J. Coloproctol. (Rio J.) vol.36 número3

jcoloproctol(rioj).2016;36(3):176–178

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Journal

of

Coloproctology

Case

Report

Inflammatory

cloacogenic

polyp:

a

rare

kind

of

benign

polyp

to

be

cured

with

endoscopic

and/or

surgical

removal

S¸

afak

Meric¸

Özgenel

_,

_Tuncer

_Temel,

_Evrim

_Yılmaz,

_Salih

_Tokmak,

_Ays¸egül

_Özakyol

Eskis¸ehirOsmangaziUniversity,FacultyofMedicine,DepartmentofGastroenterology,Eskis¸ehir,Turkey

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Articlehistory:

Received11January2016 Accepted13April2016 Availableonline9May2016

Keywords: Inflammation Solitaryrectalulcer Cloacogenicpolyp

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Background:Inflammatorycloacogenicpolypisaveryrarekindofbenignpolypwhichoccurs intheanaltransitionalzoneandlowerrectum.Thesepolypsariseinassociationwith var-iousconditions(e.g.,internalhemorrhoids,diverticulosis,colorectaltumors,andCrohn’s disease)inwhichmucosalinjuryistheunderlyingpathogenicmechanism.

Casereport:A24-year-oldmalepatientappliedtoemergencydepartmentwithbloody defe-cationforamonth.Apolypthatis1.5cminsizehadbeenobservedatrectumandanalverge junctionduringcolonoscopy,pathologicaldiagnosiswasinflammatorycloacogenicpolyp. Thereupon,colonoscopic polypectomywasperformedasthe malignanttransformation possibility.

Conclusion:Polypsoftheanorectaljunctionwithinflammatoryappearancemightbe inflam-matorycloacogenicpolypswithmalignanttransformationpotentialthatmustbetreated byendoscopicremovalorsurgeryandfolloweduproutinelywithcolonoscopicsurveillance. ©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Pólipo

cloacogênico

inflamatório:

um

raro

tipo

de

pólipo

benigno

a

ser

curado

por

remoc¸ão

endoscópica

e/ou

cirúrgica

Palavras-chave: Inflamac¸ão Úlceraretalsolitária Pólipocloacogênico

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Experiência:Póliposcloacogênicosinflamatóriosconstituemumtipomuitorarodepólipo benigno,comocorrêncianazonadetransic¸ãoanaleretobaixo.Essespólipossurgemem associac¸ãocomdiversosdistúrbios(p.ex.,hemorroidasinternas,diverticulose,tumores colorretais,edoenc¸ade Crohn)nosquaisa lesãoàmucosaéomecanismopatogênico subjacente.

∗ _{Correspondingauthor.}

E-mail:mozgenel@ogu.edu.tr(S¸.M.Özgenel).

http://dx.doi.org/10.1016/j.jcol.2016.04.005

jcoloproctol(rioj).2016;36(3):176–178

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Relatodecaso: Paciente,gêneromasculino,24anos,compareceuaoservic¸ode emergên-ciacomdefecac¸ãosanguinolentacomdurac¸ãodeummês.Duranteacolonoscopia,foi observadoumpólipomedindo1,5cmdediâmetronoretoenajunc¸ãodabordaanal;foi estabelecidoumdiagnósticopatológicodepólipocloacogênicoinflamatório. Subsequente-mente, foirealizada polipectomiacolonoscópica,diante dopotencialdetransformac¸ão maligna.

Conclusão: Pólipos da junc¸ão anorretal com aspecto inflamatório podem ser pólipos cloacogênicosinflamatórioscompotencialparatransformac¸ãomaligna,devendoser trata-dosporremoc¸ãoendoscópicaoucirúrgicaemonitoradosperiodicamentecomvigilância colonoscópica.

©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

Inflammatorycloacogenicpolyp(ICP)isavery rarekind of benign polyp to be cured with endoscopic and/or surgical removal that was first described in 1981 by Lobert et al.1 Thesepolypsariseinassociationwithvariousconditions(e.g., internalhemorrhoids,diverticulosis,colorectaltumors,and Crohn’sdisease)inwhichmucosal injuryisthe underlying pathogenicmechanism.2 _{ICPsoccur intheanaltransitional} zoneandlowerrectum.3_{AlthoughICPsaregenerallybenign,} occasionalmalignanttransformationhasbeenreported.4

Werepresentacaseofcloacogenicpolyp,aninfrequently diagnosedtypeofpolyp,whichcauseslowergastrointestinal bleeding.

Case

report

A 24-year-old male patient applied to emergency depart-ment with bloody defecation for a month. On laboratory analyzes, biochemistry panel, complete blood count, sedi-mentationand C-reactive protein was normal. Eitherfecal cultureorfecalanalysesforparasiteswerenegative.Apolyp thatis1.5cminsizehadbeenobservedatrectumandanal vergejunctionduringcolonoscopywhichwasperformedto determine the reason ofbloody defecation. (Fig. 1). In the pathologicalanalyzesofthepolyp,vesselswerestainedwith CD34andhistiocysteswerestainedwithCD68, fibromuscu-larfieldsinthelaminapropriawerestainedwithtrichrome, nofungal sporesor hyphaenutrientswere seenwith peri-odic acid schiff, there was no pathological feature with cyto-ceratin immuno-histochemical staining. The defining pathologicaldiagnosiswasICP;withulcers,minimal architec-turaldistortion,hyperplasticchangesandregenerativeatypia, fibromuscular hyperplasia in the lamina propria, and ves-selrichcolonicpolypoidtissues(Figs.2and 3).Thereupon, colonoscopicpolypectomywasperformedasthemalignant transformationpossibility.

