An unusual case of hamartomatous polyposis with malignancy complication in a patient with ulcerative colitis treated with golimumab

We report an unusual case of hamartomatous polyposis with malignant complications in a patient with ulcerative colitis on golimumab and previous thiopurine therapy. This patient was evaluated for iron deficiency anemia and underwent hemicolectomy for extensive right-side predominant inflammatory pseudopolyps. Anemia persisted post-colectomy and subsequent gastroscopy showed a fungating polypoid lesion along with numerous carpet-like strawberry appearing polyps in the stomach extending from the gastro-esophageal junction to the distal part of the antrum, necessitating a gastrectomy. Histology showed extensive hamartomatous-like polyps with adenocarcinoma and nodal metastases. Presence of alopecia totalis and hamartomas in this patient raise the possibility of Cronkhite-Canada Syndrome although this may also represent an undescribed hamartomatous polyposis associated with ulcerative colitis. Even though thiopurine analogue and anti-tumor necrosis factor agents have not been associated with increased risk of solid tumors, immunosuppression in patients with extensive polyposis should be cautiously used due to the potential accelerated malignancy risk. This case also highlights the importance of performing additional imaging of the gastrointestinal tract, in inflammatory bowel disease patients with anemia, particularly if the severity is incongruent with disease activity.

Juvenile polyposis syndrome: An unusual case report of anemia and gastrointestinal bleeding in young infant

BACKGROUND

Juvenile polyposis syndrome, a rare disorder in children, is characterized with multiple hamartomatous polyps in alimentary tract. A variety of manifestations include bleeding, intussusception, or polyp prolapse. In this study, we present an 8-month-old male infant of juvenile polyposis syndrome initially presenting with chronic anemia. To the best of our knowledge, this is the youngest case reported in the literature.

METHODS

We report a rare case of an 8-month-old male infant who presented with chronic anemia and gastrointestinal bleeding initially. Panendoscopy and abdominal computed tomography showed multiple polyposis throughout the entire alimentary tract leading to intussusception. Technetium-99m-labeled red blood cell (RBC) bleeding scan revealed the possibility of gastrointestinal tract bleeding in the jejunum. Histopathological examination on biopsy samples showed Peutz-Jeghers syndrome was excluded, whereas the diagnosis of juvenile polyposis syndrome was established.

RESULTS

Enteroscopic polypectomy is the mainstay of the treatment. However, polyps recurred and occupied the majority of the gastrointestinal tract in 6 months. Supportive management was given. The patient expired for severe sepsis at the age of 18 months.

CONCLUSION

Juvenile polyposis syndrome is an inherited disease, so it is not possible to prevent it. Concerning of its poor outcome and high mortality rate, it is important that we should increase awareness and education of the parents at its earliest stages.

Cronkhite-Canada syndrome - A Case report

BACKGROUND/AIM

Cronkhite-Canada syndrome (CCS) is a non-inherited, sporadic disorder characterized by generalized gastrointestinal polyps (hamartomas), cutaneous pigmentation, alopecia and onychodystrophy. More than 500 CCS patients have been reported, mostly from Asian countries. Patients with CCS have a propensity to develop colonic traditional serrated adenomas (TSA). Some authors found increased frequency of colonic carcinomas in CCS patients. In the present communication, we report a patient with CCS in whom a colonoscopic examination failed to disclose a coexistent TSA.

CASE REPORT

A 73-year-old female had a history of alopecia and nail atrophy. Because of iron deficiency anemia and occult gastrointestinal bleeding, she underwent a colonoscopic examination.

RESULTS

Colonoscopy revealed multiple broad-based polyps. Due to continuous bleedings, a coloproctectomy was performed four months after colonoscopy. Pathology disclosed 50 hamartomas and, unexpectedly, a TSA with high-grade dysplasia in the cecum.

