Evolution of filiform polyposis from classical pseudopolyposis in a pediatric ulcerative colitis patient.

Filiform polyposis (FP) is a morphologic variant of pseudopolyposis associated with inflammatory conditions of the gastrointestinal tract, namely, inflammatory bowel disease. Pediatric cases are uncommon in the literature. Here, we present a pediatric patient with FP arising from ulcerative colitis (UC). He initially presented at 7 years of age for an acute UC flare and was found to have classical pseudopolyposis. A follow-up colonoscopy at age 9 showed the evolution of classical pseudopolyposis to FP. The patient clinically improved with sulfasalazine monotherapy and remained in remission based on consistent pediatric ulcerative colitis activity index scores of zero and normal-range inflammatory markers. Repeat surveillance colonoscopy at age 14 showed persistent and diffuse FP in the background of healthy colonic mucosa. This case documents the development of FP from classical pseudopolyps in the setting of an asymptomatic patient in clinical remission.

Sonographic detection of massive colonic pseudopolyposis in inflammatory bowel diseases.

PURPOSE: Colonic pseudopolyps are a frequent finding in inflammatory bowel disease (IBD). Yet there are no published data describing the characteristics of pseudopolyposis in intestinal ultrasound (IUS). This study aimed at identifying the key features of pseudopolyposis in IUS. METHODS: This case-control study included 12 patients with ulcerative colitis or Crohn's colitis with extensive left colon pseudopolyposis and 18 matched IBD patients without pseudopolyps at colonoscopy. Luminal (diameters, thickening, stratification, margins, and vascularity) and intraluminal (vascular signals at color Doppler), and extraluminal (mesenteric fat) parameters of the left colon were compared. Anonymized still images and videos of these patients were blindly reviewed to estimate the accuracy in detecting this condition. RESULTS: Among the IUS parameters assessed, the anteroposterior diameter ≥ 12 mm and the presence of luminal vascular signals were significantly correlated with pseudopolyposis. The detection of both these findings were able to detect extensive pseudopolyposis a sensitivity of 75% (CI 95%: 42.8-94.5%) and a specificity of 100% (CI 95%: 81.5-100%). CONCLUSION: This is the first study describing the IUS features of pseudopolyposis in IBD. The potential use of IUS to assess pseudopolyposis might have an impact on IUS monitoring and surveillance of IBD patients with condition.

Obstructive Giant Inflammatory Polyp of the Colon in Ulcerative Colitis.

Inflammatory polyps, also known as pseudo-polyps, are a common benign condition affecting 10-20% of patients with inflammatory bowel disease. Chronic, repeated inflammation and ulceration associated with healing lead to the formation of polyp-like structures in the colon. Although there are no common symptoms accompanying these pseudo-polyps, they can present with anemia, weight loss, diarrhea, intussusception, palpable mass, abdominal pain, discomfort, and melena, not to mention bowel obstruction that happens infrequently. Finally, it is important to recognize giant inflammatory polyps as they may occasionally be mistaken for colon cancer, leading to unnecessary surgical interventions. We present the case of a 38-year-old woman who was diagnosed with ulcerative colitis 10 years back, treated with oral mesalamine for five years, and had no follow-up after this period. She came to our clinic complaining of recurrent obstructive symptoms for a few months. Examination shows tenderness in the left lower quadrant with normal vital signs and bowel sounds.

Increased risk of colorectal neoplasia in inflammatory bowel disease patients with post-inflammatory polyps: A systematic review and meta-analysis.

