Muco-submucosal Elongated Polyp Research Articles

A case of colonic muco-submucosal elongated polyp (CMSEP) misdiagnosed as a inverted colonic diverticulum (ICD).

CMSEP is a large intestine polyp with a long and broad stalk and a "worm-like" appearance which is covered by normal mucosa. The submucosal layer consists of edematous and fibrotic interstitium, adipose tissue, dilated blood vessels, and lymphatic follicles[1]. Endoscopic magnification of the mucosal surface showed a uniform honeycomb pattern of regular blood vessels, with soft and deformable "folds" and "gyrus" at the top. The exact pathogenesis of CMSEP is still unclear.

Colonic mucosubmucosal elongated polyps

Colonic mucosubmucosal elongated polyps

A stalk with no polyp-A muco-submucosal elongated polyp in the duodenum.

A 62-year-old Caucasian man was referred for upper GI endoscopy with a 6-month history of intermittent abdominal pain, nausea and bloating. Endoscopy revealed a 5-cm elongated lesion arising in D2. A pedunculated polyp (0-Ip) was suspected; however, deeper intubation revealed no polyp at the end of the stalk (Figure 1). Narrow band imaging did not reveal any adenomatous or suspicious features (Figure 2). The base of the polyp was injected with EMR solution (gelofusin, methylene blue and adrenaline 1:100,000), resected by snare cautery (Figure 3) and the defect was closed with two endoclips. Histopathology confirmed a 42 mm × 15 mm cylindrical lesion of hyperplastic duodenal mucosa with submucosal expansion by fibroconnective tissue. Histological analysis demonstrated features of a prominent submucosal vascular component with dilated lymphovascular structures, the absence of inflammatory infiltrate and the absence of significant architectural disturbance (Figure 4). These findings were consistent with a diagnosis of a muco-submucosal elongated polyp.1, 2 Muco-submucosal elongated polyp of the GIT under white light. Muco-submucosal elongated polyp of the GIT under narrow band imaging (NBI). Muco-submucosal elongated polyp of the GIT following resection. Histology section (2X) through the polyp shows architecturally normal small intestinal mucosa (yellow arrow) overlying a core of submucosa containing abundant adipose tissue (blue arrow) with submucosal vessels (green arrows). No significant inflammation is seen. Enteric muco-submucosal elongated polyps are rare, benign gastrointestinal polyps with an elongated, cylindrical ‘worm-like’ endoscopic appearance that is a hallmark of the disease.2, 3 Initially identified in the colon,1 few cases have been reported in the small bowel.3 It is hypothesised that peristaltic movements serve as mechanical traction for redundant mucosa, creating a nidus for polyp growth in these mucosal areas. They can mimic a number of other enteric lesions, in particular prolapsing mucosal folds (associated with diverticular disease) and filiform polyps (associated with inflammatory bowel disease). Immunohistochemistry demonstrates positivity for endothelial vascular markers (CD31) and endothelial lymphatic vessels (D2-40/podoplanin). Endoscopic ultrasound (EUS) can demonstrate the mucosal and submucosal layers of the polyp, with characteristic microcystic components aiding the diagnosis. Symptomatic patients can be treated by endoscopic resection, although treatment may be considered in asymptomatic cases given case reports suggesting an associated risk of intussusception,4 diverticulitis5 and non-polypoid neoplasia.6, 7 Surveillance gastroscopy 3 and 12 months post resection did not reveal any residual polyps. The authors wish to acknowledge the patients who attend, and staff who work in the Endoscopy Unit and the contribution they make to clinical research. There was no funding source for this research. The authors have no conflicts of interest to declare. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Jejunal intussusception and perforation due to enteric muco-submucosal elongated polyp: a case report and literature review