CONCLUSION

The TSA was either overlooked at colonoscopy or not interpreted as different from the other colonic polyps by the endoscopist. CCS cases are very rare in Western countries. Given this circumstance, it is suggested that, when confronting the next CCS case, endoscopists should perform a comprehensive colonoscopic examination, including chromoscopy and directed biopsies from irregular polyps, to rule out a TSA, an adenoma prone to evolve into invasive carcinoma.

Aggressive juvenile polyposis in children with chromosome 10q23 deletion

Juvenile polyps are relatively common findings in children, while juvenile polyposis syndrome (JPS) is a rare hereditary syndrome entailing an increased risk of colorectal cancer. Mutations in BMPR1A or SMAD4 are found in roughly half of patients diagnosed with JPS. Mutations in PTEN gene are also found in patients with juvenile polyps and in Bannayan-Riley-Ruvalcaba syndrome and Cowden syndrome. Several previous reports have described microdeletions in chromosome 10q23 encompassing both PTEN and BMPR1A causing aggressive polyposis and malignancy in childhood. These reports have also described extra-intestinal findings in most cases including cardiac anomalies, developmental delay and macrocephaly. In this report we describe a boy with a 5.75 Mb deletion of chromosome 10q23 and a 1.03 Mb deletion within chromosome band 1p31.3 who displayed aggressive juvenile polyposis and multiple extra-intestinal anomalies including macrocephaly, developmental delay, short stature, hypothyroidism, atrial septal defect, ventricular septal defect and hypospadias. He required colectomy at six years of age, and early colectomy was a common outcome in other children with similar deletions. Due to the aggressive polyposis and reports of dysplasia and even malignancy at a young age, we propose aggressive gastrointestinal surveillance in children with 10q23 microdeletions encompassing the BMPR1A and PTEN genes to include both the upper and lower gastrointestinal tracts, and also include a flowchart for an effective genetic testing strategy in children with juvenile polyposis.

Colorectal juvenile polyposis in an adult with ulcerative colitis

Juvenile polyposis is a rare disorder. We report an unusual case of juvenile polyposis in a 22-yr-old woman with ulcerative colitis, apparently one of the first cases reported in the literature.

Spiral enteroscopy--a novel method for the management of small bowel diseases--case report and description of technique

Small bowel diseases are associated with difficult management. Recently, new methods such as single or double balloon enteroscopy and capsule endoscopy have been implemented for the investigation of small bowel, but none is perfect. Spiral enteroscopy seems to be an alternative primising technique for the diagnosis and therapy of small bowel diseases. We report two cases in which spiral enetroscopy was useful both for diagnosis and therapy. One was the case of a man with repeated digestive bleeding of unknown cause and spiral enteroscopy helped for diagnosis and treatment with argon plasma coagulation of the vascular lesions. The later was a patient with Gartner Syndrome with multiple duodenal and intestinal polyps and spiral enteroscopy allowed small bowel evaluation. In conclusion, this novel method seems to allow a rapid and efficient diagnosis of small bowel diseases.

Cecal intussusception in an adult with Cronkhite-Canada syndrome relieved by colonoscopy

Cronkhite-Canada syndrome (CCS) is a rare, noninherited gastrointestinal polyposis syndrome associated with characteristic ectodermal abnormalities. Here, we report a case of Cronkhite-Canada syndrome with cecal intussusception relieved by colonoscopy. A 52-year-old man who was diagnosed as CCS pathologically two years previously presented abdominal pain and sub fever-up. Physical examination revealed the palpable mass sized approximate 10 cm in diameter in the upper abdominal site, in addition to the symptoms of alopecia, absent fingernails and toenails. However, abdominal wall rigidity and rebound tenderness were never expressed. Abdominal plain CT showed concentric circles from the ascending to the middle of the transverse colon, and a tumor in the lumen at the middle of the transverse colon. Colonoscopic reduction was performed first because we diagnosed it as intussusception due to CCS polyps without peritoneal irritation, and his symptoms were improved dramatically after careful reduction. Therefore, he was able to undergo the laparoscopic ascending colectomy as scheduled.

