ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Cause of Severe Hematochezia In Kyung Yoo,1 Hoon Jai Chun,1 and Chul Hwan Kim2 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, and 2Department of Pathology, Korea University Anam Hospital, Seoul, Korea
Question: An 84-yearold woman presented with a 1-month history of 2–3 episodes of dark, bloody diarrhea and was admitted to the hospital for severe hematochezia. She had no medical history of colon cancer, inflammatory bowel disease, or diverticular disease, and her physical examination was unremarkable. On admission, her hemoglobin level was 6.7 g/dL, decreased from a previous level of 13.0 g/dL measured 1 year prior. There was no evidence of bleeding on gastroscopy, but on colonoscopy, a large saddle-shaped polypoid lesion was found in the proximal ascending colon. The surface of the hemorrhagic lesion was granular, shiny, and firm. This lesion had an approximate diameter of 30 mm with mixed reddish and focal greenish color (Figure A, B). It was the suspected cause of bleeding; therefore, endoscopic resection was attempted. The lesion was lifted by submucosal injection. Then, it was gently grasped by snare and removed successfully (Figure C). The cut surface of the resected specimen was clear (Figure D). After endoscopic resection, the patient’s anemia was corrected and no further bleeding was observed. What is the diagnosis of this polypoid lesion causing severe bleeding? 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. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.05.037
Gastroenterology 2014;147:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 5: Inflammatory Fibroid Polyp
Histopathologic examination of the resected specimen revealed a polypoid lesion covered by mucosa and submucosa with surface ulceration and hemorrhage (Figure E; stain, hematoxylin and eosin; original magnification, 40). It was a submucosa-based lesion of bland spindle cells admixed with inflammatory cells, including lymphocytes, plasma cells, and eosinophils. A perivascular concentric arrangement of the cells was noted (Figure F; stain, hematoxylin and eosin; original magnification, 200). The spindle cells were positive for CD34 immunostain (Figure G; original magnification, 400), but negative for c-kit immunostain (not shown). These findings were consistent with inflammatory fibroid polyp (IFP). IFP is a rare benign tumor without malignant potential.1 IFPs are usually found in the stomach, secondarily in the small intestine, and rarely in the esophagus or large intestine.2 Endoscopic characteristics of colonic IFP are a pedunculated or smooth sessile polyp, but the unusual feature of a saddle-shaped polyp was found in our case. Although most IFPs have no clinical symptoms, site-specific symptoms of colonic IFPs usually include abdominal pain, bloody stools, weight loss, diarrhea, and intussusception.3 However, to our knowledge, none of these colonic IFPs manifested a large amount of lower gastrointestinal bleeding. This case highlights that colonic IFP is rare, especially as a cause of severe bleeding, but should be considered in the differential diagnosis.
References 1. 2. 3.
Schildhaus HU, Merkelbach-Bruse S, Binot E, et al. [Inflammatory fibroid polyp: from Vanek’s “submucosal granuloma” to the concept of submucosal mesenchymal neoplasia]. Pathologe 2010;31:109–114. Liu T-C, Lin M-T, Montgomery EA, et al. Inflammatory fibroid polyps of the gastrointestinal tract: spectrum of clinical, morphologic, and immunohistochemistry features. Am J Surg Pathol 2013;37:586–592. Jin J-S, Wu C-S, Yeh C-H, et al. Inflammatory fibroid polyp of rectum mimicking rectal cancer. Kaohsiung J Med Sci 2013; 29:460–463.
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Question: An 84-yearold woman presented with a 1-month history of 2–3 episodes of dark, bloody diarrhea and was admitted to the hospital for severe hematochezia. She had no medical history of colon cancer, inflammatory bowel disease, or diverticular disease, and her physical examination was unremarkable. On admission, her hemoglobin level was 6.7 g/dL, decreased from a previous level of 13.0 g/dL measured 1 year prior. There was no evidence of bleeding on gastroscopy, but on colonoscopy, a large saddle-shaped polypoid lesion was found in the proximal ascending colon. The surface of the hemorrhagic lesion was granular, shiny, and firm. This lesion had an approximate diameter of 30 mm with mixed reddish and focal greenish color (Figure A, B). It was the suspected cause of bleeding; therefore, endoscopic resection was attempted. The lesion was lifted by submucosal injection. Then, it was gently grasped by snare and removed successfully (Figure C). The cut surface of the resected specimen was clear (Figure D). After endoscopic resection, the patient’s anemia was corrected and no further bleeding was observed. What is the diagnosis of this polypoid lesion causing severe bleeding? 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. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.05.037
Gastroenterology 2014;147:e10–e11
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 5: Inflammatory Fibroid Polyp
Histopathologic examination of the resected specimen revealed a polypoid lesion covered by mucosa and submucosa with surface ulceration and hemorrhage (Figure E; stain, hematoxylin and eosin; original magnification, 40). It was a submucosa-based lesion of bland spindle cells admixed with inflammatory cells, including lymphocytes, plasma cells, and eosinophils. A perivascular concentric arrangement of the cells was noted (Figure F; stain, hematoxylin and eosin; original magnification, 200). The spindle cells were positive for CD34 immunostain (Figure G; original magnification, 400), but negative for c-kit immunostain (not shown). These findings were consistent with inflammatory fibroid polyp (IFP). IFP is a rare benign tumor without malignant potential.1 IFPs are usually found in the stomach, secondarily in the small intestine, and rarely in the esophagus or large intestine.2 Endoscopic characteristics of colonic IFP are a pedunculated or smooth sessile polyp, but the unusual feature of a saddle-shaped polyp was found in our case. Although most IFPs have no clinical symptoms, site-specific symptoms of colonic IFPs usually include abdominal pain, bloody stools, weight loss, diarrhea, and intussusception.3 However, to our knowledge, none of these colonic IFPs manifested a large amount of lower gastrointestinal bleeding. This case highlights that colonic IFP is rare, especially as a cause of severe bleeding, but should be considered in the differential diagnosis.
References 1. 2. 3.
Schildhaus HU, Merkelbach-Bruse S, Binot E, et al. [Inflammatory fibroid polyp: from Vanek’s “submucosal granuloma” to the concept of submucosal mesenchymal neoplasia]. Pathologe 2010;31:109–114. Liu T-C, Lin M-T, Montgomery EA, et al. Inflammatory fibroid polyps of the gastrointestinal tract: spectrum of clinical, morphologic, and immunohistochemistry features. Am J Surg Pathol 2013;37:586–592. Jin J-S, Wu C-S, Yeh C-H, et al. Inflammatory fibroid polyp of rectum mimicking rectal cancer. Kaohsiung J Med Sci 2013; 29:460–463.
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