BACKGROUND: Inflammatory bowel disease (IBD) patients with post-inflammatory polyps (PIPs) may carry an increased risk of colorectal neoplasia (CRN) including dysplasia and cancer. Current guidelines recommend active colonoscopy follow-up for these patients. However, the evidence for guidelines is still poor. In addition, some recent high-quality reports present a different view, which challenges the current guidelines. We hypothesize that IBD patients with PIPs are at increased risk of CRN. AIM: To evaluate the risk of CRN in IBD patients with and without PIPs. METHODS: A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared the risk of CRN in IBD patients with and without PIPs. In addition, we screened the reference lists and citation indices of the included studies. Quality assessment was performed using the Newcastle-Ottawa Scale. Pooled odds ratio (OR) was calculated using the random-effects model to explore the final pooled effect size of the included studies and determine whether PIPs increase the risk of CRN. Sensitivity analysis, subgroup analysis, and assessment of publication bias were performed to examine the sources of heterogeneity. RESULTS: Twelve studies with 5819 IBD patients, including 1281 (22.01%) with PIPs, were considered eligible for this meta-analysis. We found that IBD patients with PIPs were at an increased risk of CRN as compared to those without PIPs [OR 2.01; 95% confidence interval (CI): 1.43-2.83]. The results were similar when colorectal cancer was used as the study endpoint (OR 2.57; 95%CI: 1.69-3.91). Furthermore, the risk of CRN was still increased (OR 1.80; 95%CI: 1.12-2.91) when restricted to ulcerative colitis patients. Heterogeneity was high among the included studies (I² = 75%). Subgroup analysis revealed that the high heterogeneity was due to the study design. Sensitivity analysis showed that the main statistical outcomes did not essentially change after excluding any one of the included studies. No significant publication bias was found in the funnel plots. CONCLUSION: IBD patients with PIPs have an increased risk of CRN as compared with those without PIPs, which support the current guidelines. However, a high-quality randomized controlled trial is warranted.

Patients with inflammatory bowel disease and post-inflammatory polyps have an increased risk of colorectal neoplasia: A meta-analysis.

BACKGROUND: Longstanding intestinal inflammation increases the risk of colorectal neoplasia in patients with inflammatory bowel disease (IBD). Accurately predicting the risk of colorectal neoplasia in the early stage is still challenging. Therefore, identifying visible warning markers of colorectal neoplasia in IBD patients is the focus of the current research. Post-inflammatory polyps (PIPs) are visible markers of severe inflammation under endoscopy. To date, there is controversy regarding the necessity of strengthened surveillance strategies for IBD patients with PIPs. AIM: To determine whether IBD patients with PIPs carryan increased risk of colorectal neoplasia. METHODS: Researchers searched the following databases up to July 31, 2021: MEDLINE (PubMed), MEDLINE (Ovid), EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wan-Fang Data, China Science and Technology Journal Database and Chinese BioMedical Literature Database. Cohort and case-control studies that compared the risk of colorectal neoplasia between IBD patients with or without PIPs and published in English or Chinese were included. Methodological quality was assessed using the Risk of Bias in Nonrandomized Studies-of Interventions assessment tool. The outcomes of interest were the rates of various grades of colorectal neoplasia. The pooled risk ratio (RR) and 95% confidence interval (95%CI) were calculated using the random-effects model. Begg's test and Egger's test were used to calculate the publication bias. Sensitivity and subgroup analyses were performed to verify the robustness of the results. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess the overall quality of evidence supporting the outcomes of interest. RESULTS: Nine studies involving 5424 IBD patients (1944 with PIPs vs 3480 without PIPs) were included. The overall bias in each included study ranged from moderate to serious. Compared with nonconcurrent PIPs, patients with PIPs had a higher risk of colorectal neoplasia (RR = 1.74, 95%CI: 1.35-2.24, P < 0.001, I2 = 81.4%; aHR = 1.31, 95%CI: 1.01-1.70, P = 0.04, I 2 = 26.2%; aOR = 2.62, 95%CI: 1.77-3.88, P < 0.001, I 2 = 0%), advanced colorectal neoplasia (RR = 2.07, 95%CI: 1.49-2.87, P < 0.001, I 2 = 77.4%; aHR = 1.63, 95%CI: 1.05-2.53, P = 0.03, I 2 = 10.1%) and colorectal cancer (RR = 1.93, 95%CI: 1.32-2.82, P = 0.001, I 2 = 83.0%). Publication bias was not observed in Begg's test or Egger's test. Sensitivity and subgroup analyses showed that the results are robust. The overall quality of evidence was assessed as moderate to low. CONCLUSION: IBD patients with PIPs may have an increased incidence of colorectal neoplasia.

Surveillance of Gallbladder Polyps: A Literature Review.

Little has been documented in existing literature regarding incidentally found gallbladder (GB) polyps. These clinically asymptomatic lesions are mostly benign, with only 5% progressing to malignancy. GB cancer, although rare, presents as an end-stage incurable disease. According to the current guidelines, cholecystectomy is recommended for polyps >10 mm in size for a better outcome. Thus, it is essential to know the clinical picture, surveillance, and treatment of these polyps earlier in the course of the disease to avoid the advancement of polyps to malignancy. This paper discusses the signs and symptoms, surveillance, treatment, and prognosis of GB polyps.