Juvenile polyposis complicated with protein losing gastropathy

A male patient with chronic bloody stool was diagnosed as juvenile polyposis at the age of 28. He had thirty to forty colonic polyps and some were removed endoscopically, while gastric polyps were too numerous to intervene. As the polyposis advanced gradually, the patient developed intractable anemia and serious hypoproteinemia. Albumin scintigram revealed protein losing gastropathy due to progressive gastric polyposis. Total gastrectomy was carried out at the age of 34 and the patient has achieved remarkable and sustainable improvement.

[Diagnosis and effective treatment of jejunal polyposis causing massive gastrointestinal bleeding]

The authors present an interesting case of massive gastrointestinal bleeding which is caused by extended jejunal polyposis. They discuss the diagnostic challenges and the way of successful treatment of this case. The authors also summarize their experience and review the relevant literature regarding acute gastrointestinal bleeding from the small bowel.

Double-balloon enteroscopy for the diagnosis and treatment of obscure bleeding, inflammatory bowel diseases and polyposis syndromes: we see more but do we know more?

BACKGROUND/AIMS

Our aim was to report our experience with the Fujinon EN-450 T5 therapeutic double-balloon endoscope (DBE) in the diagnosis of small bowel diseases.

METHODOLOGY

Between August 2005 and October 2006, 52 DBE procedures were conducted on 47 consecutive patients (M/F: 22/25, age: 51.6 SD 19.5 years) presenting at our tertiary referral hospital (35 and 7 patients from oral and anal route, respectively; 5 patients from both). All procedures were performed using i.v. anesthesia, at our outpatient clinic.

RESULTS

Indication suspected small-bowel bleeding in 28 patients, suspected/known inflammatory bowel syndrome (IBD) in 12 and polyposis/suspected neoplasia in 7. In obscure bleeding small-bowel abnormality was found in 18 patients (64.3%) including angiodysplasias/erosions and one polypoid lesion. In suspected IBD, IBD was diagnosed in 2 out of 8 cases. In patients with polyposis syndromes, polyps were in two Peutz-Jeghers patients, while a further patient with suspected stenosis was diagnosed with primary adenocarcinoma. The average insertion length was app. 213cm. No severe complications were observed.

CONCLUSIONS

Based on our experience DBE is a safe and useful method for evaluating and treating small bowel disease in selected patients with obscure bleeding, IBD or polyposis syndromes, however the clinical importance of minute lesions still needs to be determined.

Hyperplastic polyposis in the New Zealand population: a condition associated with increased colorectal cancer risk and European ancestry

AIM

The hyperplastic polyposis syndrome (HPS) has been described in a subset of patients with multiple or large hyperplastic polyps. HPS is associated with an increased risk of colorectal cancer (CRC). In this report, we review the presentation and management of a series of individuals with HPS.

METHODS

From 2001, gastroenterologists, surgeons, and histopathologists at Middlemore Hospital were asked to report cases of HPS. Clinical records were retrospectively reviewed to confirm the number and size of polyps and the age at diagnosis, site of involvement in the colon, and nature of surgical procedures performed in cases with CRC.

RESULTS

HPS was identified in 24 patients: 14 females and 10 males. Though 46% of patients attending our gastroenterology department are non-Europeans, all HPS cases had European ancestry. A family history of CRC was identified in four patients (16.6%). All patients had small polyps (<5mm) however 15 (63%) had at least one polyp > or =10 mm, the largest being 45 mm. There were 21 CRCs in 14 patients with a mean age at diagnosis of 61 years. The tumour site was known in 19 CRC, and 16 of these (84%) occurred in the proximal colon. Synchronous cancers were identified in four patients and metachronous tumours in two patients. Twenty-two surgical procedures were performed in 17 patients. Three patients underwent prophylactic surgery due to polyp burden or dysplasia.

CONCLUSION

HPS is rarely encountered but is associated with a significant risk of CRC and is found in the European component of the New Zealand population. Identification of this syndrome has implications regarding management and surveillance for both the individual patient and their first-degree relatives.

