Filiform polyposis presenting with rapid growth and severe anemia

doi:10.21203/rs.3.rs-1959696/v1

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Case Report

Filiform polyposis presenting with rapid growth and severe anemia

https://doi.org/10.21203/rs.3.rs-1959696/v1

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Giant inflammatory polyposis (GIP) is a rare manifestation of inflammatory bowel disease (IBD), and it is described as a worm-like projection of 1.5 cm or more in diameter with unclear pathogenesis. GIP may be related to the severity of IBD. GIP presents with a wide range of symptoms, including crampy abdominal pain, anemia and intestinal obstruction. The histopathology of GIP is a polyp lined by normal colonic mucosa with superficial ulceration that may show mild crypt distortion. Our case reports a patient with ulcerative colitis diagnosed via colonoscopy and histopathology 10 months before presenting with severe anemia due to lower gastrointestinal bleeding. Colonoscopy showed GIP obstructing the descending colon, and total colectomy showed the entire colon full of worm-like polyps up to 16 cm.

Giant inflammatory polyposis (GIP)

inflammatory bowel disease (IBD)

ulcerative colitis (UC) and colorectal cancer (CRC)

Giant inflammatory polyposis (GIP), also named giant pseudopolyposis and filiform polyposis, is an uncommon pathological feature of inflammatory bowel disease (IBD). (1) GIP is identified as multiple worm-like projections measuring 1.5 cm or more in length or diameter in the colon. (2) GIP can reach up to 100 in number. (10) GIP may occur in Crohn’s disease (CD), ulcerative colitis (UC) or indeterminate colitis (IC). (1) Most of the review studies reported that GIP was higher in UC than CD (2, 3). GIP is more common in males than females, and the age group is 8 to 68 years old. (3)

Clinical manifestations of GIP are nonspecific and may present as gastrointestinal bleeding, cramping abdominal pain, intestinal obstruction or asymptomatic and incidental symptoms during colonoscopy (4). We present a case of UC with a rapid growing GIP within 10 months that caused severe anemia.

A 58-year-old Saudi male patient presented to the emergency department at King Abdulaziz General Hospital, Makkah, Saudi Arabi, complaining of fatigue and dizziness for the last two days, with a history of two weeks of cramping abdominal pain and multiple episodes of bloody diarrhea. The patient was a diabetic and was diagnosed with UC 10 months ago. There was a history of a 2-year intermittent attack of cramping abdominal pain associated with bloody diarrhea and 2 blood transfusions. The diagnosis was made after colonoscopy, which showed chronic relapsing ulcerative colitis.

Examination of the abdomen was soft, nontender, nondistended, with no guarding or rebound. Preanal examination revealed stool mixed with blood, hemoglobin 3.1, and leukocytosis 8.3.

The patient was admitted, and blood transfusion was initiated. Lower gastrointestinal bleeding was investigated. The upper endoscopy was unremarkable. Colonoscopy reached 38 cm from the anal verge to the descending colon and could not progress farther due to an obstructed colon with worm-like polyps. Some of the colon had an ulcerated surface. (pic 1) Multiple biopsies were taken. The histopathology showed chronic active colitis consistent with ulcerative colitis. An abdominal CT was performed with IV and oral contrast and showed loss of the ascending and sigmoid colon with wall thinking and multiple tubular dissecting intraluminal filling defects in the ascending and sigmoid colon, likely polyps with filiform patterns. (Pic 2)

A total colectomy with ileo-rectal anastomosis with circular end-to-end stapling devices as performed. Postoperatively, the patient had no complications and was discharged three days later.

The colon specimen grossly showed multiple projections with a worm-like shape, and the longest one was 14 cm (pic3). The histopathology showed neutrophil infiltration of the mucosa and submucosa with crypt abscesses, and no signs of dysplasia.

There are several hypotheses for the formation of IP, including severe mucosal inflammation that occurs due to the IBD, which overgrows after the inflammation subsides due to fecal stream traction or repeated inflammation and healing of mucosa during the healing period (3, 5, 6), which are seen in 17% of UC with active colitis. (7) As seen in our patient, the histopathology component was acute in addition to chronic, which formed within 6 months. According to the data in the literature, the average duration reported for formation since diagnosis with UC is approximately 3 to 276 months (4). With a length up to 16 cm (8), the sigmoid colon is the most common site, (9, 6) which is consistent with the fact that 30–50% of UCs are confined to the rectum and sigmoid colon. (10) The histopathological appearance of FP is generally normal to acute or chronic inflammatory colonic mucosa (11, 9).

The risk of colorectal cancer (CRC) is higher in UC patients than in the general population, and it is increased with extensive colitis, primary sclerosing cholangitis, family history of colorectal cancer, chronic colonic mucosal inflammation and postinflammatory polyps (12, 10). and IP is considered an independent risk factor for malignancy. (3)

The prevalence of CRC in UC decreased over the past few decades according to a Danish study, and it is 1.7% compared to the general population (13). This decrease referred to the increase in the colonoscopy surveillance in UC patients. (14) Despite the risk of malignancy in UC, the question is whether the FFP is premalignant, and it is not considered a risk factor for malignancy. (9) As in our case, histopathology did not show any neoplasia or dysplasia, as documented in many case reports, because most FFP is found incidentally and does not need further management, except usual surveillance. (11) Notably, only four case reports in the literature linked FFP with malignancy, two in IBD patients and two in non-IBD patients (15, 16, 6, 9).

Surgical intervention is indicated for FFP if it is complicated, such as bleeding or obstruction, which is reported in a few cases (1, 3–5). However, there is no clear guideline for surgical intervention for complicated FFP, but the safest methodology is to follow the guideline for the patient for the underlying disease, as in our patient with UC, with an emergency surgical option being total abdominal colectomy with end ileostomy. (10)

Inflammatory polyps have no specific management except in complicated cases, which have been reported in a few cases (3–5, 1). Otherwise, colonoscopy surveillance with multiple biopsies may be considered a safe option (11) because the risk of malignancy transformation is not clearly understood, which indicates further study.

Acknowledgment

We thank Dr. Sleman Aljondi, for taking pictures of the specimen.

Conflict of interest statement

The authors confirm that there are no known conflicts of interest.

Consent for publication

Consent have been taking from the patient for publication and pictures.

Funding

No funding needed in our case report writing.

Author's contribution in the case report writing:

- Dr. Waed Saeed Jameel

[email protected]

Main author, Literature review and writing the main manuscript.

- Dr. Noran Abdurazzaq Sultan

[email protected]

Co-author, Wrote the case report part and assist in writing the manuscript.

- Dr. Abdullah Mosleh Alkhuzaie

[email protected]

Co-author, The consultant in charge of the case during admission, also review and adjust the manuscript.

- Dr. Mohammed Saeed Aldosari

[email protected]

Co-author, review the manuscript and the pathology sample.

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No competing interests reported.

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Filiform polyposis presenting with rapid growth and severe anemia

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