heterogeneous pit pattern (OR = 4.50; 95% CI: 1.27-15.9) and absence of ulceration (OR = 0.093; 95% CI: 0.01-0.77) were independent predictors of dysplasia. No dysplasia was found in the surrounding mucosa.

Dysplasia was found in 12% of pseudopolypoid lesions, challenging the assumption that they are uniformly benign. Endoscopic features such as heterogeneous pit pattern and absence of ulceration may aid in identifying high-risk lesions. These results highlight the diagnostic uncertainty surrounding pseudopolyps in IBD and call for careful endoscopic assessment rather than routine resection.