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Video Case Report| Volume 2, ISSUE 4, P85-87, April 01, 2017

Mucosubmucosal elongated colonic polyp

Open AccessPublished:March 05, 2017DOI:https://doi.org/10.1016/j.vgie.2017.01.014
Mucosubmucosal elongated colonic polyp
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      A 78-year-old man presented for elective outpatient colonoscopy at the recommendation of his primary care provider. He had a history of adenomatous colon polyps, with 2 tubular adenomas, 3-mm to 4-mm, found on prior colonoscopy 9 years previously, and was overdue for surveillance. He was otherwise asymptomatic, without change in bowel habits, weight loss, hematochezia, melena, iron-deficiency anemia, or abdominal pain. The patient’s other medical history included right bundle branch block and palpitations, chronic cervicalgia, depression, erectile dysfunction, obstructive sleep apnea, and subacute cutaneous lupus erythematosus thought to be secondary to bupropion, which had resolved after discontinuation of the medication. The patient was taking a daily baby aspirin, multivitamin, and omega-3 fish oil and was using an ocular lubricant at the time of the procedure. He had no known allergies. There was no familial history of colorectal polyps or cancer.
      Colonoscopy demonstrated nonthrombosed external hemorrhoids and a few small-mouthed and large-mouthed diverticula in the sigmoid and descending colon (Video 1, available online at www.VideoGIE.org). A 12-mm elongated, pedunculated polyp was found in the ascending colon (Figure 1, Figure 2, Figure 3). A single-use ligating device (PolyLoop, Olympus Corporation, Tokyo, Japan) was maneuvered over the polyp stalk and was closed at the mucosal attachment base before removal to reduce the likelihood of postpolypectomy bleeding (Fig. 4). After the PolyLoop maneuver, the polyp was resected with a hot snare (Boston Scientific, El Coyol, Alajuela, Costa Rica) (Fig. 5), and retrieval was accomplished with a Roth Net (US Endoscopy, Mentor, Ohio) (Fig. 6).
      Figure thumbnail gr1
      Figure 1A 12-mm elongated, pedunculated, “wormlike” polyp in the ascending colon.
      Figure thumbnail gr2
      Figure 2A 12-mm elongated, pedunculated, “wormlike” polyp in the ascending colon, lifted with biopsy forceps.
      Figure thumbnail gr3
      Figure 3Another view of the 12-mm elongated, pedunculated, “wormlike” polyp in the ascending colon.
      Figure thumbnail gr4
      Figure 4Endoloop maneuver performed over the polyp stalk and closed at the base.
      Figure thumbnail gr5
      Figure 5Polyp resected with 13-mm hot snare distal to endoloop location.
      Figure thumbnail gr6
      Figure 6After resection, the polyp was retrieved with a 3-cm × 6-cm Roth net.
      Pathologic examination revealed a 12-mm elongated polyp with prominent submucosal elements, without features of dysplasia (Figs. 7 and 8). The findings were consistent with a colonic mucosubmucosal elongated polyp, a rare, distinctive, nonneoplastic, noninflammatory colorectal polyp. These polyps are elongated and pedunculated, sometimes referred to as having a “wormlike” appearance.
      • Tan C.L.
      • Tan S.H.
      • So J.B.
      • et al.
      Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature.
      World J Gastroenterol. 2013; 19: 1845-1849
      As the name implies, the defining histologic features include nondysplastic mucosa overlying an elongated core of submucosa, with loose collagenous stroma and sometimes containing dilated vessels and lymphatics. Adipose tissue or muscle layers are typically absent or at least not a dominant component.
      • Matake H.
      • Matsui T.
      • Yao T.
      • et al.
      Long pedunculated colonic polyp composed of mucosa and submucosa: proposal of a new entity, colonic muco-submucosal elongated polyp.
      Dis Colon Rectum. 1998; 41: 1557-1561
      These polyps have normal mucosa lining them without significant inflammatory components.
      • Tan C.L.
      • Tan S.H.
      • So J.B.
      • et al.
      Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature.
      World J Gastroenterol. 2013; 19: 1845-1849
      , 
      • Alizart M.M.
      • Rosty C.
      • Brown I.S.
      Colonic mucosubmucosal elongated polyp: a clinicopathologic study of 13 cases and review of the literature.
      Am J Surg Pathol. 2011; 35: 1818-1822
      Figure thumbnail gr7
      Figure 7Low magnification showing an elongated polyp lined by nondysplastic colonic mucosa with normal architecture (H&E, orig. mag. ×1.25).
      Figure thumbnail gr8
      Figure 8Higher magnification showing the polyp stalk to be composed of submucosal elements such as adipocytes, connective tissue, and medium-sized muscular vessels. The muscularis mucosae is clearly visible at the base of the colonic crypts (H&E, orig. mag. ×10).
      The majority are found incidentally, most commonly in the large bowel.
      • Tan C.L.
      • Tan S.H.
      • So J.B.
      • et al.
      Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature.
      World J Gastroenterol. 2013; 19: 1845-1849
      , 
      • Alizart M.M.
      • Rosty C.
      • Brown I.S.
      Colonic mucosubmucosal elongated polyp: a clinicopathologic study of 13 cases and review of the literature.
      Am J Surg Pathol. 2011; 35: 1818-1822
      Case series have found their sizes to range from 10 mm to 160 mm, with an elongated shape. No correlation with sex, age, or subjective symptoms has been identified. The etiologic factors are uncertain, but they are benign and rarely cause any clinical concern.
      • Tan C.L.
      • Tan S.H.
      • So J.B.
      • et al.
      Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature.
      World J Gastroenterol. 2013; 19: 1845-1849
      , 
      • Alizart M.M.
      • Rosty C.
      • Brown I.S.
      Colonic mucosubmucosal elongated polyp: a clinicopathologic study of 13 cases and review of the literature.
      Am J Surg Pathol. 2011; 35: 1818-1822
      Endoloops (Endoloop, Olympus), or PolyLoops, are detachable ligating devices that are placed at the base of large polyps to prevent bleeding after removal of a lesion. The technique is similar to placing a tourniquet around the stalk of the polyp in such a fashion as to tamponade any vessels that may be present.
      • Boujaoude J.
      • Honein K.
      • Hobeika E.
      • et al.
      Endoscopic resection of large pedunculated colonic polyps using Endoloop. Three case reports and review of the literature [in French with English abstract].
      J Med Liban. 2006; 54: 221-224
      , 
      Rastogi SMaA
      Endoloop-assisted polypectomy technique.
      Video J Encyclopedia GI Endosc. 2012; 13: 323-324
      This technique may be used prophylactically during the removal of large, pedunculated polyps, and it has been demonstrated to reduce the rate of postpolypectomy bleeding.
      • Di Giorgio P.
      • De Luca L.
      • Calcagno G.
      • et al.
      Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study.
      Endoscopy. 2004; 36: 860-863
      , 
      • Katsinelos P.
      • Kountouras J.
      • Paroutoglou G.
      • et al.
      Endoloop-assisted polypectomy for large pedunculated colorectal polyps.
      Surg Endosc. 2006; 20: 1257-1261

