Rectal polypoid lesion with a nodular surface

Article information

Intest Res. 2019;17(2):281-282

Publication date (electronic) : 2019 February 7

doi : https://doi.org/10.5217/ir.2018.00172

Jae Hyun Kim

Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea

Correspondence to Jae Hyun Kim, Department of Internal Medicine, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea. Tel: +82-51-990-5061, Fax: +82-51-990-5055, E-mail: kjh8517@daum.net

Received 2018 December 26; Accepted 2018 December 29.

Question: A 60-year-old man presented to the Gastroenterology Clinic at Kosin University Gospel Hospital for the management of abnormalities detected on colonoscopic examination. He underwent colonoscopic examination for a health checkup at another hospital, 2 months prior to presenting to this hospital. He denied abdominal symptoms, although he admitted to a habit of excessive straining during bowel movements. Colonoscopic examination revealed a rectal polypoid lesion measuring approximately 2.5 cm in size with a nodular surface, located 5 cm from the anal verge with convergent folds around it (Fig. A). EUS showed a homogeneous hypoechoic lesion originating from the submucosal layer (Fig. B). Malignancy could not be ruled out; therefore, endoscopic mucosal resection was scheduled for the removal of the lesion and for histopathological diagnosis. What is the diagnosis in this case?

Answer to the Images: Mucosal Prolapse Syndrome

The lesion showed a positive non-lifting sign in response to submucosal saline injection. However, endoscopic mucosal resection was performed successfully (Fig. C). The histopathological diagnosis was mucosal prolapse syndrome. As shown in Fig. D (H&E, ×100), fibromuscular obliteration of the lamina propria was observed with bundles of muscularis mucosa invading the lamina propria. The lamina propria showed inflammatory cell infiltration and a small quantity of hemorrhage.

Mucosal prolapse syndrome is an uncommon chronic inflammatory disorder attributable to chronic mechanical stimulation [1]. The diagnosis of this condition is important because it may be clinically indistinguishable from malignancy. Mucosal prolapse syndrome can be diagnosed based on a combination of the patient’s symptoms, clinical findings, and histopathological abnormalities. Therefore, thorough examination of medical history is important. The pathogenesis of this condition is not well-established; however, chronic straining during defecation and difficulty initiating defecation might cause direct mucosal trauma with consequent formation of an ulcer or a polypoid lesion.

Mucosal prolapse syndrome includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps [2]. The common endoscopic findings are ulcerated, polypoid, or flat and elevated-type lesions [3]. Patients usually present with the passage of blood and/or mucus during defecation, as well as abdominal pain and/or constipation [4]. The characteristic histopathological findings are fibrous obliteration of the lamina propria, thickening of the muscularis mucosa, and distortion of the crypt architecture [5]. The treatment of mucosal prolapse syndrome primarily depends on the severity of symptoms, and asymptomatic patients may not require any treatment.