Inflammatory Cloacogenic Polyps Research Articles

Inflammatory cloacogenic polyps in children: diagnostic yield of rectal retroflexion during colonoscopy

Background and aimsInflammatory cloacogenic polyps (ICPs) are inflammatory lesions occurring around the anal transitional zone. These are rare in the pediatric population, and most reported cases are found in adults. Therefore, this study aimed to evaluate the usefulness of rectal retroflexion (RR) during colonoscopy in detecting ICPs in children.MethodsA total of 1837 colonoscopies were performed in 1278 children between September 2003 and August 2020 at the Seoul National University Bundang Hospital. The laboratory test results and colonoscopic and histopathological findings were retrospectively reviewed. ICP was detected using the RR and was diagnosed based on the histologic findings of the polyp.ResultsA total of 69 patients were diagnosed with juvenile polyps (n = 62) or ICP (n = 7), with the latter being detected through RR. All children with ICP were diagnosed from 2013 onwards when RR during colonoscopy came to be routinely performed in our medical center. The patients with ICP were older at diagnosis and more associated with a family history of colorectal polyps than JP. Stool occult blood and the polyps’ endoscopic characteristics, such as number, location, volume, and shape, significantly varied between the two groups. Additionally, there was a statistically significant difference in the polypectomy method. During the long-term follow-up, there was no recurrence of ICP.ConclusionsDue to their location at the anorectal junction, ICPs may be overlooked during colonoscopy, leading to misdiagnosis. Therefore, a retroflexion view during colonoscopy may help detect ICPs in pediatric patients, especially those presenting with hematochezia.

Inflammatory Cloacogenic Polyp: A Distinctive Cause of Hematochezia

Inflammatory cloacogenic polyp (ICP) is a special type of benign polypoid growth arising from the transitional zone of the anorectal junction. This lesion was first described by Lobert and Appleman in 1981 and It is believed to result from a mucosal prolapse that produces repetitive local trauma and ischemic injury leading to chronic inflammation. Typically, it presents with rectal bleeding, tenesmus and altered bowel habits resembling anorectal neoplasia clinically and macroscopically. We describe a rare case of hematochezia caused by an ICP that was ovelooked on direct vision colonoscopic exam until a retroflexion was done. 43 year old man presents with intermittent rectal bleeding and tenesmus of one year duration. Blood was mixed with stools and symptoms worsened over the last 6 months. Review of system was significant for chronic constipation but he denied weight loss, melena, abdominal pain, fever or upper gastrointestinal symptoms. Previously healthy, he denied taking any medications, drinking alcohol, smoking cigarettes or any family history of colon cancer. Vital signs were normal. Blood count and chemistry profile were unremarkable, namely no anemia. Colonoscopy was performed to show unremarkable colon on direct vision till cecum, however upon retroflexion in the rectum a frond like, semi-pedunculated polypoid lesion was noted at the anorectal junction. The lesion was then examined carefully in direct vision: it measured 15 mm and appeared inflammatory with areas of superficial ulcerations (Fig 1). Complete resection of the polyp was performed by a snare cautery. Histopathology disclosed prolapsed colonic mucosa with disrupted muscularis mucosa, fibromuscular and epithelial hyperplasia, dense inflammatory infiltrate within the lamina propria consistent with inflammatory cloacogenic polyp, no dysplasia (Fig 2&3). Patient's rectal bleeding resolved thereafter. Inflammatory cloacogenic polyps are rare and unique inflammatory anorectal lesions with an estimated annual incidence of 1/100.000. ICPs constitute a diagnostic challenge due to their clinical and macroscopic similarities to adenomas and anorectal neoplasms. These lesions occur around the transitional zone in the lower anorectum and hence they may be overlooked at colonoscopy, as in our case, unless an endoscopic retroflexion maneuver is performed. Endoscopists should be familiar with this entity, which should be considered in the differential diagnosis of anorectal polypoid lesions.Figure: (A) Colonoscopy image of the lesion upon retroflexion (B) Direct vision colonoscopy image showing areas of inflammation and superficial ulceration.Figure: Histopathology (H$E stain) disclosing active chronic inflammation with a prominent underlying reactive lymphoid follicle (Arrow).Figure: Microscopic examination showing a disrupted muscularis mucosa, fibromuscular and epithelial hyperplasia, with dense inflammatory infiltrate within the lamina propria consistent with inflammatory cloacogenic polyp.