BackgroundA muco-submucosal elongated polyp is a non-neoplastic growth composed of mucosa and submucosa. Although muco-submucosal elongated polyps are commonly reported in the large intestine, they are rare in the small intestine, in which they are called enteric muco-submucosal elongated polyps. We herein present a case of jejunal intussusception and perforation due to an enteric muco-submucosal elongated polyp.Case presentationA 46-year-old woman presented with abdominal pain and vomiting. Computed tomography revealed jejunal intussusception, which was reduced via a nasointestinal ileus tube. Oral double-balloon endoscopy showed an elongated polyp in the proximal jejunum. The patient refused surgical resection and thus, the polyp was monitored. Six months later, the patient was readmitted with the recurrence of jejunal intussusception and underwent emergency surgery. Intraoperative findings revealed an intussuscepted bowel with an elongated polyp and multiple perforations in the proximal jejunum. We resected approximately 90 cm of the bowel, including the intussuscepted segment and perforated sites. The pedunculated polyp, which was 60 mm in length, was located on the oral side of the resected specimen. Histopathologically, the polyp was covered by normal mucosa and the submucosa consisted of edematous loose connective tissue. The histopathological diagnosis confirmed an enteric muco-submucosal elongated polyp.ConclusionsSymptomatic patients with enteric muco-submucosal elongated polyps may be at risk of complications, as observed in the present case, and need to undergo timely resection.

Polypectomy of a colonic mucosubmucosal elongated polyp

Polypectomy of a colonic mucosubmucosal elongated polyp

Two Cases of Leiomyoma in the Colon Masquerading as Other Types of Colonic Pedunculated Polyps

We describe two cases of leiomyoma in the colon that were diagnosed histologically after endoscopic resection. The first case was a 79-year-old Japanese woman who presented with a pedunculated polyp of 14 mm length at the splenic flexure. Preoperative diagnosis suggested a colonic mucosubmucosal elongated polyp. The second case was a 29-year-old Japanese woman who presented with a pedunculated polyp of 40 mm length at the hepatic flexure and had an ulcer on top of the polyp. Preoperative diagnosis suggested an inflammatory fibroid polyp. A pathological diagnosis of colonic leiomyoma was made after endoscopic resection in both cases. Both tumors were confirmed to originate, not from the proper muscle layer, but from the muscularis mucosae. These cases underscore that although colonic involvement is infrequent, leiomyomas can display pedunculated morphology in the colon rather than the typical gross appearance of gastrointestinal submucosal tumors seen with sessile morphology.

A Large Pedunculated Polyp With Surprising Pathology Results

We present a unique case of an inverted diverticulum mimicking a large adenomatous pedunculated polyp. Inverted colonic diverticulosis (ICD) is a rare finding described in 0.7% of colonoscopies.1 ICD is typically a few millimeters in size, located in the sigmoid colon and resembles a polyp. Our finding was unusual based on its size, location and appearance. An initial colonoscopy on a 50-year-old male found a pedunculated polyp in the transverse colon with a 2.0 cm stalk and 9 mm polypoid head. Believed to be an adenomatous polyp by inspection with a firm head, snare cautery was used to remove the polyp. The patient tolerated the procedure well without complication. Surprisingly, histology showed polypoid prolapsing mucosa fold consistent with a diverticular disease associated polyp. The differential diagnosis of a pedunculated colonic lesion is broad including an adenomatous pedunculated polyp, a mucosubmucosal elongated polyp, an inflammatory polyp, a filiform polyp associated with inflammatory bowel disease, autoamputation of a pedunculated polyp, ICD and rarely colonic intussusception of an adenoma. There can be significant overlap between inflammatory polyps and prolapse polyps, but the smooth muscle extending between glands is fairly iconic of prolapse polyps and not found in other entities. Our patient's histopathology was consistent with ICD (Figure 1b). Generally, ICD mucosal pattern on a lesion is similar to surrounding mucosa. In our case, the endoscopic appearance of the polyp head was not similar to the stalk one. Hypothetically, this could be due to vascular congestion, trauma of the polyp head, or the presence of inflammatory changes. Histologically, the latter seems to fit best as there is clear crypt architectural abnormalities seen on the head not seen on the stalk or base. ICD may appear polypoid and even present as pedunculated polyps. It is important for endoscopists to distinguish between ICD and adenomatous polyps to prevent complications that can arise with biopsy. In our patient, there was no evidence of perforation likely due to the cautery that sealed the mucosa closed. If there is suspicion of ICD after polyp removal, a resolution clip or over the scope clip could close the defect and prevent complications.Figure: Histopathology of lesion with lobulation and fibrous septa.Figure: focal epithelial denudation, hyperplastic crypt architecture with branching crypts, a lamina propria with prominent fibromuscular proliferation and smooth muscle projections between individual glands, a polymorphic inflammatory infiltrate, dilated capillaries, and hypertrophy and upward extension of the muscularis mucosae.Figure: High definition endoscopic image of transverse pedunculated polyp.

