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Pseudomelanic Polyposis of the Colon
Electronic Clinical Challenges and Images in GI Pseudomelanic Polyposis of the Colon Antonio Brage,1 Laura Vázquez Pérez-Coleman,1 and Romina Giacomodonato2 1Gastroenterology
Department and 2Pathology Department, Complexo Hospitalario Universitario A Coruña, Spain
Question: A 50-year-old man presented an episode of left iliac fossa pain with peritoneal irritation 2 years before. Physical and analytical parameters were otherwise normal. Initial laboratory studies revealed a hemoglobin 14.7 g/dL (normal, 13.5–17). An abdominal contrast-enhanced computed tomography was undertaken, revealing enlargement of the sigmoid colon and isolated diverticula. A diagnosis of diverticulitis was established and improved with medical therapy. Two colonoscopic follow-up explorations were carried out annualy with similar findings: Multiple hyperpigmented polypoid lesions and isolated diverticula were found in the sigmoid colon, without a neoplastic appearance either in the conventional colonoscopy (Figures A–D) or with narrow band imaging (Figure D), which revealed the presence of regularity of the colonic mucosa and the absence of an aberrant vascular pattern. Several biopsies, by using biopsy forceps endoscopic, were taken from the polypoid lesions. Histologic examination revealed only chronic inflammatory cell infiltration. In order to obtain an accurate diagnosis we performed macrobiopsies (Figures E–G). He was treated conservatively and has remained asymptomatic for 3 years. What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2012.09.045
GASTROENTEROLOGY 2013;144:e3– e4
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 2: Mucosal Prolapse Syndrome The macrobiopsies (Figures E–G; stain: hematoxyin and eosin; original magnification, 20⫻) showed mucosa with elongated hyperplastic crypts without dysplastic changes, hemosiderin deposits in macrophages of the lamina propia and in the submucosa (stain: Perl’s Prussian=s blue; original magnification, 20⫻), and submucosal fibrosis and thick walled tortuous blood vessels findings (stain: Mason’s trichrome; original magnification, 20⫻) compatible with a diagnosis of mucosal prolapse syndrome (MPS). Polypoid lesions in the colon with histologic findings compatible with MPS were described for the first time in 1985.1 MPS is a little-known condition that is usually confused with neoplastic polyps. Based on this diagnosis, incorrect therapeutic measures are frequently taken such as operative resection or endoscopic polypectomy.2 MPS does not present specific clinical findings, is asymptomatic, or causes recurrent abdominal pain, hematochezia, and change in normal intestinal habits.3 Computed tomography may show nonspecific, segmentary parietal thickening. Neither does conventional colonoscopy define specific peculiarities.2 The study with narrow band imaging showed regularity of the colonic mucosa and the absence of an aberrant vascular pattern.The diagnosis was established with a macrobiopsy of the polyps identifying the features of MPS with numerous siderophages in the lamina propia giving them the pseudo-melanic appearance. Diagnosis of prolapsing mucosal polyps by the examination of biopsy obtained by using biopsy forceps can be difficult because of the small size and depth of obtained specimens. Treatment must always be conservative and symptomatic, reserving surgery for complications, such as intestinal obstruction, persistent bleeding, or perforation.2 References 1. Franzin G, Fratton A, Manfrini C. Polypoid lesions associated with diverticular disease of the sigmoid colon. Gastrointest Endosc 1985;31:196 –199. 2. 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. 3. 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.
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Department and 2Pathology Department, Complexo Hospitalario Universitario A Coruña, Spain
Question: A 50-year-old man presented an episode of left iliac fossa pain with peritoneal irritation 2 years before. Physical and analytical parameters were otherwise normal. Initial laboratory studies revealed a hemoglobin 14.7 g/dL (normal, 13.5–17). An abdominal contrast-enhanced computed tomography was undertaken, revealing enlargement of the sigmoid colon and isolated diverticula. A diagnosis of diverticulitis was established and improved with medical therapy. Two colonoscopic follow-up explorations were carried out annualy with similar findings: Multiple hyperpigmented polypoid lesions and isolated diverticula were found in the sigmoid colon, without a neoplastic appearance either in the conventional colonoscopy (Figures A–D) or with narrow band imaging (Figure D), which revealed the presence of regularity of the colonic mucosa and the absence of an aberrant vascular pattern. Several biopsies, by using biopsy forceps endoscopic, were taken from the polypoid lesions. Histologic examination revealed only chronic inflammatory cell infiltration. In order to obtain an accurate diagnosis we performed macrobiopsies (Figures E–G). He was treated conservatively and has remained asymptomatic for 3 years. What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2013 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2012.09.045
GASTROENTEROLOGY 2013;144:e3– e4
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 2: Mucosal Prolapse Syndrome The macrobiopsies (Figures E–G; stain: hematoxyin and eosin; original magnification, 20⫻) showed mucosa with elongated hyperplastic crypts without dysplastic changes, hemosiderin deposits in macrophages of the lamina propia and in the submucosa (stain: Perl’s Prussian=s blue; original magnification, 20⫻), and submucosal fibrosis and thick walled tortuous blood vessels findings (stain: Mason’s trichrome; original magnification, 20⫻) compatible with a diagnosis of mucosal prolapse syndrome (MPS). Polypoid lesions in the colon with histologic findings compatible with MPS were described for the first time in 1985.1 MPS is a little-known condition that is usually confused with neoplastic polyps. Based on this diagnosis, incorrect therapeutic measures are frequently taken such as operative resection or endoscopic polypectomy.2 MPS does not present specific clinical findings, is asymptomatic, or causes recurrent abdominal pain, hematochezia, and change in normal intestinal habits.3 Computed tomography may show nonspecific, segmentary parietal thickening. Neither does conventional colonoscopy define specific peculiarities.2 The study with narrow band imaging showed regularity of the colonic mucosa and the absence of an aberrant vascular pattern.The diagnosis was established with a macrobiopsy of the polyps identifying the features of MPS with numerous siderophages in the lamina propia giving them the pseudo-melanic appearance. Diagnosis of prolapsing mucosal polyps by the examination of biopsy obtained by using biopsy forceps can be difficult because of the small size and depth of obtained specimens. Treatment must always be conservative and symptomatic, reserving surgery for complications, such as intestinal obstruction, persistent bleeding, or perforation.2 References 1. Franzin G, Fratton A, Manfrini C. Polypoid lesions associated with diverticular disease of the sigmoid colon. Gastrointest Endosc 1985;31:196 –199. 2. 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. 3. 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.
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