Non-familial juvenile polyposis in prolapsed rectum

Juvenile polyposis located solely on prolapsed rectal mucosa is very unusual. We report the case of a 17-year old boy who presented to us with a history of passage of blood and mucus per rectum of a mass protruding through the anus during defecation. Per rectal and colonoscopic examinations revealed numerous polyps located solely on the prolapsed rectal mucosa. Histopathology was consistent with juvenile polyposis. He was managed with repeated sessions of endoscopic polypectomy. Family screening was negative for colonic polyps.

Nonfamilial juvenile polyposis coli manifesting as massive lower gastrointestinal hemorrhage: report of two cases

Juvenile polyposis syndrome is an uncommon hamartomatous disorder with gastrointestinal (GI) manifestations of varying degree and malignant potential. We report the cases of an 8-year-old girl and a 5-year-old girl who suffered massive lower GI hemorrhage. Neither patient had a family history of polyposis. After the patients were stabilized, radiological evaluation, laparotomy, and intraoperative colonoscopy revealed multiple polyps in the colon. Both patients underwent total colectomy, mucosal proctectomy, and ileoanal anastomosis. The diagnosis of nonfamilial juvenile polyposis was based on the histological findings and the absence of a family history. To our knowledge, this presentation of juvenile polyposis has been reported only twice before. We discuss the clinical features and diagnosis of juvenile polyposis and the treatment options. Although juvenile polyposis is a rare condition in children, it should be considered in the differential diagnosis of life-threatening GI hemorrhage.

Ileal polyposis as manifestation of neurofibromatosis syndrome

A 13-year-old girl presented with features of intestinal obstruction. At surgery, the terminal 25 cm of ileum, which was resected along with the right colon, showed plexiform neurofibromatosis of the serosa and mesentery, hyperplastic submucosal and myenteric nerve plexuses and proliferation of neural tissue in the lamina propria, which manifested as diffuse polyposis of the ileal mucosa. The patient had a single inconspicuous external neurofibroma and a few café-au-lait spots on the back.

The effect of sublingual captopril versus intravenous enalaprilat on angiotensin II plasma levels

A 44-year-old woman, with a history of familial adenomatous polyposis, complicated by carcinoma of the colon, for which a proctocolectomy had been performed, now presented with metastasis located in the pancreas. Treatment consisted of chemotherapy followed by a partial pancreaticoduodenectomy. Due to ischemia, resection of the small intestines was performed the same day. After admission, a transesophageal echocardiography showed an ejection fraction of 40%. Because enteral administration of drugs was impossible, intravenous enalaprilat 2 mg once a day for 1 day followed by sublingual captopril 25 mg twice a day were started. Blood samples were taken before and after administration. After 1 day of sublingual captopril treatment the angiotensin II level decreased with more than 50%, comparable to the decrease seen after intravenous administration of enalaprilat. Sublingual captopril has been used in the treatment of hypertensive crisis and heart failure. Although frequently reported, no study has investigated the effect on angiotensin II levels after sublingual administration in heart failure patients. This case-report demonstrated that sublingual administration of 25 mg captopril twice a day yielded a considerable decrease in angiotensin II plasma levels which was comparable to the effect seen after an intravenous administration of 2 mg enalaprilat.

Prospective comparison of laparoscopic left hemicolectomy for colon cancer with laparoscopic left hemicolectomy for benign colorectal disease

BACKGROUND

Short-term outcome and anorectal function results after laparoscopic hemicolectomy for colon cancer were compared with results after laparoscopic hemicolectomy for benign diseases.

METHODS

A total of 108 patients who underwent laparoscopic left colectomy (60 for colon cancer, 48 for diverticulitis or polyposis) were enrolled in the study. Left hemicolectomy in patients affected by cancer was performed by high ligation of the inferior mesenteric artery. A questionnaire concerning anorectal function was mailed to patients 6 months after surgery.

