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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 38-40

Giant rectal polyp in children: An uncommon entity


Department of Pediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission05-Jun-2020
Date of Acceptance17-Jun-2020
Date of Web Publication11-Aug-2020

Correspondence Address:
Anand Pandey
Department of Pediatric Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_2_20

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  Abstract 

Colorectal polyp is the leading cause of bleeding per rectum in children. The juvenile polyp is the most common kind of polyp identified in the pediatric age group. The term giant rectal polyp in the pediatric age group has not been reported in the literature. We treated two patients who presented with anemia, generalized weakness, and bleeding per rectum. A giant juvenile polyp was determined as the cause. To the best of our knowledge, this is the first description of giant rectal polyp in the pediatric population.

Keywords: Bleeding per rectum, giant rectal polyp, juvenile polyp, rectal polyp


How to cite this article:
Bothara VP, Singh A, Pandey A, Gupta A. Giant rectal polyp in children: An uncommon entity. Indian J Colo-Rectal Surg 2019;2:38-40

How to cite this URL:
Bothara VP, Singh A, Pandey A, Gupta A. Giant rectal polyp in children: An uncommon entity. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2020 Sep 29];2:38-40. Available from: http://www.ijcrsonweb.org/text.asp?2019/2/2/38/291870


  Introduction Top


Colonic polyp is the most common cause of bleeding per rectum in children aged 1–10 years.[1] Of various types of the polyp, the juvenile polyp is the most common type.[1] It is mostly single, pedunculated, and to the left side of the colon.[2] The most common presentation is bleeding per rectum.[2] However, features such as abdominal pain, weakness, or anemia may also be there. Usually, the size of the polyp may be between 10 and 12 mm.[2],[3] Rarely, it may be up to 3 cm.[4] Juvenile rectal polyp of more than 5 cm size has not been reported in the literature. We treated two children having juvenile rectal polyp of this type, which are being communicated with a review of the relevant literature.


  Case Reports Top


Patient 1

An 11-year-old male child presented to our department with a complaint of bleeding per rectum for 4 months. He had received treatment for anemia and progressively worsening fatigue and generalized weakness for the past 4 years elsewhere. Physical examination, including per rectal examination in the outpatient department, did not reveal any abnormality.

Colonoscopy was performed, which revealed a large pedunculated solitary rectal polyp arising from the posterior rectal mucosa about 6 cm away from the anal verge. The rest of the colonic mucosa up to the splenic flexure was normal. Since the patient was severely anemic (hemoglobin [Hb] – 6.4 g%), two units of packed red blood cells (PRBCs) was transfused. After anesthetic fitness, he underwent a digital rectal examination under general anesthesia. A large solitary pedunculated rectal polyp was felt approximately 6 cm from the anal verge. Digital rectal polypectomy was performed. The size of the excised polyp was 5.5 cm × 4 cm. The postoperative period was uneventful, and the patient was discharged in satisfactory condition.

Patient 2

A 10-year-old male child presented to the department with a complaint of persistent bleeding per rectum for 1 month duration. On the initial per rectal (PR) assessment, a large mass was felt inside the rectum. However, on close examination, it was found to be a pedunculated solitary rectal polyp, which was around 4 cm from the anal verge. Clinically, he was anemic, which was confirmed on Hb evaluation (Hb – 7 g%). One unit of PRBC was transfused for the same.

After anesthetic fitness, digital rectal polypectomy was performed [Figure 1]a. The size of the excised rectal polyp was approximately 5 cm × 5 cm [Figure 1]b. The postoperative period was uneventful, and the patient was discharged in satisfactory condition. Histopathological examination revealed the diagnosis of a juvenile rectal polyp. It included neutrophilic infiltration, cystic dilatation of the glands, and transition of the mucosal lining from columnar to either stratified or single layer of the squamous cells [Figure 2] and [Figure 3].
Figure 1: (a) Intraoperative picture of giant rectal polyp. (b) Excised polyp. The dimension is about 5 cm

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Figure 2: Microphotograph of juvenile polyp showing large cystic dilated mucinous gland (A), columnar lining of the glands (B), capillaries with blood (C), neutrophils (D) (H and E, ×10)

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Figure 3: Microphotograph of juvenile polyp showing neutrophils (A), capillaries with blood (B), cystic dilatation of mucinous gland (C), normal mucinous gland (D), stratified epithelium of dilated gland (E), columnar lining of the gland (F) (H and E, ×40)

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  Discussion Top


Polyps are abnormal growths of tissue that can be found in any hollow viscus that has blood vessels. Colon, nose, and/or uterus are common organs. Most polyps are noncancerous (benign) though some can eventually undergo malignant transformation. Colon and stomach are the most common sites for polyps in the Gastro-intestinal tract (GIT). Polyps can be classified according to their structure (pedunculated or sessile) or histological type (malignant, adenomas, hamartomas, hyperplastic, or inflammatory).

