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 Pathology of Inflammatory Polyps,

Inflammatory Cap Polyps

and Polypoid Mucosal Prolapse

of the Large Intestine

Dr Sampurna Roy MD


August  2015

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)

 

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Normal Histology of the Large Intestine

Interpretation of Large Intestinal Biopsies

Assessment of abnormalities - 1 (lumen, surface epithelium, subepithelial zone)

Assessment of abnormalities - 2  (crypt density , architecture and epithelium)

Assessment of abnormalities - 3 (changes in the lamina propria, muscularis mucosae and submucosa) 

Pathology of Amebic Colitis 

Gross examination of polypectomey specimens

Microscopic ; collagenous  colitis

Pseudo membranous colitis

Eosinophilic Gastroenteritis

Gross examination of colorectal resection specimens in non-neoplastic diseases

Pathology of Ulcerative Colitis

Gross examination of polypectomey specimens

Hyperplastic polyps and serrated adenomas

 

Normal Histology of Esophagus

An approach to the reporting of esophageal biopsies

 1. Squamous papilloma of the esophagus

 2. Inflammatory fibroid polyp of the esophagus

 3. Leiomyoma of the esophagus

 4. Granular cell tumour of the esophagus

 5. Esophageal cysts 

 6. Glycogenic acanthosis 

Reporting of esophageal resection specimens

Squamous epithelial dysplasia of the esophagus

Small cell carcinoma of the esophagus 


GI Path Online-Home Page Pathology of Large  Intestine - Home Page

Inflammatory polyps are the most common type of polyp in Inflammatory bowel disease.

These polyps usually occur in patients with moderate to severe colitis but persist in patients with quiescent disease.

Inflammatory polyps also occur in association with Crohn's disease and other inflammatory disorders of the GI tract such as ischemic colitis or infectious colitis.

These polyps may occur in infective conditions such as amoebiasis, schistosomiasis and bacillary dysentery.

A special form of inflammatory polyp develops in the colon at the site of ureteric implantation where probably due to chemical irritation there is localized expansion of lamina propria and cystic dilatation of glands.

In order to determine the underlying disease it is necessary to examine non-polypoid mucosa, which should be biopsied at the same time.

Formation of inflammatory polyps:

These are developed as a regenerative response to localized or diffuse inflammation and ulceration of the mucosa followed by regeneration of the intervening non-ulcerated epithelium.

Eventually the regenerated mucosa become completely re-epithelized and persists above the level of the surrounding mucosa as inflammatory polyps.

Sometimes inflammatory polyps represent spared mucosa surrounding areas of deep ulceration.

Some polyps decrease in size, most remain stable a few may continue to grow if they undergo torsion or prolapse.

Gross:                                          

May be sessile, pedunculated or may consist of long finger-like projection referred to as 'filliform'.

These polyps may be single or numerous in number and the size range between 0.5 - 1.0 cm.

'Giant Inflammatory polyps' may cause bleeding, obstruction, prolapse or intussusception.

Histopathological features:

The inflammatory polyps are characterized by :

Inflamed lamina propria ; distorted colonic epithelium - tortuous, branched, elongated and cystic crypts; surface erosion ; congestion ; haemorrhage ; crypt abscesses.

In some cases pseudosarcomatous changes are noted characterized by :          

Enlarged spindle or epithelioid shaped multinucleated bizarre stromal cells,  present at the surface of ulcerated polyp.

Differential diagnosis -

Sarcoma: 

(1) These lesions lack atypical mitosis 

(2) Located within granulation tissue and below areas of ulcerataion

(3) Positive for endothelial and myofibroblastic markers.


Rarely dysplasia or carcinoma may develop in inflammatory polyps. However, the risk of developing dysplasia is very low and these polyps are not considered pre-neoplastic lesions.


Pathology of Inflammatory Cap Polyps:

   

Inflammatory cap polyps are defined as an inflammatory polyp either with or without prolapse-related changes that contain an overlying 'cap' of necroinflammatory debris and granulation tissue.

These inflammatory polyps may develop in inflammatory bowel disease either primarily or secondarily as a result of peristalsis or trauma induced mucosal prolapse.

This may lead to traction and twisting of polyps causing localized ischemic damage, regeneration and repair of the lamina propria and epithelium and the development of an inflammatory polyp.

There may be associated diverticular disease.

These polyps are usually isolated lesions, but can be numerous in number - ( 'cap polyposis').

Cap polyps are usually located in the sigmoid colon and rectum of adults. These are sessile haemorrhagic polyps, present on the crest of mucosal folds and are less than 1 cm in diameter.

The patients present with rectal bleeding and mucous diarrhea.