RESULTS

Complications were more frequent in the cancer group than in the benign disease group: overall morbidity rate (29.6% versus 8.7%; P = 0.009), diarrhea during the first 6 postoperative months (58.7% versus 34.1%; P = 0.022), and anorectal function problems (fecal incontinence and/or the inability to discriminate between gas and stool, and/or urgency, and/or tenesmus) (65.2% versus 31.7%; P = 0.002).

DISCUSSION

The level of ligation of the lower mesenteric artery and damage at the lower mesenteric ganglion could explain the poorer anorectal function outcome in the colon cancer group.

Intestinal polyposis syndromes: progress in understanding and treatment

PURPOSE OF REVIEW

Dramatic advances in the understanding of the genetic basis for inherited diseases and in diagnosis and treatment are particularly applicable to intestinal polyposis. Recent contributions have impacted our understanding of the molecular basis for the disease and improved our ability to treat them.

RECENT FINDINGS

Insights into the genetic basis of the spectrum of disease and refinement of genetic screening, diagnostic tests, and surgical management of intestinal polyposis and extraintestinal manifestations are reviewed.

SUMMARY

Our understanding of the genetic basis for the intestinal polyposis syndromes remains incomplete, but recent studies have contributed to filling in significant gaps in our knowledge. Specific genetic alterations have been identified in the majority of the 30% of patients with familial adenomatous polyposis that do not test positive for mutations in the APC gene with routine testing. A novel gene ENG has been identified in a subgroup of patients with Peutz-Jegher's syndrome and a hypothesis has been proposed to explain the pathogenesis of the mucosal defects. Technological advancements in diagnosis and treatment include the use of capsule endoscopy for screening and the minimally invasive approach to total colectomy with ileoanal pullthrough. Treatment of desmoid tumors remains a challenge, but new chemotherapy regimens show some promise in treating this rare, but devastating, extraintestinal manifestation.

Diagnosis and management of gastrointestinal polyps: pediatric considerations

Painless, bright red, rectal bleeding with normal stool frequency and consistency is the hallmark presentation of colorectal polyps at any age. Most polyps in children are sporadic, usually isolated, colorectal juvenile polyps that do not require any further surveillance after they are removed. There is, however, increasing recognition of syndromes, including familial adenomatous polyposis, juvenile polyposis coli, Peutz-Jeghers syndrome, and infrequent conditions, such as PTEN hamartoma and hereditary mixed polyposis syndromes. The aim of this review is to allow the reader to correctly identify the patients who do not require follow-up and the smaller group of patients who do require follow-up because of syndromic polyp conditions.

[Peutz-Jeghers syndrome: an account of 3 cases in the same family and a review of the literature]

Peutz-Jeghers syndrome is a rare autosomal dominant polyposis characterized by mucocutaneous pigmentation, intestinal hamartomas and an increased risk mainly for gastrointestinal and gynaecological cancer. Our interest in this syndrome is due to the observation of three cases in the same family, two of whom presented the classic Peutz-Jeghers syndrome, while the other had perioral pigmentation only. Therefore, the main clinical elements emerge in the two first cases presenting with recurrent abdominal pain and sub-occlusion. The condition was managed by a combination of radiological, endoscopic and surgical procedures which enabled us to map and remove several gastrointestinal polyps. On histopathological examination the polyps were mainly hamartomas, though some presented both hamartomatous and adenomatous features, while others, removed endoscopically during the follow-up, were identified as true adenomas with initial carcinomatous changes. Furthermore, in one case follow-up examination allowed the early diagnosis and treatment of a cervical carcinoma. In agreement with the literature, our experience suggests that simple polypectomy, via an endoscopic and/or surgical approach, is the treatment of choice in Peutz-Jeghers syndrome. However, if gangrene due to invagination or neoplastic change occurs, an intestinal resection is mandatory. Cancer surveillance must be the first aim of follow-up.