Ultrasound Radiomics Effective for Preoperative Identification of True and Pseudo Gallbladder Polyps Based on Spatial and Morphological Features.

Purpose: To explore the value of ultrasound radiomics in the preoperative identification of true and pseudo gallbladder polyps and to evaluate the associated diagnostic accuracy. Methods: Totally, 99 pathologically proven gallbladder polyps in 96 patients were enrolled, including 58 cholesterol polyps (55 patients) and 41 gallbladder tubular adenomas (41 patients). Features on preoperative ultrasound images, including spatial and morphological features, were acquired for each lesion. Following this, two-stage feature selection was adopted using Fisher's inter-intraclass variance ratios and Z-scores for the selection of intrinsic features important for differential diagnosis achievement with support vector machine use. Results: Eighty radiomic features were extracted from each polyp. Eight intrinsic features were identified after two-stage selection. The contrast 14 (Cont14) and entropy 6 (Entr6) values in the cholesterol polyp group were significantly higher than those in the gallbladder adenoma group (4.063 ± 1.682 vs. 2.715 ± 1.867, p < 0.001 for Cont14; 4.712 ± 0.427 vs. 4.380 ± 0.720, p = 0.003 for Entr6); however, the homogeneity 13 (Homo13) and energy 8 (Ener8) values in the cholesterol polyp group were significantly lower (0.500 ± 0.069 vs. 0.572 ± 0.057, p < 0.001 for Homo13; 0.050 ± 0.023 vs. 0.068 ± 0.038, p = 0.002 for Ener8). These results indicate that the pixel distribution of cholesterol polyps was more uneven than that of gallbladder tubular adenomas. The dispersion degree was also significantly lower in the cholesterol polyp group than the gallbladder adenoma group (0.579 ± 0.054 vs. 0.608 ± 0.041, p = 0.005), indicating a lower dispersion of high-intensity areas in the cholesterol polyps. The long axis length of the fitting ellipse (Maj.Len), diameter of a circle equal to the lesion area (Eq.Dia) and perimeter (Per) values in the cholesterol polyp group were significantly lower than those in the gallbladder adenoma group (0.971 ± 0.485 vs. 1.738 ± 0.912, p < 0.001 for Maj.Len; 0.818 ± 0.393 vs. 1.438 ± 0.650, p < 0.001 for Eq.Dia; 2.637 ± 1.281 vs. 5.033 ± 2.353, p < 0.001 for Per), demonstrating that the cholesterol polyps were smaller and more regular in terms of morphology. The classification accuracy, sensitivity, specificity, and area under the curve values were 0.875, 0.885, 0.857, and 0.898, respectively. Conclusions: Ultrasound radiomic analysis based on the spatial and morphological features extracted from ultrasound images effectively contributed to the preoperative diagnosis of true and pseudo gallbladder polyps and may be valuable in their clinical management.

Does the Presence of Giant Pseudopolyps in a Patient with Newly Diagnosed Inflammatory Bowel Disease Increase the Risk of Major Thrombotic Events?

Giant inflammatory polyp and thromboembolism are uncommon complications in inflammatory bowel disease (IBD) patients. Colon mucosal inflammation is possibly the main mechanism of pathogenesis for these two complications. IBD has long been associated with hypercoagulability and thromboembolism. In fact, thromboembolism has been noted in 0.7% to 7.7% of IBD patients, with the deep veins of the legs and the pulmonary veins accounting for 90% of the cases. The proposed mechanism of this hypercoagulability involves the promotion of hemostasis that results from the inflammatory process underlying the IBD, as well as the loss of proteins, including antithrombotic factors, resulting from the inflamed bowel and increased permeability of the colonic mucosa. This process may be exacerbated by the presence of giant inflammatory polyps, which are defined as polyps in the setting of IBD with dimensions greater than 1.5 cm. The presence of these polyps leads to an increase in inflamed colonic surface area, which can accelerate the rate of protein loss, leading to an increased incidence of thrombosis. Here, we report the case of a 21-year-old female with inferior vena cava and left renal vein thromboses secondary to a newly diagnosed IBD and the presence of severe giant inflammatory polyposis. These thromboses were detected incidentally in this patient after 1 week of hospitalization. She had presented with hypoalbuminemia and elevated inflammatory markers, which raised the suspicion for possible giant inflammatory polyposis as a potential risk for her major thromboembolic events. More studies are required to explore this plausible correlation further.