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      • Download .mp4 (62.57 MB)
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        Video 1

        Colonoscopy video of a 12-mm mucosubmucosal elongated colonic polyp, with demonstration of ligation device and hot snare removal.

      References

        • Tan C.L.
        • Tan S.H.
        • So J.B.
        • et al.
        Muco-submucosal elongated polyps of the gastrointestinal tract: a case series and a review of the literature.
        World J Gastroenterol. 2013; 19: 1845-1849
        View in Article
        • Matake H.
        • Matsui T.
        • Yao T.
        • et al.
        Long pedunculated colonic polyp composed of mucosa and submucosa: proposal of a new entity, colonic muco-submucosal elongated polyp.
        Dis Colon Rectum. 1998; 41: 1557-1561
        View in Article
        • Alizart M.M.
        • Rosty C.
        • Brown I.S.
        Colonic mucosubmucosal elongated polyp: a clinicopathologic study of 13 cases and review of the literature.
        Am J Surg Pathol. 2011; 35: 1818-1822
        View in Article
        • Boujaoude J.
        • Honein K.
        • Hobeika E.
        • et al.
        Endoscopic resection of large pedunculated colonic polyps using Endoloop. Three case reports and review of the literature [in French with English abstract].
        J Med Liban. 2006; 54: 221-224
        View in Article
        • Rastogi SMaA
        Endoloop-assisted polypectomy technique.
        Video J Encyclopedia GI Endosc. 2012; 13: 323-324
        View in Article
        • Di Giorgio P.
        • De Luca L.
        • Calcagno G.
        • et al.
        Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study.
        Endoscopy. 2004; 36: 860-863
        View in Article
        • Katsinelos P.
        • Kountouras J.
        • Paroutoglou G.
        • et al.
        Endoloop-assisted polypectomy for large pedunculated colorectal polyps.
        Surg Endosc. 2006; 20: 1257-1261
        View in Article

      Article Info

      Publication History

      Published online: March 05, 2017

      Footnotes

      Written transcript of the video audio is available online at www.VideoGIE.org.

      Identification

      DOI: https://doi.org/10.1016/j.vgie.2017.01.014

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      © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.

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