Giant Inflammatory Pseudopolyposis Mimicking Colonic Tumor in an Ulcerative Colitis Patient

Abstract

Introduction: We report a case of giant inflammatory pseudopolyposis in an ulcerative colitis patient who had been refractory to medical management and eventually had a total colectomy. Case Report: A 21-year-old man presented with fatigue, unintentional weight loss, and intermittent abdominal pain. He developed significant anemia, and his hemoglobin levels were 7.1 g/dL. He was diagnosed as having pan-ulcerative colitis after a colonoscopy that demonstrated moderately severe colitis extending from the rectum to hepatic flexure. Additionally, colonic biopsies showed that he had chronic active colitis with cryptitis and crypt abscesses with glandular tissue distortion consistent with chronic inflammatory bowel disease. The patient was treated with budesonide-MMX and mesalamine, but his response was minimal, so his treatment was changed to anti-tumor necrosis factors - first adalizumab and then golizumab. A follow-up colonoscopy one year later showed a near-obstructing mass at the level of hepatic flexure and ascending colon, and it prohibited the movement of the colonoscope to the traverse colon (Figure 1). A computerized tomography scan of the abdomen demonstrated a solid appearing mass measuring 8 cm in size that was suspicious for a colonic neoplastic lesion (Figure 2). The patient then underwent a laparoscopic total abdominal colectomy and the resulting surgical pathology showed chronic, active ulcerative colitis with a diffuse infiltration of mixed inflammatory cells and large inflammatory pseudopolyposis but no evidence of dysplasia or malignancy. Discussion: Giant inflammatory pseudopolyps, defined as polyps larger than 1.5 cm in size, were first described in 1965 and tend to occur during the early and active disease course of young inflammatory bowel disease patients. The pathological features typically are a benign inflammatory process. Only one case has been reported with occult variable degrees of dysplasia. There are reported cases of regression of giant pseudopolyps after initiation of IBD therapy. When these pseudopolyps become refractory to medical treatment or cause obstructive symptoms, surgery is indicated.Figure 1Figure 2