Knowledge of the anatomical polyp location might bias the pathological classification of histologically equivocal colorectal serrated polyps – A consensus study performed by pathology trainees

Colorectal serrated polyps (CSPs) comprise hyperplastic polyps (HPs), traditional (TSAs) and sessile (SSAs) serrated adenomas, as well as inflammatory cloacogenic polyps (ICPs). These lesions have typical anatomical locations and share a histomorphological overlap. In this study, we assessed the so far neglected issue as to what extent the histological classification of these lesions performed by pathology trainees is biased by the pathologists’ knowledge of the polyp location in dependency on the duration of their training. To reach this aim, 49 CSPs were classified by three pathology trainees blinded to clinical data. In a second round of examination, the same raters were provided with the polyp location. A third round was conducted after a consensus conference. Intra- and inter-rater analyses were performed using Kappa ( K) statistics and Spearman correlations. Our data suggest that the histological classification of CSPs performed by pathology trainees might be influenced in a clinically significant fashion by knowledge of the anatomical polyp location depending on the duration of their pathology training.

Inflammatory myoglandular polyp of the cecum: case report and review of literature

BackgroundInflammatory myoglandular polyp (IMGP) is a rare non-neoplastic polyp of the large bowel, commonly with a distal localization (rectosigmoid), obscure in its pathogenesis. Up till now, 60 cases of IMGP have been described in the literature, but none located in the cecum.Case presentationWe report a case of a 53-year-old man who was admitted to our hospital for further evaluation of positive fecal occult blood test associated to anemia. A colonoscopy identified a red, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, partially ulcerated. The histological examination of the biopsy revealed the presence of inflammatory granulation tissue with lymphocytic and eosinophil infiltration associated to a fibrous stroma: it was diagnosed as inflammatory fibroid polyp. Considering the polyp's features (absence of a peduncle and size) that could increase the risk of a polypectomy, a surgical resection was performed. Histological examination of the specimen revealed inflammatory granulation tissue in the lamina propria, hyperplastic glands with cystic dilatations, proliferation of smooth muscle and multiple erosions on the polyp surface: this polyp was finally diagnosed as IMGP. There was also another little polyp next to the ileocecal valve, not revealed at the colonoscopy, 0.8 cm in diameter, diagnosed as tubulovillous adenoma with low grade dysplasia.ConclusionsThis is the first case of IMGP of the cecum. It is a benign lesion of unknown pathogenesis and must be considered different from other non-neoplastic polyps of the large bowel such as inflammatory cap polyps (ICP), inflammatory cloacogenic polyps, juvenile polyps (JP), inflammatory fibroid polyps (IFP), polyps secondary to mucosal prolapse syndrome (MPS), polypoid prolapsing mucosal folds of diverticular disease. When symptomatic, IMGP should be removed endoscopically, whereas surgical resection is reserved only in selected patients as in our case.

Inflammatory cloacogenic polyp: diagnostic features by confocal endomicroscopy

Inflammatory cloacogenic polyps (ICPs), first described in 1981, 1 Lobert P.F. Appelman H.D. Inflammatory cloacogenic polyp: a unique inflammatory lesion of the anal transitional zone. Am J Surg Pathol. 1981; 5: 761-766 Crossref PubMed Scopus (64) Google Scholar are relatively rare lesions of the anal transitional zone. It is presently thought that ICPs are regenerative changes of the rectal mucosa caused by recurrent prolapse. 2 Saul S.H. Inflammatory cloacogenic polyp: relationship to solitary rectal ulcer syndrome/mucosal prolapse and other bowel disorders. Hum Pathol. 1987; 18: 1120-1125 Abstract Full Text PDF PubMed Scopus (53) Google Scholar , 3 Tendler D.A. Aboudola S. Zacks J.F. et al. Prolapsing mucosal polyps: an unrecognized form of colonic polyp—a clinicopathological study in 15 cases. Am J Gastroenterol. 2002; 97: 370-376 PubMed Google Scholar These polyps arise in association with various conditions (eg, internal hemorrhoids, diverticulosis, colorectal tumors, and Crohn's disease) in which mucosal injury is the underlying pathogenic mechanism. 3 Tendler D.A. Aboudola S. Zacks J.F. et al. Prolapsing mucosal polyps: an unrecognized form of colonic polyp—a clinicopathological study in 15 cases. Am J Gastroenterol. 2002; 97: 370-376 PubMed Google Scholar Most cases of ICP are benign, although occasionally malignancy has been reported.

Polypoid mucosal prolapse complicating low rectal adenomas: beware the inflammatory cloacogenic polyp!

