Cap Polyposis: Can the Problem of Recurrent Rectal Bleeding Be Solved?

A previously healthy 9-year-old girl was admitted due to a year-long history of recurrent presence of blood and mucus in the stool preceded with abdominal pain in lower abdominal quadrants. She had regular bowel movements, and the stools were of normal consistency. The patient was afebrile, well, and gaining weight steadily. Apart from her grandfather who had a colorectal carcinoma, no other significant family history of gastrointestinal diseases was recorded. She was previously evaluated in another hospital due to her symptoms; rectoscopy was performed 4 times with macroscopical findings always indicating proctitis. The patient was prescribed mesalamine suppositories for 6 months, but the therapy was ineffective. Upon admission to our tertiary pediatric gastroenterology unit, the patient appeared to be well, but experienced daily presence of blood and mucus in stools. Apart from 2 anal fissures, physical examination was deemed unremarkable, and the results of laboratory investigations were normal with calprotectin level being 78.9 mg/kg. Infectious cause of the symptoms was deemed unlikely due to the negative results of coproculture. Helicobacter pylori antigen in the stool sample was negative. Colonoscopy was performed and revealed only the aforementioned anal fissures disjoined by a polypoidlike mucosal prolapse. The girl was prescribed lactulose; however, the episodes of rectal bleeding persisted, and the patient was re-admitted after 18 months. During the digital rectal examination, polypoid mass was detected. Laboratory investigations’ results were once again normal. Complete colonoscopy was repeated and 2 irregularly shaped, grape-like, sessile polyps were identified in the rectum. The polyps’ sizes were 1.3 × 1 × 0.8 cm3 and 2.7 × 1 × 0.8 cm3, respectively. Microscopically, both polyps were composed of connective stroma permeated with inflammatory cells and erythrocytes as well as of partly tubular, elongated, and partly cystically dilated glands lined with dentate epithelium. The surface of the polyps was partially covered with the multilayered squamous epithelium, but was for the most part ulcerated, covered with abundant granulation tissue permeated with inflammatory infiltrate (Figure 1). The histological findings primarily corresponded with the inflammatory cap polyps.