Giant Inflammatory Polyposis of the Rectum as a Complication of Ulcerative Colitis
Theeran Gill1, Jaikumar Nallamuthu1, Shabbar Husain2, Wazir Azzam1, Firdaus Hayati3, Ismail Sagap4
1Department of General Surgery, 94 Armed Forces Hospital Terendak, Melaka, Malaysia
2Department of General Surgery, Hospital Angkatan Tentera Tuanku Mizan, Malaysia
3Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
4Department of Surgery, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur, Malaysia
Received: 22 Jul 2021; Revised: 30 Jan 2021; Accepted: 07 Feb 2022; Available online: 28 Mar 2022
Inflammatory bowel disease is an emerging gastrointestinal disease in Malaysia. One of its rare complications includes giant inflammatory polyposis (GIP). A 39-year-old woman presented with worsening per rectal mucous discharge, associated with blood, colicky abdominal pain, and weight loss. A series of endoscopies at another hospital did not provide an inconclusive diagnosis. Another repeat colonoscopy showed a left-sided colitis with marked erythema and friability with islands of polyps; this was concluded to be an ulcerative colitis based on histopathology; thus, medical treatment was commenced. However, 2 months later, the patient presented with constipation, which required laxatives, as well as a worsened lower abdominal pain. Subsequent colonoscopy revealed obstruction-caused GIP at the mid rectum extending to the lower rectum, which was confirmed by imaging modalities. She was diagnosed with obstructing GIP coupled with ulcerative colitis, and panproctocolectomy and ileal pouch anal anastomosis were planned.
Keywords: Case report, Colonoscopy, Inflammatory bowel disease, Ulcerative colitis
Ann Afr Surg. 2022; 19(3): 165-168
© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Inflammatory bowel disease (IBD) was once considered rare in the Asian population. However, recent data have shown an emerging trend of IBD cases in Eastern Asia (1). In Malaysia, the mean crude incidence has doubled to 1.46 per 100,000 person-years (1). Giant inflammatory polyposis (GIP) is a rare complication of IBD. It is diagnosed when an inflammatory polyp is >1.5 cm in any given dimension or with the presence of filiform projections that look like “mass of worms” or a “fungating mass.” It occurs more frequently in ulcerative colitis than in Crohn disease (2, 3).
However, the presence of GIP in the rectum is very rare; if present, it appears continuous with the colon. Thus, dysplasia-associated lesions can be mistaken for colorectal cancer, or even mass, because of its peculiar characteristics. Hence, histopathological examination is essential for differentiation, and a suitable mode of treatment should be applied. We present a case of GIP in the rectum without colonic involvement.
A 39-year-old woman, who was referred from another hospital, presented with a worsening per rectal mucous discharge associated with blood, colicky abdominal pain localized over the left iliac fossa and a weight loss of 9 kg. The patient has been experiencing mucous per rectal discharge with soiling for the past 10 years. Her past medical history revealed a bronchial asthma. Otherwise, there was no family history of cancer or drug abuse.
Click to view figure 1: (A) Islands of friable pseudopolyps with minimal slough at the lower rectum. (B) Circumferential friable pseudopolyps of varying sizes, causing partial obstruction with cauliflower-like appearances. (C) Chronic active colitis with islands of pseudopolyps extending from the mid-rectum with slough. (D) Giant inflammatory polyposis (tubulovillous adenomas) >1.5 cm extending from the mid-rectum to the lower rectum with contact bleeding and slough.
Prior to the patient’s visit at our hospital, she had undergone serial endoscopies at a district hospital. Her first colonoscopy showed low rectal polypoidal growth with contact bleeding and slough 2 cm from the anal verge. The result of her histopathological examination was suggestive of a hyperplastic polypoidal mucosa but was negative for malignancy. Her subsequent endoscopy was scheduled a month later at the same hospital. Sigmoidoscopy was performed, and it revealed multiple growths up to 10 cm from the anal verge; although suspicious in nature, histopathological examination revealed inflamed granulation tissue instead.
The patient was then referred to our hospital for further investigation of her condition. On admission, she was hemodynamically stable. Physical examination showed mild tenderness to deep palpation from the suprapubic region extending to the left iliac fossa. The results of laboratory tests showed a hemoglobin count of 10 g/dL (normal range, 10–12 g/dL) and an albumin level of 34 g/L (normal range, 35–54 g/L), whereas other blood investigations were normal, including carcinoembryonic antigen. Her stool examination for Clostridium di