Rectal Cap Polyposis Masquerading as Ulcerative Colitis with Pseudopolyposis and Presenting as Chronic Anemia: A Case Study with Review of Literature
A 27-year-old man visited another hospital with chief complaints of generalised weakness, pallor and intermittent rectal bleeding for 2 years prior to his presentation. Physical examination was unremarkable. His haematological profile showed low haemoglobin levels (8.5 g/dl). The rest of the laboratory parameters including total serum protein and erythrocyte sedimentation rate were within normal limits. Stool culture was negative for pathogenic organisms. Colonoscopy revealed pseudopolyps along with multiple erythematous and eroded mucosal lesions in the rectum []. He was diagnosed clinically as ulcerative colitis for which he received oral aminosalicylic acid followed by prednisolone for 6 months. However, the patient was non-responsive to this medical therapy. He was also transfused blood on two separate occasions along with hematenimics because of persistently low hemoglobin. One year after the initial treatment he was admitted to our hospital because of worsening of symptoms, which were now accompanied by mucous diarrhoea, straining at defecation and rectal prolapse (feeling of mass protruding out from rectum). Laboratory data at the time of present admission also revealed low hemoglobin (8.0 g/dl) however, remaining hematological investigations were within normal limits. On digital rectal examination, multiple soft elevated lesions were palpable. Contrast enhanced computed tomography of the lower abdomen and pelvis showed multiple rectal polyps and thickening of the rectal wall with a maximum wall thickness of 12 mm along with its abnormal inferior descent [].\nAs the patient was non-responsive to medical therapy, low anterior resection of the rectum was done. Intra-operatively, multiple sessile polyps were noted in the rectum along with erythema of the surrounding mucosa. An intra-operative diagnosis of inflammatory polyposis was considered. The post operative course of the patient was uneventful.\nGross examination of the resected specimen revealed multiple sessile rectal polyps, ranging in size from 0.3 cm to 3.0 cm in maximum diameter. The surface of these polyps was ulcerated and was covered with a yellow white fibrinous exudate. The surrounding colonic mucosa showed mild erythema while the intervening colonic mucosa was unremarkable []. Histologically, the surface of these polyps had “caps” of inflammatory granulation tissue and exudate while the base had hyperplastic and cystically dilated crypts. The lamina propria contained a large number of lymphomononuclear cells as well as mucin lakes. Hemosiderin laden macrophages were also observed at places. There was no evidence of adenomatous change or malignancy []. The histopathological findings were consistent with the diagnosis of inflammatory CP.\nThree months post-operatively the hemoglobin levels had improved to 11.3 g/dl.