Colonic mucosubmucosal elongated polyp:a clinicopathologic analysis

Colonic mucosubmucosal elongated polyp:a clinicopathologic analysis

Familial Occurrence of Enteric Muco-Submucosal Elongated Polyp

We report 2 cases of enteric muco-submucosal elongated polyps (EMSEPs) that presented with gastrointestinal bleeding. The 2 patients are siblings. They both had a history of percutaneous coronary intervention for coronary artery disease and were on dual antiplatelet therapy. They underwent endoscopic resection of the polyps, which displayed identical endoscopic and histological features compatible with EMSEP. This is the first report of familial occurrence of EMSEP, suggesting possible genetic involvement. It is also important to note that the use of antiplatelet agents appears to be a predisposing factor for gastrointestinal bleeding from EMSEP.

A Case of Giant Colonic Muco-submucosal Elongated Polyps Associated with Intussusception.

Colonic muco-submucosal elongated polyp (CMSEP), a newly categorized non-neoplastic colorectal polyp, is a pedunculated and elongated polyp composed of normal mucosal and submucosal layers without any proper muscle layer. We herein report a giant variant of CMSEP associated with intussusception in the rectosigmoid colon, with a review of the literature. A 48-year-old woman underwent a laparoscopic low anterior resection due to multiple large submucosal polypoid masses associated with intussusception. Grossly, the colonic masses were multiple pedunculated polyps with a long stalk and branches ranging in size from a few millimeters to 14.0 cm in length. Microscopically, there was no evidence of hyperplasia, atypia, or active inflammation in the mucosa. The submucosal layers were composed of edematous and fibrotic stroma with fat tissue, dilated vessels, and lymphoid follicles.

Colonic mucosubmucosal elongated polyp: report of a series of 14 cases and review of the literature.

Most colorectal polyps can be reliably assigned to one of the known polyp categories, but a subset of polyps named colonic mucosubmucosal elongated polyps (CMSEPs) do not fall into any of these categories. First described in the Japanese literature, CMSEPs seem to be under-recognized in the Western literature. The aims of this study were to describe the clinicopathological features of 14 CMSEPs, discuss potential pathogenetic mechanisms, and increase awareness of this entity among pathologists. Fourteen pedunculated colorectal polyps that met the histopathological criteria for CMSEP (as described by Matake et al. and Alizart et al.) were assessed (12 males and two females; mean age 59.7 years). Five polyps were located in the sigmoid colon, four in the rectum, two in the descending colon, and three in the colon not otherwise specified. Nine of 14 polyps were discovered incidentally: two of nine on routine screening colonoscopy, two of nine on surveillance colonoscopy for inflammatory bowel disease (IBD), and five of nine upon surgical intervention for carcinoma or IBD. None coexisted with diverticular disease. The polyps were long and slender, varied from 5 to 30 mm in length (mean 15.9 mm), and showed a normal-looking colonic mucosal layer and underlying loose submucosa with thick-walled and congested blood vessels and lymphatics. CMSEPs show subtle but distinctive pathological features, and occur in normal and diseased colons. Pathologists need to be aware of this entity, to avoid confusion with other more commonly encountered colorectal polyps. With increasing colon cancer screening programmes and surveillance colonoscopy, it is likely that CMSEPs will be encountered more often.

十二指腸球部のmuco-submucosal elongated polypを内視鏡的に切除した1例

十二指腸球部のmuco-submucosal elongated polypを内視鏡的に切除した1例

Clinicopathological characteristic analysis of three cases of colonic muco-submucosal elongated polyp

Objective To explore the clinicopathological features,diagnosis and differential diagnosis of colonic muco-submucosal elongated polyp (CMSEP).Methods The clinical manifestations,endoscopic and histological features of three cases of CMSEP were analyzed.The literature was reviewed with regard to the diagnostic criteria and differential diagnosis.Results Three patients were male,and aged 25,45 and 75 years old.Two polyps were at transverse colon and one at rectum.Under colonoscope,all three cases showed the long pedunculated polyps.The surfaces of two polyps were smooth and the colors were similar to colonic mucosa while one polyp appeared mucosal erosion and congestion on the top.Under optical microscope,three cases had similar lesions.The axis of the lesions was expanded submucosa and the surface was the layer of colonic mucosa.The expanded and thick walled blood vessels were seen paralleled to the long axis in the submucosa of the axis of lesions.One polyp with mucosal erosion on the top presented with adenocarcinomal changes.Conclusions CMSEP is a kind of specific polypoid lesion,with characteristic colonoscopic and pathological features.Most are benign changes,however malignant changes occur in a few cases.In histology,CMSEP should be identified with mucosal prolapse syndrome associated inflammatory polyp. Key words: Intestinal mucosa; Colonic polyps; Colonoscopy; Pathology, clinical; Dignosis,differential; Colonic muco-submucosal elongated polyp

