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An Uncommon Category of Polyp Lesion in a Western Colon
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
An Uncommon Category of Polyp Lesion in a Western Colon Q2
Vincent Zimmer1,2 and Christoph Heinrich3 1 Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany; 2Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany; and 3Insitute of Pathology Saarbrücken-Rastpfuhl, Saarbrücken, Germany
Question: An 87-year-old woman of European descent underwent ileocolonoscopy for workup of abdominal pain. In the ascending colon, a worm-like polypoid lesion appeared estimated at 12 mm with a slightly edematous appearance and a drumstick-like tip (Figure A). After a change in patient positioning, the lesion was raised by gravitation, further highlighting the featureless glassy aspects in its head without evidence of adenomatous polyp quality (Figure B). Of interest, on further optic assessment of the narrow base concentric rings were visualized reminiscent of so-called Aurora rings otherwise characteristic for inverted colonic diverticula (Figure C). However, although multiple inconspicuous diverticula were indeed present in the patient’s sigmoid colon, the patient proceeded to endoscopic resection under a specific working diagnosis. What diagnosis might be suggested considering the unusual, however characteristic, endoscopic presentation? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2019 by the AGA Institute 0016-5085/$36.00 https://doi.org/10.1053/j.gastro.2019.07.019
Gastroenterology 2019;-:e1–e2 DIS 5.6.0 DTD YGAST62769 proof 4 November 2019 7:07 pm ce
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 6: Colonic Mucosubmucosal Elongated Polyp
Given typically findings in terms of the worm-like extension with a rounded tip as well as edematous, glassy fine structure without neoplastic features, a provisional endoscopic diagnosis of colonic muco-submucosal elongated polyp (CMSEP) was established. By contrast, filiform polyp as another set of non-neoplastic finger-like projections tend to arise in multiple numbers in an inflammatory bowel disease-affected colon as are inflammatory pseudopolyps. Likewise, prolapsing mucosal folds as a potential differential in endoscopic diagnosis typically arises in the distal colon with diverticular disease and rather exhibit leaf-like appearances with a broader base. Although in pedunculated colon lesion, endoscopic resection is traditionally by electrocautery, we performed cold snare polypectomy, which has not yet been reported in the literature, at the very mucosal entry point of the slender stalk with preparations made in case relevant bleeding would occur. Although minor, self-limited oozing occurred, as is typical of cold snare polypectomies, a peculiar finding in the resection bed was noted, designated the “red whirl sign” (Figure D). Final histopathology confirmed a diagnosis of CMSEP as an uncommonly reported polyp category mostly described by Japanese groups.1,2 Pathology findings included near-normal colonic mucosa without significant crypt alterations and/or significant inflammatory changes as well as a slender submucosal stalk with dilated venous and capillary blood vessels running parallel to its long axis, potentially underlying the red whirl sign3 (Figure E, F, stain: hematoxylin and eosin; original magnification 1.6 and 5.0, respectively; Figure G, stain: CD31 immunohistochemistry; original magnification 5). Although typically an incidental, benign finding thought to relate to mechanical traction secondary to peristaltic waves, CMSEP have only individually been reported in Western populations and are thus larger unknown to Western endoscopists and GI pathologists alike. Thus, a high endoscopic suspicion and proper communication with the pathologist are essential to arrive at an equivocal diagnosis.
References 1. 2. 3.
Matake H, Matsui T, Yao T, et al. Long pedunculated colonic polyp composed of mucosa and submucosa: proposal of a new entity, colonic muco-submucosal elongated polyp. Dis Colon Rectum 1998;41:1557–1561. Tan CL, Tan SH, So JB, et al. Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature. World J Gastroenterol 2013;19:1845–1849. Ali RH, Mohammad NM, Serra S, et al. Colonic mucosubmucosal elongated polyp: report of a series of 14 cases and review of the literature. Histopathology 2016;69:592–599.
