EP293 - Diagnosis and Management of a Giant Filiform Pseudopolyp in Crohn’s Disease: A Case Report and Review of the Literature.

Purpose/Background: Inflammatory pseudopolyps or post inflammatory polyps (PIPs) are polypoid mucosal tags found in the bowel in cases of inflammatory bowel disease. Known to be fairly uncommon, found in 10-20% of patients with IBD with a 2:1 ratio of rates seen in UC: CD. They are thought to be the result of the repetitive inflammatory process during IBD attacks with inflammatory phase, followed by healing of inflammation, with polypoid configuration of tissue during regenerative phase as the ulcerated mucosa of the bowel becomes surrounded by granulation tissue. Giant PIPs, defined as size >15mm, are even more rare, with reported incidence of 4.6%. The presence of PIPs in IBD suggests prior severe inflammation and increased risk of disease burden which is an intermediate risk for CRC and requires increased surveillance. Direct malignant transformation of PIPs is unlikely, but case control studies suggest 1.0-2.5 fold increased CRC risk if noted to have a PIP so more frequent colonoscopy surveillance is generally recommended. Medical treatment with immunomodulating agents can lead to regression and endoscopic treatment is considered in symptomatic lesions. Surgical resection is an option when more conservative options fail or if there is concern that the lesion is malignant.

Methods/Interventions: We present a 33-year-old female with a history of CD managed on infliximab then vedolizumab. She had a screening colonoscopy 10 months after her diagnosis, which was significant for a 4cm polyp in the descending colon which could not be traversed with colonoscope. Biopsy was consistent with a PIP and was categorized as a giant PIP. She was counseled on recommendations for colon resection for polyp removal given its large size and risk of it becoming obstructing.

She was preoperatively optimized with the Enhanced Recovery After Surgery (ERAS) standard protocol. She underwent laparoscopic left hemicolectomy. Intraoperatively, the mid-descending colon was notably inflamed, and a tattoo from the endoscopy was appreciated distal to the area of inflammation. There were no intra-operative or post-operative complications, and she progressed well on ERAS pathway with discharge on post-operative day 2.

Results/Outcomes: PIPs are a rare complication of IBD with giant PIPs reportedly seen in 4.6% of cases which suggests severe recurrent bouts of inflammation. Though it is more commonly seen in UC, we present a unique case of a 33-year-old female with CD and an asymptomatic giant filiform PIP found on screening colonoscopy who underwent resection. Surgical management was chosen given that the PIP would not be amendable to endoscopic resection given inability to traverse with colonoscope, as well as concern for eventual obstruction given its size. In this patient in particular, she had only been diagnosed with her inflammatory bowel disease for 2 years prior to discovery of this giant PIP which suggests the severity of her disease in this area.

Conclusion/Discussion: There is a scarcity of information on PIPs in the literature, and it is an important, yet rare, marker indicating the severity of IBD. Alone, the polyps are not malignant and have low malignant transformation potential, but it is essential that we have appropriate understanding of the pathophysiology of these lesions which gives us insight into the disease severity of the patient and triggers us to shorten the interval of their surveillance colonoscopies as well as optimize their medical management.

Colonoscopy
Polypoid lesion found in the descending colon.

Gross Specimen
The opened specimen revealing polyp with ruler placed for measurement of polyp which is approximately 4 cm length extending into colon lumen.