Polypoid mucosal prolapse near the anorectal junction mimics adenomas endoscopically and histopathologically. The aim was to describe the phenomenon of polypoid mucosal prolapse arising secondary to adenomas at the anorectal junction. Four cases of low rectal adenoma with polypoid mucosal prolapse were assessed histopathologically, as well as with p53 and Ki67 antibodies. Two were male and two female; the mean age was 45 years. Available follow-up has revealed no recurrence in any patient. All cases showed mucosal expansion with ulceration or erosion, crypt architectural irregularity, fibromuscular proliferation between crypts and variable epithelial serration and inflammation. Each case also showed unequivocal dysplasia, often co-mingled with features of prolapse, highlighted by p53 and Ki67 immunohistochemistry, which demonstrated positivity within dysplastic areas. Histopathologists must recognize the potential for adenomatous/dysplastic foci in anorectal lesions to superficially resemble inflammatory cloacogenic polyps. We recommend use of immunomarkers p53 and Ki67 to aid the interpretation of challenging cases. We believe that polypoid mucosal prolapse changes can be a secondary phenomenon, due to adenomas close to or at the anorectal junction.

Non-neoplastic colorectal polyps

Summary With the explosion in the number of screening colonoscopic procedures, pathologists have learned to recognize a host of non-neoplastic polyps that can be loosely categorized as those stemming from mucosal prolapse, hamartomatous lesions, incidental benign stromal polyps and polyps associated with systemic diseases. We briefly review solitary rectal ulcer syndrome, inflammatory cloacogenic polyps, diverticular disease-associated prolapse polyps, cap polyps, juvenile polyps, Peutz–Jeghers polyps, Cronkhite–Canada polyposis, elastosis, benign fibroblastic polyps, inflammatory fibroid polyps, pneumatosis, vascular lesions, filiform polyps, lymphoid polyps, malakoplakia, amyloidosis and endometriosis.

Pólipos inflamatorios cloacogénicos: una causa inusual de sangrado rectal

Inflammatory cloacogenic polyps are infrequent lesions that usually arise in the anorectal zone. The most common clinical presentation is rectal bleeding. Two cases of rectal bleeding related to cloacogenic polyps with different endoscopic appearance are reported. Endoscopists should be familiar with this entity, which should be considered in the differential diagnosis with other polypoid lesions observed in colonoscopy.

Prolapsing mucosal polyps: an underrecognized form of colonic polyp--a clinicopathological study of 15 cases.

Prolapsing intestinal mucosa occurs in many forms throughout the GI tract. We describe 15 patients with polypoid masses in the sigmoid colon and histological features of mucosal prolapse. Fifteen patients with colon polyps demonstrating endoscopic and histological features of mucosal prolapse were retrospectively identified from our database. Twelve patients presented with signs and symptoms that were nonspecific, but consistent with mucosal prolapse, such as occult or gross intestinal bleeding and lower abdominal pain. Three patients were asymptomatic. The polyps occurred in the sigmoid colon, usually in association with diverticular disease, and appeared more often in men. Endoscopically, the polyps appeared to be well-circumscribed, hyperemic masses that contrasted sharply with normal-appearing adjacent mucosa. Histological features include glandular crypt abnormalities, fibromuscular obliteration of the lamina propria, and thickened and splayed muscularis mucosa. Prolapsing mucosal polyps of the colon are histologically similar to other mucosal prolapsing conditions in the GI tract, such as the solitary rectal ulcer syndrome, inflammatory cloacogenic polyps, inflammatory "cap" polyps, and gastric antral vascular ectasia, and should therefore be designated as part of the "mucosal prolapse syndrome."

Prolapsing mucosal polyps: an underrecognized form of colonic polyp—a clinicopathological study of 15 cases

OBJECTIVE: Prolapsing intestinal mucosa occurs in many forms throughout the GI tract. We describe 15 patients with polypoid masses in the sigmoid colon and histological features of mucosal prolapse. METHODS: Fifteen patients with colon polyps demonstrating endoscopic and histological features of mucosal prolapse were retrospectively identified from our database. RESULTS: Twelve patients presented with signs and symptoms that were nonspecific, but consistent with mucosal prolapse, such as occult or gross intestinal bleeding and lower abdominal pain. Three patients were asymptomatic. The polyps occurred in the sigmoid colon, usually in association with diverticular disease, and appeared more often in men. Endoscopically, the polyps appeared to be well-circumscribed, hyperemic masses that contrasted sharply with normal-appearing adjacent mucosa. Histological features include glandular crypt abnormalities, fibromuscular obliteration of the lamina propria, and thickened and splayed muscularis mucosa. CONCLUSIONS: Prolapsing mucosal polyps of the colon are histologically similar to other mucosal prolapsing conditions in the GI tract, such as the solitary rectal ulcer syndrome, inflammatory cloacogenic polyps, inflammatory “cap” polyps, and gastric antral vascular ectasia, and should therefore be designated as part of the “mucosal prolapse syndrome.”

