Serrated Polyposis Syndrome: An Unusual Presentation Discovered After an Episode of Ischemic Colitis

Abstract

Introduction: Serrated polyposis syndrome is a disease characterized by numerous, large, proximal sessile polyps. The polyps are often flat and tend to develop within the haustral folds with adherent mucus, which makes them difficult to detect on colonoscopic evaluation. Case Presentation: A 64-year old female with a past medical history of Hypertension, Coronary Artery Disease, and no previous colorectal neoplasia screening presented with the acute onset of diffuse abdominal pain and hematochezia. There was no recent travel history or antibiotic use. CT scan of the abdomen revealed circumferential thickening of the colon from the splenic flexure to the rectum with associated soft tissue stranding. Flexible Sigmoidoscopy performed upon admission showed severe inflammation of the sigmoid colon consistent with ischemic colitis. The patient was treated supportively with improvement in her presenting symptoms. Several weeks after her hospitalization, she underwent a full colonoscopy, which revealed multiple sessile polyps proximal to the sigmoid colon. The majority of the polyps were located in the ascending colon, the largest of which measured approximately 20 mm. Most, but not all, were resected, and pathology was consistent with sessile serrated polyps. Several more sessile polyps were removed from the proximal colon during a follow-up exam performed three months later. Pathology was again consistent with sessile serrated adenomas. Discussion: Serrated Polyposis Syndrome remains both a diagnostic and therapeutic dilemma. It is relatively uncommon disease, representing approximately 1 case for every 2000 screening colonoscopies performed. Sessile serrated polyps are believed to be more aggressive than common tubular adenomas, therefore a high index of suspicion is required. However, the characteristics of sessile serrated polyps (flat with minimal discoloration) make detection difficult on routine colonoscopic evaluation. The flat nature of these polyps also makes for an increased risk of incomplete resection and possibly even colonic perforation. Surveillance intervals have also not been concretely defined, but current recommendations suggest repeat colonoscopy every one to two years as some studies suggest an increased future risk of colorectal cancer.Figure 1Figure 2