Application of technetium-99m-labeled human serum albumin scan to assist surgical treatment of protein-losing enteropathy in Cronkhite-Canada syndrome: report of a case

Cronkhite-Canada syndrome is a rare form of nonhereditary gastrointestinal polyposis associated with ectodermal change and protein-losing enteropathy. Here we report a 63-year-old male presenting with diffuse gastrointestinal polyposis, onychodystrophy, cutaneous pigmentation, alopecia, diarrhea, hypoalbuminemia and lower leg edema. Technetium-99m-labeled human serum albumin scan confirmed the patient to have protein-losing enteropathy, which originated from the transverse and descending colon. Subtotal colectomy was performed. Albumin level and ectodermal change were gradually improved during three years of outpatient clinic follow-up. Based on our finding, Technetium-99m-labeled human serum albumin scintigraphy is helpful to localize the protein-losing origins and surgery is an effective treatment for Cronkhite-Canada syndrome with protein-losing enteropathy.

[One case of Cronkhite-Canada syndrome, in which the course from onset to spontaneous curing could be followed]

The case is a 62 years old male. No polyposis was found by upper gastrointestinal endoscopy or barium enema examination performed at the time of cholecystectomy in March 1994. Symptoms such as dysgeusia, diarrhea, loss of hair and atrophy of nails began to appear from May. Examination of the digestive tract performed in October revealed clustered polyposis in the stomach, duodenum, small intestine and large intestine. Pathologically, all the polyps were found to be of the juvenile type, so a diagnosis of Cronkhite-Canada syndrome (CCS) was made. Histologic patterns of rectal polyp after polypectomy showed well differentiated adenocarcinoma continuous with the juvenile type polyp. The above-mentioned symptoms improved with the clinical course. At present, 6 years after the development of the disease, no recurrence of polyposis in the stomach and large intestine has been found. Our results suggest that ectodermal changes and lesions of the digestive tract in CCS appear and disappear in a short time.

A case of Cronkhite-Canada syndrome with vestibular disturbances

A 66-year-old Japanese man with Cronkhite-Canada syndrome (CCS) presented with complaints of long-lasting dysequilibrium. On neuro-otological examination, he showed gaze-evoked nystagmus at the rightward and leftward gaze, and saccadic pursuit. On the caloric test, he showed no response in either side, and on the head-impulse test he showed bilateral loss of vestibule-ocular reflexes around the yaw axis, while he had bilateral normal responses on the vestibular-evoked myogenic potential testing. Neuro-otological findings suggested that he had lesions in the peripheral vestibular system as well as the central nervous system. Neurological disorders such as sensory neuropathy have been reported in patients with CCS. This patient's balance problems could be due to CCS itself.

[Familial adenomatous polyposis with extracolonic manifestations--case report]

The familial adenomatous polyposis syndrome is an autosomal dominant inherited disease characterized by progressive development of multiple adenomatous polyps throughout the colon and rectum. Due to the malignant potential of adenomatous polyps, colorectal cancer develops in 100% of cases, approximately 10-15 years after the onset of symptoms. Extracolonic manifestations of the disease including adenomatous polyps of the stomach, duodenum, small intestine and periampullatory region are rare. The etiology of the disease is germline mutation at the site of tumor suppressor gene located on chromosomes 5q21-22. A case is described of a 48-year-old man hospitalized at the Department of Abdominal Surgery, Sveti Duh General Hospital in Zagreb for the treatment of familial adenomatous polyposis syndrome. For some time the patient reported occasional abdominal pain, frequent stools and diarrhea with blood, anemia and body weight loss. Laboratory, radiology and endoscopy examinations verified multiple adenomatous polyps of the colon and rectum, also with polyps of the stomach, duodenum and jejunum. Histopathology confirmed the polyps to show moderately poorly differentiated cylindric epithelium and moderate to severe dysplasia. Radical surgery was required, so proctocolectomy with Brook ileostomy was performed. The postoperative recovery and wound healing were normal. The patient was discharged twelve days of the surgery for home care. Oncologic treatment was suggested. Verified extracolonic manifestations of the disease require periodical endoscopic follow up and possible treatment.