Reclassifying Pseudopolyps in Inflammatory Bowel Disease: Histologic and Endoscopic Description in the New Era of Mucosal Healing.

INTRODUCTION: In this study, we identify the frequency of pseudopolyps (PPs) with normal histology and their association to surrounding tissue. METHODS: Patients were enrolled in a study identifying endoscopic characteristics of PPs (n = 29) or were collected as part of our IBD biobank (n = 16). Statistical analysis included Stata v.15.0. chi-square and Student t-test. RESULTS: A total of 45 patients with 117 PP biopsies were identified. More patients with healed PP were in endoscopic remission compared with those with inflammatory PP (82.6% vs 17.4%, respectively). CONCLUSION: This is the first study to find mucosal healing of PPs and its association with deep remission.

Has the time been reached for pseudopolyps to be re-enrolled in endoscopic inflammatory bowel disease scores?

Patients with inflammatory bowel diseases (IBD) represent heterogeneous groups with different characteristics and different clinical course. A great deal of effort is made to discover proxies for more severe disease needing more intense treatment and early intervention to gain the maximum therapeutic benefit. Endoscopy remains an invaluable method in assessment of patients with IBD. Pseudopolyps are often encountered during endoscopy and, although they are a well described entity, their presence is of unclear importance. In one of our recent studies and in conjunction with one study with a large cohort of patients with IBD and pseudopolyps, patients with pseudopolyps were found to face a higher inflammatory burden in terms of receiving more intense biological treatment. This letter comes as a comment and proposition regarding the concept of re-evaluation of pseudopolyps as a promising marker in IBD scores.

Presence of pseudopolyps in ulcerative colitis is associated with a higher risk for treatment escalation.

BACKGROUND: Pseudopolyps in ulcerative colitis (UC) are considered as indicators of previous episodes of severe inflammation and ulceration of the mucosa. The aim of the study was to investigate the long-term outcomes of patients treated for UC, with or without pseudopolyps. METHODS: This was a retrospective single-center study. Consecutive patients with UC and available endoscopic data from 2000 until 2016 were eligible for the study and were followed until June 2017. Patients with incomplete medical/endoscopic charts or interrupted follow up were excluded from the study. Primary outcomes included time to treatment escalation, treatment escalation to biological agents or surgery, and UC-related hospitalization. RESULTS: Eighty-three UC patients were included in the study, of whom 25 (30%) had pseudopolyps. The median duration of follow up was 2.8 years (interquartile range: 1.1-4.9). Multiple Cox regression analysis identified the presence of pseudopolyps as the only variable independently associated with treatment escalation (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.2-4.3; P=0.014) and escalation to biological agents or surgery (HR 6.3, 95%CI 1.9-20.7; P=0.002). CONCLUSION: This retrospective single-center study provides the first preliminary evidence that patients with UC and pseudopolyps may represent a subpopulation with a higher inflammatory burden and a greater need for treatment escalation, including to biological agents or surgery. Large, prospective multicenter studies are certainly warranted to confirm these findings.

[Rectal giant inflammatory pseudopolyps : an unusual cause of rectal bleeding]. / Pseudo-polypes inflammatoires géants du rectum : une cause rare de rectorragies.

Giant inflammatory pseudopolyps are begnin lesions that have been described usually in patients with inflammatory bowel disease. Rarely, they have been reported in patient without any colonic disease. We report the case of a 40-old woman, without previous colonic pathology, who presented with rectal giant inflammatory pseudopolyps revealed by rectal bleeding.

Les pseudo-polypes inflammatoires géants sont des tumeurs bénignes du tube digestif. Ils ont principalement été décrits chez les malades atteints de maladie inflammatoire chronique de l'intestin. Exceptionnellement, ils ont été rapportés chez des patients n'ayant aucune pathologie digestive. Nous rapportons l'observation d'une patiente de 40 ans, présentant de multiples pseudo-polypes inflammatoires géants du rectum, en l'absence de toute autre pathologie colorectale, révélés par des rectorragies.

Pseudopolyps in inflammatory bowel diseases: Have we learned enough?