Squamous cell carcinoma in situ arising in inflammatory cloacogenic polyps: report of two cases with PCR analysis for HPV DNA

Inflammatory cloacogenic polyp (ICP) is regarded as part of the spectrum of pathological changes encountered in mucosal prolapse syndrome (MPS)/solitary rectal ulcer. We present the clinicopathological features of two females with squamous cell carcinoma in situ arising in their ICPs. Human papillomavirus (HPV) type 16 was demonstrated in the areas of squamous carcinoma in situ in both polyps by polymerase chain reaction. These cases highlight the need for close scrutiny of the squamous components of these lesions.

Rectal prolapse in pediatrics.

Rectal prolapse in pediatrics has its highest incidence in infancy and is uncommonly seen in industrialized countries. The prolapse may involve only the mucosa (mucosal prolapse) or all layers of the rectum (complete prolapse or procidentia). It is usually detected by the child's parents and is brought urgently to medical attention; however, it is usually spontaneously reduced by the time they reach the practitioner's office. Rectal prolapse should be viewed as a symptom of an underlying condition rather than a discrete disease entity. Potential causes are increased intraabdominal pressure, diarrheal and neoplastic diseases, malnutrition, and conditions predisposing to pelvic floor weakness. Its strong association with cystic fibrosis makes the sweat test mandatory for infants and children with recurrent rectal prolapse. Of particular importance are three entities related to rectal prolapse that may easily escape diagnosis by practitioner: occult rectal prolapse, solitary ulcer of the rectum syndrome, and inflammatory cloacogenic polyps. The treatment of rectal prolapse is mainly conservative and is directed at the underlying conditions. Surgical intervention may be required for recurrent rectal prolapse refractory to conservative measures. The simplest, less invasive, yet highly effective approach, appears to be perirectal injection with a sclerosing agent. While the majority of children experience spontaneous resolution of the prolapse, the prognosis is worse when presentation occurs after the age of 4 years.

Expression of proliferating cell nuclear antigen in hyperplastic polyps, adenomas and inflammatory cloacogenic polyps of the large intestine.

To compare proliferating cell nuclear antigen (PCNA) immunoexpression in hyperplastic polyps, adenomas, and inflammatory cloacogenic polyps of the human colon and rectum using paraffin wax embedded tissue. The monoclonal antibody PC10 was used to demonstrate PCNA immunoreactivity in 88 polypoid lesions from 68 patients. Cases in which immunoexpression was completely absent were excluded, leaving 32 hyperplastic polyps, 31 adenomas, and seven inflammatory cloacogenic polyps for analysis. Labelling indices for the upper and lower third of each lesion and for adjacent normal mucosa were calculated. The upper third labelling indices for adenomas were substantially higher than those for hyperplastic polyps or normal mucosa, whereas those for the upper thirds of hyperplastic polyps and normal mucosa did not differ greatly. The differences between the lower third samples were not significant. In 16 (50%) hyperplastic polyps positive cells persisted onto the luminal surface. Some adenomas showed the most intense staining and the highest labelling indices in the upper third, with strong staining of surface cells; this pattern was not seen in the other lesions. The inflammatory cloacogenic polyps did not show a consistent pattern of immunoexpression. Differences in cell kinetics between adenomas, hyperplastic polyps, and normal mucosa may be shown in formalin fixed, paraffin wax embedded tissue using PC10 as a marker of proliferative activity. PCNA expression also persists into the upper portions of hyperplastic polyps. Assuming that hyperplastic polyps are hypermature lesions with a slower rate of cell migration, this finding suggests that there may be an alteration in PCNA protein metabolism.

Prolapse‐induced inflammatory polyps of the colorectum and anal transitional zone

A clinicopathological study of polypoid lesions of the lower gastrointestinal tract from 12 patients was undertaken. Clinically, the majority had signs and symptoms of rectal prolapse despite having a variety of other primary diagnoses (e.g. carcinoma of the bowel or diverticular disease). Three patients were asymptomatic. The polyps were more common in females and were usually solitary. Histologically, fibrin 'caps', fibromuscular hypertrophy and obliteration of the lamina propria, goblet cell hypertrophy and serrated tubules were consistently noted. The fibromuscular tissue often extended into the lamina propria in a radial fashion. This study shows that mucosal prolapse underpins a variety of lesions that are part of a histological spectrum of changes. Inflammatory cloacogenic polyps, inflammatory 'cap' polyps, polypoid prolapsing mucosal folds of diverticular disease and inflammatory myoglandular polyps are all due to mucosal prolapse.