Journal of Pediatric Gastroenterology & Nutrition:
Clinical Quiz

Clinical Quiz

Fitzgerald, Joseph F.; Troncone, Riccardo; Sood, Manu; Murphy, M. Stephen

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Department of Paediatric Gastroenterology and Nutrition, Institute of Child Health, Birmingham, United Kingdom

A 12-year-old girl complained of bloody diarrhoea 10 days after returning to the United Kingdom from a vacation in Bulgaria. She passed up to 20 bloody, mucoid stools daily associated with marked tenesmus. Physical examination, including digital rectal examination, was normal. Stool microbiological studies were negative. Colonoscopy showed mild mucosal erythema in the distal rectum. However, retroflexion of the colonoscope revealed a pale, mucosal polyp approximately 1 cm diameter at the anorectal junction (Fig. 1). Rectal mucosal biopsies showed mild nonspecific inflammation. The polyp was surgically excised and submitted for histologic examination.

Fig. 1
Fig. 1
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A. What was the diagnosis?

B. What is the pathophysiology of this disorder?

Answer: An inflammatory cloacogenic polyp (ICP).

Histology showed areas of surface erosion and disorganization of the muscularis mucosa with upward extension through the lamina propria--a feature characteristic of this condition (Fig. 2).

Fig. 2
Fig. 2
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This child had "mucosal prolapse syndrome," which leads to mucosal injury, probably as a consequence of ischemia. In this syndrome, either ICPs or solitary rectal ulcer may result. Similar histologic abnormalities are seen in these two related entities. These patients often suffer from tenesmus and may engage in repetitive nonproductive straining. They pass small quantities of blood and mucus. ICPs are a well-recognized cause of rectal bleeding and tenesmus in adults, but have only recently been described in children (1,2). They are soft, friable polyps and therefore may be missed on digital rectal examination. They can be overlooked at colonoscopy because of their distal location. Performing a retroflexion manoeuvre of the colonoscope may help to visualise the anorectal junction.

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REFERENCES

1. Poon KKH, Mills S, Booth IW, Murphy MS. Inflammatory cloacogenic polyp: an unrecognized cause of hematochezia and tenesmus in childhood. J Pediatr 1997;130:327-9.

2. Bass J, Soucy P, Walton M, Nizalik E. Inflammatory cloacogenic polyp in children. J Pediatr Surg 1995;30:585-8.

© 1998 Lippincott Williams & Wilkins, Inc.

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