Multiple Rectal Polyps in a Young Woman with Constipation

A 27-year-old Asian-American woman presented for evaluation of long-standing constipation. Her first severe episode of constipation occurred at age 7 and resolved with colonic lavage. Colonoscopy at that time was normal. She then experienced complete resolution of her symptoms from ages 7 to 17, when she started again experiencing defecatory difficulties with infrequent and hard stools, difficulties with evacuation, and a sensation of incomplete rectal emptying. On presentation in July 2009, she was dependent on two Senna pills per day; without them, she would not have a bowel movement for up to 1 week. She also reported episodes of rectal bleeding or blood in toilet paper, and abdominal bloating and pain that were relieved with bowel evacuation, as well as continuous and severe straining at evacuation with a feeling of incomplete evacuation. She did not, however, use finger manipulations to facilitate defecation. Her past medical and surgical history was negative and she was using no other medications except for oral contraceptives and multivitamins. She was single, worked as a program manager, lived with her boyfriend, and exercised 3–4 times/week. She did not smoke cigarettes, and drank wine socially. She was vaccinated against human papillomavirus (HPV). Family history was significant for her mother having lung cancer and her father with diabetes mellitus; she had one healthy sister. Upon further review of systems, she reported 8 lbs of weight gain, general fatigue, headaches, and mild anxiety. Her physical examination was normal except for small external hemorrhoids. Complete blood count, comprehensive chemistry panel, and thyroid function tests were all normal. On initial assessment of her constipation, a lactulose breath test was negative. A colon transit study using Sitzmarks was normal. An anorectal motility and compliance study showed a normal anal sphincter length of 5 cm, a normal internal anal sphincter pressure of 72 mmHg, and a slightly decreased external anal sphincter pressure of 91 mmHg. Rectal sensation was impaired since she barely sensed a rectal balloon filled with 50 cc of water. The anorectal inhibitory reflex was present and elicited with 30 cc of balloon distention, thereby excluding Hirschsprung’s disease. Rectal compliance was normal, but she was unable to expel an empty rectal balloon, which was suggestive of pelvic floor dysfunction. Colonoscopy revealed multiple inflammatory polyps in the rectal vault extending circumferentially to the anorectal junction. Biopsies of the polyps were performed and were associated with significant oozing that required control with application of hemostatic clips (Fig. 1). Pathologic examination of the polyp biopsies revealed six separate fragments of rectal mucosa. Five of these fragments showed polypoid hyperplastic mucosa with areas of ulceration, consistent with rectal prolapse. One of these fragments showed an area of moderate squamous epithelial dysplasia (AIN 2). No evidence of an invasive lesion was identified (Fig. 2). Despite her previous vaccination history, HPV immunohistochemistry was positive. She was then treated with polyethylene glycol twice daily for the next 3 months with some improvement of her G. Triadafilopoulos (&) Division of Gastroenterology and Hepatology, Stanford University Medical Center, Alway Building, Room M 211, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: vagt@stanford.edu