Rectal Pyogenic Granuloma in a Child With Hematochezia

A previously healthy 8-year-old girl presented with a 2-week history of painless rectal bleeding. She also reported hard stools with associated straining, pain, and rectal prolapse during defecation. She denied fever or weight loss. There was no personal or family history of inflammatory bowel disease or polyps.

Results of a guaiac fecal occult blood test were positive. Physical examination findings, including rectal examination, were unremarkable.

Colonoscopy revealed a 0.6 × 0.5 × 0.4-cm polypoid lesion in the rectum (A), which was removed via snare polypectomy. Histologic evaluation yielded a polyp that was largely denuded of epithelial lining, with edematous stroma and prominent vascular proliferation (B). Heavy lymphoplasmacytic infiltrate with scattered eosinophils and neutrophils, particularly toward the surface, was noted.

After polyp removal, the girl remained asymptomatic until 8 months later, when rectal bleeding recurred. She underwent a second colonoscopy and polypectomy; pathology revealed similar findings, consistent with pyogenic granuloma.

Pyogenic granuloma is a polypoid form of capillary hemangioma resembling granulation tissue. Histopathologic characteristics include proliferation of capillary-sized vessels arranged in a distinctive lobular pattern, associated with an inflamed and edematous stroma, with or without ulceration on the surface.¹ Solitary pyogenic granulomas comprise 0.5% of all skin nodules in children and most commonly are found on the skin and in the oral or nasal mucosa.²

Rarely, a pyogenic granuloma occurs in the gastrointestinal (GI) tract.³ GI pyogenic granuloma shares macroscopic and histologic features with pyogenic granuloma of the skin.³ To date, 25 cases of GI pyogenic granuloma have been documented in adults.¹ Very few cases have been reported in children.^2,4-6

GI bleeding is the primary presentation in most patients.⁷ Although the exact pathogenesis is unknown, predisposing factors such as trauma, infection, and pregnancy have been suggested.^1,2,6,7

Characteristic macroscopic features seen via endoscopy include exophytic, protruding, polypoid, or pedunculated lesions with or without superficial erosions. Secondary to the copious proliferation of blood vessels, the overlying mucosa appears red.⁷ Pathologic examination is needed for a definitive diagnosis.

Definitive treatment is endoscopy with polypectomy or surgical resection, since this benign lesion is not known to recur or to undergo malignant transformation.

Although most children presenting with chronic lower GI bleeding receive a diagnosis of colorectal polyps, pyogenic granuloma must be included in the differential diagnosis.

References

1. Carmen Gonzáles-Vela M, Fernando Val-Bernal J, Francisca Garijo M, García-Suárez C. Pyogenic granuloma of the sigmoid colon. Ann Diagn Pathol. 2005;9(2):106-109.

2. Blanchard SS, Chelimsky G, Czinn SJ, Redline R, Splawski J. Pyogenic granuloma of the colon in children. J Pediatr Gastroenterol Nutr. 2006;43(1):119-121.

3. Hirakawa K, Aoyagi K, Yao T, Hizawa K, Kido H, Fujishima M. A case of pyogenic granuloma in the duodenum: successful treatment by endoscopic snare polypectomy. Gastrointest Endosc. 1998;47(6):538-540.

4. Serban DE, Florescu P. Colonic pyogenic granuloma in children: a rare or rarely recognized entity. Am J Gastroenterol. 2003;98(9):2106-2107.

5. Veres G, Lukovich P, Győrffy H. Pyogenic granuloma. J Pediatr Gastroenterol Nutr. 2011;52(1):1.

6. Mandhan P. Sigmoidoscopy in children with chronic lower gastrointestinal bleeding. J Paediatr Child Health. 2004;40(7):365-368.

7. Chen TC, Lein JM, Ng KF, Lin CJ, Ho YP, Chen CM. Multiple pyogenic granulomas in sigmoid colon. Gastrointest Endosc. 1999;49(2):257-259.