Gastroenterology
Volume 137, Issue 3 , Pages e1-e2, September 2009

Unusual Colon Polyps

  • Shou-jiang Tang, MD

      Affiliations

    • Department of Gastroenterology, Hepatology and Endoscopy, Trinity Mother Frances Hospitals and Clinics, Tyler, Texas
    • ,
  • Yisheng V. Fang, MD

      Affiliations

    • Department of Pathology, The UT Southwestern Medical Center, Dallas, Texas

published online 31 July 2009.

David A. Katzka and David L. Jaffe, Section Editors

Article Outline

 

Question: A 39-year-old Hispanic man with a 7-year history of intermittent left lower quadrant abdominal pain and hematochezia. He is otherwise healthy. On several computed tomography (CT) scans, there were diffuse colonic diverticula. During acute attacks, inflammatory changes were noted within the pelvis adjacent to a large, inflamed, sigmoid diverticulum. These finings were consistent with acute sigmoid diverticulitis. He was treated with antibiotics. During colonoscopy, there was significant sigmoid luminal narrowing with near circumferential erythematous and bluish mucosa (Figure A and Video Clip) at 35 cm from the anal verge. This discolored mucosal segment was actually the base of several elongated and pedunculated polyps (Figure B). The pedicles of these polyps were hyperemic and adenomatous tissue was not observed. One of these pedunculated polyps was removed through snare polypectomy uneventfully. What is the diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 1: Prolapsing Mucosal Polyps of the Colon 

This patient has prolapsing mucosal polyps (PMP) of the colon. Histologically, there are surface erosions with fibrin/inflammatory exudates, fibromuscular proliferation in lamina propria with mucosal architectural distortion (encircling some crypts showing hyperplastic or villiform appearance with minimum inflammation and reactive epithelial atypia; Figure C). The muscularis mucosae is thickened and mucosal blood vessels are telangiectatic. The current understanding is that the PMP of the colon are histologically similar to other mucosal prolapsing conditions in the gastrointestinal (GI) tract, such as the solitary rectal ulcer syndrome, inflammatory cloacogenic polyps (in the anus), inflammatory cap polyps, and gastric antral vascular ectasia, and should therefore be designated as part of the mucosal prolapse syndrome.1, 2, 3 In our case, we hypothesize that on one hand these PMP with their associated luminal narrowing caused his recurrent diverticulitis and left lower quadrant abdominal pain. On the other hand, recurrent diverticulitis and intermittent obstruction might have exacerbated these PMP and mucosal venous congestion.

PMP of the colon usually occurs in the sigmoid colon and is associated with diverticulosis.2, 3 There is a male predominance of this condition. These patients present with occult or gross lower GI bleeding and lower abdominal pain.2 On endoscopy, the polyps appear well-circumscribed and hyperemic, either broad based or pedunculated in larger polyps.2, 3 The polyps can be multiple or solitary and their sizes vary.2 In some cases, the large polyps can encompass the colon wall circumferentially as in our patient. Adenomatous tissue is not present. The treatment options for symptomatic PMP of the colon include conservative management, endoscopic polypectomy if feasible, and surgical resection of the involved colon in cases of very large polyps, circumferential, and obstructive lesions.2, 3 Our patient underwent sigmoid colectomy. Surgical pathology confirmed multiple PMP and the largest polyp at 1.8 cm × 1.8 cm × 4.0 cm in size.

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References 

  1. Chetty R, Bhathal PS, Slavin JL. Prolapse-induced inflammatory polyps of the colorectum and anal transitional zone. Histopathology. 1993;23:63–67
  2. Tendler DA, Aboudola S, Zacks JF, et al. Prolapsing mucosal polyps: an underrecognized form of colonic polyp—a clinicopathological study of 15 cases. Am J Gastroenterol. 2002;97:370–376
  3. Cheung DY, Kim JI, Park YB, et al. Prolapsing mucosal polyps in the sigmoid colon: presenting with chronic abdominal cramping pain and colonic obstruction. Intern Med. 2007;46:1701–1704

 Conflicts of interest The authors disclose no conflicts.

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PII: S0016-5085(09)00162-0

doi:10.1053/j.gastro.2009.01.058

Gastroenterology
Volume 137, Issue 3 , Pages e1-e2, September 2009

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