Muco-submucosal elongated polyps of the gastrointestinal tract: A case series and a review of the literature

We present three cases of gastrointestinal muco-submucosal elongated polyps, two located in the duodenum and one in the descending colon. All three cases had a characteristic, "worm-like" endoscopic appearance and were lined by unremarkable mucosa. The vascular component was located in the submucosa and was composed of a mixture of variably dilated blood vessels (capillaries and veins) and lymphatics. The duodenal polyps displayed lipomatous metaplasia of the submucosal stroma. The dual vascular phenotype of the vascular component was confirmed by immunohistochemistry with D2-40 and CD31.

小腸のmuco-submucosal elongated polypの1例

小腸のmuco-submucosal elongated polypの1例

Colonic muco-submucosal elongated polyp (CMSEP) の1例

Colonic muco-submucosal elongated polyp (CMSEP) の1例

A Case of Nonpolypoid Cancer Arising from Colonic Muco-submucosal Elongated Polyp

A colonic muco-submucosal elongated polyp (CMSEP) was identified at colonoscopy in a 53-year-old male patient with lower gastrointestinal bleeding. Non-polypoid depressed type of early cancer was noted at the tip of the colonic polyp. The CMSEP is very rare and incidentally found in most cases. Moreover, its association with colonic neoplasia is extremely rare. To our knowledge, this is the second case report of CMSEP associated with a cancerous transformation.

Colonic Mucosubmucosal Elongated Polyp

Colonic mucosubmucosal elongated polyp (CMSEP) is a distinctive non-neoplastic colorectal polyp characterized by pedunculated, elongated shape and is composed mainly of expanded submucosa with a normal mucosal lining. Only a small number of these polyps have been reported, exclusively from Japan. We report the clinicopathologic characteristics of 13 CMSEPs occurring in 11 patients, mostly from European ancestry. Ten of these polyps were resected during colonoscopy, and 3 were diagnosed in a patient who underwent sigmoid resection for diverticular disease. Among patients who had undergone a colonoscopy, 4 had altered bowel habit, and 1 suffered from abdominal discomfort; the other 5 patients had routine screening colonoscopy. Eight polyps were located in the sigmoid colon, 3 in the right colon, 1 in the rectosigmoid junction, and 1 in the descending colon. Polyp size ranged from 10 to 150 mm. Histologically, CMSEPs were characterized by unremarkable large bowel mucosa and submucosal stalk containing dilated thick-walled veins running parallel to the long axis of the polyp. Mucosal inflammation or fibromuscular proliferation characteristic of mucosal prolapse was absent. The pathogenesis of CMSEP may involve mechanical traction of the mucosa and the superficial submucosa during peristalsis in a fragile area of the colon. Despite the occasional large size, CMSEP is a benign lesion seldom leading to clinical complications.

Small Muco-Submucosal Elongated Polyp of the Sigmoid Colon

A 79-year-old man visited our hospital for a positive fecal occult blood test. Colonoscopy revealed a pedunculated polyp, of about 7 mm in diameter, in the sigmoid colon (Picture 1A). A short stalk and innominate grooves were enhanced by indigocarmine (Picture 1B). The lesion seemed to be covered by normal mucosa, and we speculated that this polyp might be a colonic muco-submucosal elongated polyp (CMSEP) or a pedunculated leiomyomatous polyp (PLP). Endoscopic polypectomy was performed. The lesion consisted of edematous loose connective tissue. The resected specimen demonstrated dilatation of blood vessels and lymphatics in the submucosal layer (Picture 2). This polyp was diagnosed as a CMSEP. The incidence of CMSEP was only 0.39% in one endoscopic polypectomy series (1). CMSEPs should be distinguished from other submucosal lesions such as PLPs, lipoma and lymphangioma (1). The endoscopic findings of CMSEP in the present case resembled those of a PLP (2).

Polypectomy of a colonic muco-submucosal elongated polyp

Polypectomy of a colonic muco-submucosal elongated polyp