Pseudopolyps are a well described entity in the literature and even though the exact pathogenesis of their formation is not completely understood, they are considered non-neoplastic lesions originating from the mucosa after repeated periods of inflammation and ulceration associated with excessive healing processes. Their occurrence is less common in Crohn's disease than in ulcerative colitis, and their overall prevalence ranges from 4% to 74%; moreover, they are found more often in colon but have been detected in other parts of the gastrointestinal tract as well. When their size exceeds the arbitrary point of 1.5 cm, they are classified as giant pseudopolyps. Clinical evaluation should differentiate the pseudopolyps from other polypoid lesions, such as the dysplasia-associated mass or lesion, but this situation represents an ongoing clinical challenge. Pseudopolyps can provoke complications such as bleeding or obstruction, and their management includes medical therapy, endoscopy and surgery; however, no consensus exists about the optimal treatment approach. Patients with pseudopolyps are considered at intermediate risk for colorectal cancer and regular endoscopic monitoring is recommended. Through a review of the literature, we provide here a proposed classification of the characteristics of pseudopolyps.

Pólipos postinflamatorios y enfermedad inflamatoria intestinal: Reporte de caso y revisión de la literatura / Literature Review and Case Report of Post-Inflammatory Polyps and Inflammatory Bowel Disease

En pacientes con enfermedad inflamatoria intestinal (EII) de larga duración, pueden aparecer pólipos postinflamatorios o seudopólipos, los cuales se presentan en los sitios en donde previamente hubo inflamación severa. Se describe el caso de un paciente con colitis ulcerativa de 5 años de evolución, en quien se encontró una poliposis postinflamatoria generalizada durante la colonoscopia de control. Se hace una revisión del significado de esta alteración, su clasificación y de su tratamiento.

Post-inflammatory polyps or “pseudopolyps” may occur in patients who have long-term inflammatory bowel disease (IBD). They occur at sites where severe inflammation had previously occurred. We describe the case of a patient who had suffered from ulcerative colitis for five years when generalized post-inflammatory polyposis was discovered during a follow-upl colonoscopy. We review the meaning of this condition as well as its classification and treatment

Filiform polyps and filiform polyp-like lesions are common in defunctioned or diverted colorectum resection specimens.

We describe filiform polyps (FPs) in a series of defunctioned rectums with diversion colitis. A 6-year search of all defunctioned rectal resection specimens revealed 8 cases with 17 macroscopically observed FPs. They occurred in 4 females and 4 males aged between 12 and 64 years. Four had defunctioning colostomies for ulcerative colitis, 3 for Crohn disease and 1 for diverticular disease. Multiple lesions were seen in 6 of 8 cases: 1 case having 4 FPs, 1 patient with 3 lesions, and 4 cases with 2 lesions. The FP varied in length from 4 to 11 mm; mean length was 7.8 mm. No evidence of mucosal prolapse was seen in any of the polypoid lesions. In 65 cases without grossly observed polypoid lesions, prominent mucosal polypoid projections in keeping with FP were seen in 47 cases. These were observed in nonulcerated sections and were histologically identical to the 17 macroscopically observed FPs ranging from 3 to 8 mm, and 3 to 5 such polypoid lesions were seen in 20 cases. We suggest that FP and FP-like lesions are commonly encountered in defunctioned resection specimens.

Filiform Polyposis in Non-Inflammatory Bowel Disease: A clinicopathologic analysis of five cases / 대한소화기내시경학회지

Filiform polyposis(FP), an unusual form of inflammatory polyposis, has been recently designated to a lesion characterized by multiple, long slender, finger-like projections of mucosa and submucosa of the gastrointestinal tract. We present 5 cases of FP, of which two were associated with irritable bowel syndrome, two with advanced colon carcinoma, and one with active ileotyphlitis(Behcet's disease). The polyps ranged from 1.0 cm to 3 cm; they were either isolated or aggregated, and their numbers were up to 100. The common microscopic feature was filiform polyps which consisted of central submucosal core covered by intact or minimally inflamed intestinal mucosa, comparable with that in reparative processes and formation of inflammatory(redundant) pseudopolyps. We conclude that awareness of FP in non-inflammatory bowel disease may promote the endoscopists to search its underlying disease and prevent unnecessary surgical procedure. Behcets enterocolitis in the ileocecal junction seems an additional preceding disorder of a localized form of FP.