In children, the most common colorectal polyps are nonmalignant, sporadic, and single. Juvenile polyps constitute 84%–97% of pediatric cases of polyps.[2] The most common age of presentation is 2–6 years, with slight male preponderance.[2],[5],[6],[7]

Most frequently, juvenile polyp presents as painless rectal bleeding.[2] Other modes of presentation are mass prolapsing through the anus (sometimes erroneously labeled as rectal prolapse), mucopurulent stools, abdominal pain, and fatigue, or weakness. Other rare presentations are intestinal obstruction, intussusception, or shock due to massive perrectal bleed.[2],[8] Solitary juvenile polyps carry no risk of intestinal cancer.[9] Colonoscopy with polypectomy and histological review are sufficient for the management of isolated juvenile polyps.[10]

A vital consideration in this report is the size of the polyp, which was greater than 4 cm in size. As described in the literature, the usual size of the polyp is between 10 and 12 mm.[2],[3] Occasionally, the size of up to 3 cm has also been reported.[4] Our literature search did not reveal the use of the word “giant” for a polyp in the pediatric age group. Hence, it appears that the term giant rectal polyp in the pediatric age group has not been described until now, although it has been used in the adult population. We would like to coin the term “giant rectal polyp” for those polyps in the pediatric age group, which are greater than 4.5 cm in size.

If not thought of, the giant rectal polyp may be difficult to diagnose, as it appears like a mass in rectum. Besides, as mentioned in the first patient, it may lead to severe anemia, for which treatment may be needed. We must be cautious while excision of giant rectal polyp as there may be a possibility of rupture. It may also be difficult to retrieve it from the anal canal. Utmost vigilance is necessary while ligating the pedicle as ligature slippage may lead to catastrophic bleed.


  Conclusion Top


Juvenile polyps are the most common cause of perrectal bleeding in the pediatric age group. However, uncommon symptoms masked by complications due to delayed seeking of medical help can make the doctor's job of reaching a diagnosis difficult. A neglected child may also present with a terminal event turning a benign condition into a potentially life-threatening one. To the best of our knowledge, this is the first description of giant rectal polyp in the pediatric population. A high index of suspicion is needed for diagnosing it. Care during the intraoperative and postoperative period is essential due to the size. If properly taken care of, the results are good. Histopathological confirmation is vital to rule out any possibility of malignant potential.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zahmatkeshan M, Fallahzadeh E, Najib K, Geramizadeh B, Haghighat M, Imanieh MH. Etiology of lower gastrointestinal bleeding in children: A single center experience from Southern Iran. Middle East J Dig Dis 2012;4:216-23.  Back to cited text no. 1
    
2.
Corredor J, Wambach J, Barnard J. Gastrointestinal polyps in children: Advances in molecular genetics, diagnosis, and management. J Pediatr 2001;138:621-8.  Back to cited text no. 2
    
3.
Perisic VN. Colorectal polyps: An important cause of rectal bleeding. Arch Dis Child 1987;62:188-9.  Back to cited text no. 3
    
4.
Cano-Contreras AD, Meixueiro-Daza A, Grube-Pagola P, Remes-Troche JM. Giant Rectal Polyp Prolapse in an Adult Patient With the Peutz-Jeghers Syndrome. BMJ Case Rep 2016;2016. pii: Bcr2016215629.  Back to cited text no. 4
    
5.
El-Shabrawi MH, El Din ZE, Isa M, Kamal N, Hassanin F, El-Koofy N, et al. Colorectal polyps: A frequently-missed cause of rectal bleeding in Egyptian children. Ann Trop Paediatr 2011;31:213-8.  Back to cited text no. 5
    
6.
Waitayakul S, Singhavejsakul J, Ukarapol N. Clinical characteristics of colorectal polyp in Thai children: A retrospective study. J Med Assoc Thai 2004;87:41-6.  Back to cited text no. 6
    
7.
Attard TM, Young RJ. Diagnosis and management of gastrointestinal polyps: Pediatric considerations. Gastroenterol Nurs 2006;29:16-22.  Back to cited text no. 7
    
8.
Pillai RB, Tolia V. Colonic polyps in children: Frequently multiple and recurrent. Clin Pediatr (Phila) 1998;37:253-7.  Back to cited text no. 8
    
9.
Nugent KP, Talbot IC, Hodgson SV, Phillips RK. Solitary juvenile polyps: Not a marker for subsequent malignancy. Gastroenterology 1993;105:698-700.  Back to cited text no. 9
    
10.
Jalihal A, Misra SP, Arvind AS, Kamath PS. Colonoscopic polypectomy in children. J Pediatr Surg 1992;27:1220-2.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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