Juvenile Polyp

A 2-year-old girl presents to the pediatric emergency department (ED) for evaluation of a fleshy mass protruding from her rectum. The mass, which had been present for 1 day, protruded spontaneously and not during defecation. There is no history of cough, constipation, diarrhea, vomiting, weight loss, or parasitic or chronic disease. However, the child has been having episodic, painless bleeding during the past month. There is no family history of GI disease.

The 1 × 2-cm red, friable, non-tender mass that protrudes from the rectum of this child is a juvenile polyp, writes Raja Mouallem, MD, of Louisiana State University Health Sciences Center, department of pediatric emergency medicine, in New Orleans. It is attached by a thick stalk to the lateral wall of the rectum.

The mass was removed by a surgeon in the ED; there were no complications. The pathology report was consistent with a diagnosis of juvenile retention polyp with hemorrhage and acute inflammation. There was no evidence of malignancy.

The incidence of juvenile polyps in asymptomatic children is 1%; this condition is more common among children between 2 and 10 years old.¹ Approximately 40% of polyps are found in the rectum or sigmoid colon; the remaining 60% are evenly distributed throughout the proximal colon. The cause is unknown. Typically, these polyps present with painless bright red rectal bleeding, which can cause iron deficiency anemia in about 30% of patients.² Less common presentations include a protruding rectal mass and abdominal pain.

The differential diagnosis includes Meckel diverticulum, intussusception, infectious diarrhea, anal fissure, hemorrhoid, Henoch-Schnlein purpura, and inflammatory bowel disease. The absence of abdominal pain in this patient and the otherwise normal physical examination made these less likely considerations.

The photograph shows a doughnut-shaped mass, which makes rectal prolapse a possibility. However, the fact that the lesion was pedunculated suggested a prolapsed polyp-as did its dark beefy red color.

In general, the diagnosis of juvenile polyps is by pancolonoscopy, which is both diagnostic and therapeutic and is preferred over contrast enema examination.³

Polypectomy can be safely performed by sigmoidoscopy or colonoscopy; the diagnosis can then be confirmed histologically. A juvenile polyp is considered a benign hamartomatous or inflammatory growth with a low risk of malignancy so long as there are only 1 or 2 polyps and if there is no family history of cancer.4 An air-contrast barium enema is indicated to determine whether additional and more proximal polyps are present. When the air-contrast barium enema does not provide a sufficient view of the entire colon, colonoscopy should be performed.

In one study, 18% of children who had undergone pan-colonoscopy examination for juvenile polyps had 5 or more lesions.3 The risk of malignancy is greater if the child has more than 3 to 5 polyps or when there is a family history of juvenile polyposis or other polyposis syndrome.

REFERENCES:1. Winter SH. Intestinal tumor: one intestinal polyp. In: Walker WA, Durie PR, Walker-Smith JA, Watkins JB, eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. 3rd ed. Hamilton, Ontario: BC Decker; 2000:799-800.
2. Shilyansky J. Tumors of the digestive tract. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia: WB Saunders Co; 2004:1289-1299.
3. Corredor J, Wambach J, Barnard J. Gastrointestinal polyps in children: advances in molecular genetics, diagnosis, and management. J Pediatr. 2001;138:621-628.
4. Nugent KP, Talbot IC, Hodgson SV, Phillips RK. Solitary juvenile polyps: not a marker for subsequent malignancy. Gastroenterology. 1993;105:698-700.