A Yo-Yo Appendiceal Tubular Adenomatous Polyp - Now What Do We Do?

Abstract

Purpose: 52 year old homeless African American male with no known GI history presents with acute on chronic anemia. He was admitted for dizziness and found to have a drop in his baseline hemoglobin from 10 gm/dl to 3 gm/dl. He did not describe overt bleeding. On physical examination he had conjunctival pallor and a flow murmur. An EGD and colonoscopy was performed. On colonoscopy, upon intubation of the cecum, the appendiceal orifice initially appeared normal (Figure 1). However, just prior to withdrawal from the cecum, a polyp with honeycombed capillary appearance protruding from the appendiceal orifice was discovered (Figure 2). The cecum was reintubated and the appendiceal orifice again appeared normal. The cecum was desufflated and the appendiceal orifice was manipulated and suctioned. A long pedunculated appearing polyp was seen protruding in and out of the appendiceal orifice like a yo-yo. It was extracted with biopsy forceps (Figure 3). The polyp was not resected as we were unable to gauge the extent of the polyp within the appendiceal orifice. Biopsies were taken and were consistent with a tubular adenoma. The patient is being evaluated for surgical resection. Tubular adenomatous polyps of the appendix are exceedingly rare, found in 0.02% of appendiceal specimens on post surgical resection and in 0.01% postmortem in one autopsy study. (1,2,3) The identification of appendiceal polyps endoscopically is even more uncommon. Appendiceal polyps are usually asymptomatic, however, if they become significantly enlarged they can cause intussusception. (4) Radiographic studies may aide in detection of appendiceal polyps if colonoscopy is at first negative. However, colonoscopy is the preferred first choice as it also provides the opportunity to acquire tissue for diagnosis. There is concern that appendiceal tubular adenomas may progress to adenocarcinoma as in the colon. There is an association between appendiceal tubular adenomatous polyps and colon cancer, up to 20% in two different studies. (5,6) Management has varied from endoscopic resection to surgical resection. Endoscopic resection must be taken carefully as some appendiceal polyps may masquerade as a prolapsed appendix. A few case reports suggest that surgical resection might be a better approach. (1) Previous endoscopic treatment was later found to have residual tubular adenoma still present in the appendix after appendectomy. (1) In conclusion, appendiceal polyps must be examined carefully with emphasis on surgical resection. Care must be taken to examine the colon thoroughly, as up to 20% of patients with appendiceal tubular adenomas also have colon cancer.