In some cases these are also seen in the small intestine complicating carcinoid tumour.


Pathology of Polypoid Mucosal Prolapse:

Few important features:  

- Classical solitary ulcer (mucosal prolapse) can be polypoid.

- May be present in diverticular disease on the apices of mucosal folds.

- Subsequent to previous surgery (Example: Stomas or pelvic ileal reservoir)

- Inflammatory Cloacogenic polyps - At the anorectal junction. There is florid villiform epithelial hyperplasia. Associated with haemorrhoids and pelvic descent syndromes.

- Inflammatory Myoglandular polyps - Usually in sigmoid colon.
 

                                                      
Further reading:

Prolapsing mucosal polyps: an underrecognized form of colonic polyp--a clinicopathological study of 15 cases.

The solitary rectal ulcer today. A review of the literature.

Protruded variants in solitary ulcer syndrome of the rectum.

Solitary rectal ulcer syndrome. Its clinical and pathological underdiagnosis.

Clinicopathologic comparison of eroded polypoid hyperplasia and solitary rectal ulcer syndrome.

Polypoid prolapsing mucosal folds in diverticular disease.

Inflammatory cloacogenic polyp. A unique inflammatory lesion of the anal transitional zone.

Inflammatory cloacogenic polyp: relationship to solitary rectal ulcer syndrome/mucosal prolapse and other bowel disorders.

Inflammatory cloacogenic polyp in a child: part of the spectrum of solitary rectal ulcer syndrome.

Inflammatory myoglandular polyps of the colon and rectum. A clinicopathological study of 32 pedunculated polyps, distinct from other types of polyps.

Angiogenic polypoid proliferation adjacent to ileal carcinoid tumors: a nonspecific finding related to mucosal prolapse.

Prolapse- induced inflammatory polyps of the colorectum and anal transitional  zone. 
Eroded polypoid hyperplasia of the rectosigmoid.

Filliform polyposis of the colon in chronic inflammatory bowel disease ( so called giant inflammatory polyps).

Localized giant inflammatory polyposis of the cecum associated with distal ulcerative colitis.

Filiform polyposis: a case report describing clinical, morphological, and immunohistochemical findings.

Polypoid and pseudopolypoid manifestations of inflammatory bowel disease.

Pseudosarcomatous changes in inflammatory pseudopolyps of the colon.

Cap polyposis: further experience and review.

Cap polyposis occurring in the postoperative course of pelvic surgery.

Cap polyposis--an unusual cause of diarrhoea.

 


GI Path Online-Home Page Pathology of Large  Intestine - Home Page

An outline of the anatomy and normal histology of the  stomach for pathologists.

Reporting of gastric biopsies (non-neoplastic gastric lesions).

Pathology and pathogenesis of peptic ulcer.

Acute Gastritis 

Chronic Gastritis

Helicobacter pylori  associated(TypeB)  Gastritis 

Autoimmune Gastritis (Type A) 

Reactive /Reflux/ Chemical Gastritis (Type C)

Lymphocytic Gastritis

Collagenous Gastritis

Granulomatous Gastritis

Eosinophilic Gastritis

Gastric Xanthoma/Xanthelasma

Other Non-Neoplastic Gastric Lesions

Benign tumour and tumour- like lesions

Gastric Lymphoma

Gastric Carcinoid Tumour

Gastrointestinal Stromal Tumour

Gastric Epithelial Dysplasia

Early Gastric Carcinoma

Gross Examination of the Gastrectomy Specimen 

Drug related lesions of the gastrointestinal tract

 

Normal histology of the small intestine for anatomic pathologists

An approach to evaluation of small intestinal biopsy.

Malabsorption syndrome

Coeliac Disease

Enteropathy-associated T-cell lymphoma

Intestinal lymphan giectasia

Giardiasis

Cryptosporidium

Isosporiasis

Mycobacterium Avium Intracellulare

Whipple's disease

Peptic Ulcer

Meckel's  diverticulum

Ischemic bowel disease 

Brunner's Gland Adenoma

Duodenal  Gangliocytic Paraganglioma

Lymphoma of the small intestine

Pathology Quiz Case 68  56 year old male presented with iron deficiency anaemia.  Upper gastrointestinal  endoscopy demonstrated  a 4 cm , ulcerated  polypoid mass in the second part of the duodenum, protruding into the lumen. 

Pathology Quiz Case 87   A 55 year old female with a duodenal polyp, 2cm in diameter.

Pathology Quiz Case 5:   A 41 year old male with a small well circumscribed nodule on the stomach wall

Pathology Quiz Case 79: A 54 year old female. Gastric Antral Biopsy for diagnosis.

 

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