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Rectal Tonsil

Homan, Matjaž*; Volavšek, Metka

Journal of Pediatric Gastroenterology & Nutrition: May 2012 - Volume 54 - Issue 5 - p 575
doi: 10.1097/MPG.0b013e3182432187
Image of the Month

*Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital

Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.

Address correspondence and reprint requests to Matjaž Homan, MD, PhD, Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital, Ljubljana, Slovenia (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 6-year-old girl was referred to our hospital with an 8-week history of intermittent bright red rectal bleeding. Rectal examination revealed a sessile mass within the lower rectum at 4 cm from the anal verge. Otherwise, she was an alert girl without any other symptoms. In addition, her clinical examination and laboratory studies were completely normal. A complete colonoscopy with ileal intubation revealed a sessile rectal polyp (Fig. 1), which was removed by standard electrocautery settings without any complications. Histologic examination revealed a flattened superficial mucosa from underlying expansive lymphatic growth caused by follicular hyperplasia (Fig. 2) with intermingled reactive blasts, which may mimic different lymphoproliferative lesions including low- or high-grade lymphomas. Immunohistochemistry (CD20, CD3, bcl-2, bcl-6, CD23, Ki-67, CD30) and in situ hybridization (κ, λ light chains) proved the benign nature of lesions.

The localized lymphoid hyperplasia of the large intestine is also known as rectal tonsil (RT), benign lymphoid polyp, and lymphoid polyp (1). RTs are located mainly in the rectum, just above the dentate line. They often cause intermittent rectal bleeding but rarely any abdominal pain. Endoscopic differentiation from lymphomas is not possible. Histologic distinction between RT and different B-cell lymphomas, especially mucosa-associated lymphoid tissue-type or diffuse large B-cell lymphoma, also is challenging (2). Immunohistochemical and genotypic studies are necessary to prove the reactive nature of the lesion. Published cases of RT in children are scarce (2).

The presented case shows that RT also appears in children and that careful histologic examination including the use of immunohistochemistry and genotypic studies is necessary to avoid overdiagnosis and overtreatment.

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1. Kojima M, Itoh H, Motegi A, et al. Localized lymphoid hyperplasia of the rectum resembling polypoid mucosa-associated lymphoid tissue lymphoma: a report of three cases. Pathol Res Pract 2005; 201:757–761.
2. Farris AB, Lauwers GY, Ferry JA, et al. The rectal tonsil: a reactive lymphoid proliferation that may mimic lymphoma. Am J Surg Pathol 2008; 32:1075–1079.
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