e2 DIS 5.6.0 DTD YGAST62769 proof 4 November 2019 7:07 pm ce
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Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
An Uncommon Category of Polyp Lesion in a Western Colon Q2
Vincent Zimmer1,2 and Christoph Heinrich3 1 Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany; 2Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany; and 3Insitute of Pathology Saarbrücken-Rastpfuhl, Saarbrücken, Germany
Question: An 87-year-old woman of European descent underwent ileocolonoscopy for workup of abdominal pain. In the ascending colon, a worm-like polypoid lesion appeared estimated at 12 mm with a slightly edematous appearance and a drumstick-like tip (Figure A). After a change in patient positioning, the lesion was raised by gravitation, further highlighting the featureless glassy aspects in its head without evidence of adenomatous polyp quality (Figure B). Of interest, on further optic assessment of the narrow base concentric rings were visualized reminiscent of so-called Aurora rings otherwise characteristic for inverted colonic diverticula (Figure C). However, although multiple inconspicuous diverticula were indeed present in the patient’s sigmoid colon, the patient proceeded to endoscopic resection under a specific working diagnosis. What diagnosis might be suggested considering the unusual, however characteristic, endoscopic presentation? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2019 by the AGA Institute 0016-5085/$36.00 https://doi.org/10.1053/j.gastro.2019.07.019
Gastroenterology 2019;-:e1–e2 DIS 5.6.0 DTD YGAST62769 proof 4 November 2019 7:07 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 6: Colonic Mucosubmucosal Elongated Polyp
Given typically findings in terms of the worm-like extension with a rounded tip as well as edematous, glassy fine structure without neoplastic features, a provisional endoscopic diagnosis of colonic muco-submucosal elongated polyp (CMSEP) was established. By contrast, filiform polyp as another set of non-neoplastic finger-like projections tend to arise in multiple numbers in an inflammatory bowel disease-affected colon as are inflammatory pseudopolyps. Likewise, prolapsing mucosal folds as a potential differential in endoscopic diagnosis typically arises in the distal colon with diverticular disease and rather exhibit leaf-like appearances with a broader base. Although in pedunculated colon lesion, endoscopic resection is traditionally by electrocautery, we performed cold snare polypectomy, which has not yet been reported in the literature, at the very mucosal entry point of the slender stalk with preparations made in case relevant bleeding would occur. Although minor, self-limited oozing occurred, as is typical of cold snare polypectomies, a peculiar finding in the resection bed was noted, designated the “red whirl sign” (Figure D). Final histopathology confirmed a diagnosis of CMSEP as an uncommonly reported polyp category mostly described by Japanese groups.1,2 Pathology findings included near-normal colonic mucosa without significant crypt alterations and/or significant inflammatory changes as well as a slender submucosal stalk with dilated venous and capillary blood vessels running parallel to its long axis, potentially underlying the red whirl sign3 (Figure E, F, stain: hematoxylin and eosin; original magnification 1.6 and 5.0, respectively; Figure G, stain: CD31 immunohistochemistry; original magnification 5). Although typically an incidental, benign finding thought to relate to mechanical traction secondary to peristaltic waves, CMSEP have only individually been reported in Western populations and are thus larger unknown to Western endoscopists and GI pathologists alike. Thus, a high endoscopic suspicion and proper communication with the pathologist are essential to arrive at an equivocal diagnosis.
References 1. 2. 3.
Matake H, Matsui T, Yao T, et al. Long pedunculated colonic polyp composed of mucosa and submucosa: proposal of a new entity, colonic muco-submucosal elongated polyp. Dis Colon Rectum 1998;41:1557–1561. Tan CL, Tan SH, So JB, et al. Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature. World J Gastroenterol 2013;19:1845–1849. Ali RH, Mohammad NM, Serra S, et al. Colonic mucosubmucosal elongated polyp: report of a series of 14 cases and review of the literature. Histopathology 2016;69:592–599.
e2 DIS 5.6.0 DTD YGAST62769 proof 4 November 2019 7:07 pm ce
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