Pyogenic granuloma presenting as a rectal polyp at the site of a previous polypectomy

Table of Contents

A pyogenic granuloma is a polypoid form of capillary hemangioma that generally forms on the skin or in the oral cavity; rarely, these lesions can also be found in other parts of the gastrointestinal tract [1]. The pathogenesis of pyogenic granulomas is uncertain, in that they might have an infectious cause or they could represent a type of hemangioma [1] [2].

A 26-year-old woman was referred for endoscopic ultrasound to evaluate an area of submucosal compression that had been noted near a rectal polyp. The patient initially presented for endoscopy at an outside hospital for polyp follow-up. At that time, a 2-cm polyp above the anal verge was removed by snare polypectomy. Flexible sigmoidoscopy just prior to endoscopic ultrasound 2 months later showed a reddish-colored, 5-mm sessile polyp (Figure [1]), 1 - 2 cm proximal to the dentate line (around the prior polypectomy site). A slight submucosal bulge was seen at the base of the polyp. Endoscopic ultrasound was performed, which revealed a sessile polyp originating from the mucosal layer. The deep echo layers were preserved and there were no intramural or extramural lesions (Figure [2]). The polyp was removed by saline-assisted snare polypectomy, and subsequent pathological examination revealed the lesion to be a pyogenic granuloma (Figure [3]).

Figure 1 Flexible sigmoidoscopy revealed a reddish-colored, 5-mm-diameter sessile polyp in the rectum at the site of a previous polypectomy.

Figure 2 Endoscopic ultrasound revealed a sessile polyp originating from the mucosal layer. The deep echo layers were preserved and there was no evidence of intramural or extramural lesions.

Figure 3 Photomicrographs of the pyogenic granuloma. The whole lesion is seen at lower magnification, with congested capillaries and inflammatory cells (a). At higher magnifications, there is evidence of proliferation of small blood vessels against a background of stromal edema (b), with a mixed population of plasma cells, neutrophils, lymphocytes, and some macrophages (c).

Pyogenic granulomas are benign in nature and have been excised endoscopically. Four cases of pyogenic granuloma of the large intestine have been reported in the literature [3] [4] [5] [6]: three patients presented with rectal bleeding and a solitary pyogenic granuloma; the fourth patient presented with diarrhea and was found to have multiple lesions [4]. Our patient was asymptomatic and only presented for polyp surveillance. She was noted to have some submucosal compression and so underwent a flexible sigmoidoscopy and endoscopic ultrasound, which revealed a pyogenic granuloma at a previous polypectomy site. Pyogenic granulomas rarely occur in the colorectal area and only a few cases have been reported in the literature. Based on the limited data available, they appear to be benign lesions but they could be confused with other polyps that require a different follow-up regime.

Endoscopy_UCTN_Code_CCL_1AD_2AC

References

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