Discussion

ICPsoftheanaltransitionalzonewerefirstdescribedin1981 byLobertPFandAppelmanHD.Rectalbleedingisthemost

Fig.1–Colonoscopicappearanceoftheinflammatory cloacogenicpolyp.

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Fig.2–Elongated,irregularcryptstructures,hyperplastic changesinthelaminapropriafibromuscularhyperplasia andchronicinflammation(hematoxylineosine×100).

of116casesrevealedthatsolitaryrectalulcersmightalsobe foundcoexistingwithpolyps,ulcerativecolitis,hemorrhoids andcolonicmalignancy.6

ICPsaremorecommoninwomenusuallyoccurringfrom childhood to the fourth–the sixth decade of life.7,8 Lead-ing complaints are rectal bleeding, constipationand rectal tenesmus.8 _{Diagnosisisusuallyreachedbyendoscopyand} biopsy.Itisdifficulttobedifferentiated from otherbenign andmalignantlesionsduringendoscopy.4 _{Thesepolypsare} usually 1–5cm in the anorectal region and often sessile, and rarely occurs with pedincule. They may be single or multipleand canbefoundsimultaneous withhyperplastic oradenomatouspolyps.Anatomo-pathologicpropertiesare, erodedsurface,reactiveatypiaandhyperplasticchangeswith irregularbranchinginglandsandgranulationtissue.8,9

TransformationtosquamouscellcarcinomaforICP’sare mentioned.DysplasiawasdetectedincasesofParfittetal.4 andHansonandArmstrongfoundanalintraepithelial neo-plasia in his case.10 _{P53 and Ki67 immuno-histochemistry} mustbeperformedtointerpretchallengingcasesby patholo-gists.Healsosimultaneouslydetectedthepresenceofhuman papillomavirus (HPV). Therefore,HPV screeningshould be consideredfortheICPbackground.

Fig.3–Increasedcollagenfibersandsmoothmusclefibers inthelaminapropriawithtrichrome(100×).

Ondifferentialdiagnosis,inflammatory,ischemicorother types ofpolyps,inflammatorybowel disease,Cowden syn-dromeandmalignanciesmustbeconsidered.8

Endoscopic removal orsurgical treatment isappliedfor treatment,2 _{patientsmusttakehigh fiberdietwith} colono-scopic surveillance after polypectomyor surgical resection becauseoftherecurrencerisk.3

Inconclusion,itmustbebearinmindthatpolypsofthe anorectaljunction withinflammatoryappearancemightbe ICPs withmalignanttransformation potentialthatmustbe treatedbyendoscopicremovalorsurgeryandfollowedup rou-tinely withcolonoscopicsurveillance.CaseswithICPsmust beinvestigatedforunderlyingCrohn’sdisease,malabsorption syndromes,diverticulosis,hemorrhoids,adenocarcinomaand HPVinfection.Forpathologicaldiagnosisofchallengingcases immuno-histochemicalstainingcouldbebeneficial.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

Thework conforms totheprovisions oftheDeclarationof Helsinki and the written consent ofthe subject has been acknowledged.

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2.TendlerDA,AboudolaS,ZacksJF,O’BrienMJ,KellyCP. Prolapsingmucosalpolyps:anunrecognizedformofcolonic polypsaclinicpathologicalstudyin15cases.AmJ

Gastroenterol.2002;97:370–6.

3.ZamanS,MistryP,HendrickseC,BowleyDM.Cloacogenic polypsinanadolescent:ararecauseofrectalbleeding.J PediatrSurg.2013;48:E5–7.

4.ParfittJR,ShepherdNA.Polypoidmucosalprolapsed complicatinglowrectaladenomas:bewaretheinflammatory cloacogenicpolyp!Histopathology.2008;53:91–6.

5.MadiganMR,MorsonBC.Solitaryulceroftherectum.Gut. 1969;10:871–81.

6.AbibS,KhawajaA,BhimaniSA,AhmadZ,HamidS,JafriW. Theclinical,endoscopicandhistologicalspectrumofthe solitaryrectalulcersyndrome:asingle-centerexperienceof 116cases.BMCGastroenterol.2012;12:72.

7.PoonK,MillsS,BoothL,MurphyS.Inflammatorycloacogenic polyp:anunrecognizedcauseofhematocheziaandtenesmus inchildhood.JPediatr.1997;130:327–9.

8.López-RamosCS,Rodríguez-GómezS,Bailador-AndrésC, Baizán-GarcíaMJ.Inflammatorycloacogenicpolyp:arare causeoflowergastrointestinalbleeding.RevEspEnfermDig. 2013;105:240–1.

9.MathialaganR,TurnerMJ,GorardDA.Inflammatory cloacogenicpolypmimickinganorectalmalignancy.EurJ GastroenterolHepatol.2000;12:247–50.

10.HansonIM,ArmstrongGR.Analintraepithelialneoplasiain aninflammatorycloacogenicpolyp.JClinPathol.