Ulcerative Colitis With Pseudopolyps

For 6 weeks, a 29-year-old previously healthy man had between 10 and 15 episodes daily of small-volume bloody diarrhea with intermittent paraumbilical pain. Anorexia and the loss of 25 lb accompanied the diarrhea. The patient had no significant medical history, took no medications, had not traveled recently, and had no contact with sick persons. He denied fever, chills, nausea, vomiting, and all other symptoms. Major Chad M. Sisk, DO, United States Army, Fort Sam Houston, Tex, writes that the mildly cachectic, alert, and oriented patient was in no acute distress. The paraumbilical area and the left lower quadrant were slightly tender to palpation; there was no guarding, rebound, or peritoneal signs. Rectal examination revealed bright red blood with no visible stool; hemorrhoid disease and other anorectal pathology were absent. Laboratory results were normal except for a mild normocytic anemia; serum hematocrit was 36% (normal level, 42% to 48%). The stool culture revealed no ova or parasites, amebae, or Clostridium difficile toxin; however, the stool was guaiac-positive, and fecal leukocytes were found. Initial treatment in the hospital consisted of intravenous fluid hydration, dietary restriction, and supportive care. A colonoscopy revealed diffuse ulceration with loss of vascularity and mucosal surfaces that extended from the rectum to the cecum. Pseudopolyps (A, arrows; B, arrow)-distinct, irregular, raised areas of normal-appearing mucosa-were noted among the areas of friability, fibrous stranding, and ulceration. The terminal ileum appeared to be normal. Multiple biopsies revealed the acute and chronic inflammation and architectural distortion of ulcerative colitis. Pseudopolyps, which represent a combination of reactive hyperplasia and mucosal ulceration, are not an uncommon finding in severe or chronic ulcerative colitis. The histologic structure of these growths is inflammatory, not dysplastic. Typically, pseudopolyps are seen in patients who have had a severe episode of ulcerative colitis; they may also be found in patients with other colitides and in those with long-term disease.¹ Pseudopolyps occur most commonly in the rectosigmoid and left colon and may coexist with adenomatous polyps. The frequency of pseudopolyp development is unknown; however, researchers in one study found the growths in 14.9% of their patients with ulcerative colitis.² Other studies have shown that as many as 20% of patients are affected. This patient initially responded to mesalamine and prednisone therapy; however, very frequent episodes of bloody diarrhea returned within 2 weeks. A trial of infliximab and azathioprine failed to ameliorate the condition. A colectomy was performed; the patient's recovery was uneventful. At the 6-month follow-up, he had no GI complaints and had regained the lost weight.