Gastrointestinal polyps and polyposis syndromes in children

Colonoscopic finding in children with lower gastrointestinal complaints

Background and Aim

Colonoscopy is an important tool for the diagnosis and treatment of lower gastrointestinal (LGI) diseases in both children and adults. This study describes an endoscopic profile of children at the Shinnwari Gastroenterology Diagnostic Clinic in Jalalabad, Afghanistan.

Methods

This is a cross-sectional descriptive study conducted in children ≤16 years, taken from recorded colonoscopy reports from 1 January 2021 to 30 December 2022.

Results

Of the 672 colonoscopy procedures, 250 were diagnostic in children (7.41 years median age; 2.5:1 male/female ratio) without serious complications. Abnormal findings were recorded in 201 (81.2%) procedures; the most common presentation was hematochezia, which was higher in 5-8-year-olds. More frequent findings were colorectal polyps (50%), infection (16.4%), internal hemorrhoid (IH; 10%), and inflammatory bowel disease (IBD; 1.2%). Incidences of colorectal polyps were higher in those aged <9 years (37.2% vs 12.8%; P < 0.001). Conversely, internal IH and IBD tended to be higher in older children (aged ≥9 years) (IH: 6.8% vs 3.2%; P < 0.005; IBD: 1.2% vs 0%; P < 0.02). Colonoscopy procedures were completed without major complications.

Conclusion

Colonoscopy is an important and safe procedure for the diagnosis of LGI compliants, especially hematochezia, which is frequently accompanied by colorectal polyps.

Characteristics and risk factors for colorectal polyps among children in an urban area of Wenzhou, China: a retrospective case control study

BACKGROUND

Scarce evidence exists on pediatric colorectal polyp risk factors. This study explored the clinical manifestations, morphological and pathological characteristics of, and risk factors for pediatric colorectal polyps.

METHODS

This retrospective case-control study included children who received colonoscopy, divided into a colorectal polyp group and a normal control group based on colonoscopy results. The risk factors for colorectal polyps in children were analyzed through logistic regression analysis.

RESULTS

The mean age of children with polyps was 6.77 ± 3.44 years. Polyps were detected predominantly in males (72.9%); hematochezia was the primary clinical manifestation (80.25%). Most polyps were juvenile (88.9%) and solitary (87.7%); 50.6% were located in the rectosigmoid area. Univariate analysis showed that gender (P = 0.037), age (P < 0.001), family aggregation (P < 0.001), specific immunoglobulin E (sIgE) (P < 0.001), platelet count (P = 0.001), aspartate aminotransferase (AST) (P = 0.016), meat intake (P = 0.010), and vegetable intake (P < 0.001) were significantly associated with colorectal polyps. Age ≤ 6 years (3-6 years: OR: 26.601, 95% CI: 3.761-160.910; < 3 years: OR: 22.678, 95% CI: 1.873-274.535), positive family aggregation (OR: 3.540, 95% CI: 1.177-10.643), positive sIgE (OR:2.263, 95% CI: 1.076-4.761), and higher meat intake (OR:1.046, 95% CI: 1.029-1.063) were risk factors for pediatric colorectal polyps in logistic regression analysis. Higher vegetable intake (OR: 0.993, 95% CI: 0.986-1.000) was a protective factor against pediatric colorectal polyps. The area under the curve (AUC) of meat intake in the receiver operating characteristic (ROC) curve analysis for predicting colorectal polyps was 0.607; the best cut-off value was 92.14 g/d (P = 0.010, 95% CI: 0.527-0.687). The meat and vegetable intake combination AUC in predicting pediatric colorectal polyps was 0.781 (P < 0.001, 95% CI: 0.718-0.845).

CONCLUSIONS

Juvenile, solitary, and located in the rectosigmoid region polyps are most common in children. Hematochezia is the main clinical manifestation. Most polyps were, but multiple and proximally located polyps were also detected. Age ≤ 6 years, especially 3-6 years, positive family aggregation, positive sIgE, and higher meat intake are risk factors for pediatric colorectal polyps. A higher vegetable intake is a protective factor.

CD163+ macrophages suppress T cell response by producing TGF-β in pediatric colorectal polyps

The local immune response plays an important role in the pathogenesis of colorectal carcinoma. Patients with colorectal polyps are at increased risk of colorectal cancer. However, the immunoregulation of early-stage colorectal polyps remain unknown. In the study, 202 biopsy samples from 80 pediatric patients with colorectal polyps and from 42 normal controls were collected. We found that the number of CD4⁺, CD8⁺T cells and CD19⁺B cells were reduced, whereas CD68⁺macrophages (Mϕ) were increased in colorectal polyps compared to the distal normal tissue from the same patients and the tissue from healthy donors. The frequency of Mϕwas negatively correlated with the number of CD4⁺ and CD8⁺T cells but not CD19⁺B cells in colorectal polyps. We further identified that CD163 was highly expressed on Mϕϕ from colorectal polyps compared to those from normal controls. Furthermore, real-time PCR revealed that TGF-β, but not IL-10 and IL-4, was increased in colorectal polyps. Immunofluorescence and flow cytometry showed that TGF-β was predominantly produced by CD163⁺Mϕ. In vitro experiments demonstrated that the supernatant from cultured polyps induced CD163 expression and TGF-β production in blood-derived Mϕ. A co-culture experiment revealed that purified Mϕ from colorectal polyps suppressed T cell proliferation. Based on these results, we hypothesized that abundant CD163⁺Mϕ may promote the progression of colorectal polyps by inhibiting the local T cell response through TGF-β production.

Sonographic diagnosis of colorectal polyps in children: Diagnostic accuracy and multi-factor combination evaluation

This study was established to evaluate the diagnostic value of ultrasonography in screening colorectal polyps in children and to discuss the necessity of colonic preparation before an ultrasonic examination.In this study, 288 children with colorectal polyps managed at our hospital between January 2007 and December 2016 were retrospectively reviewed. All patients were examined before and after basic colon preparation. The colorectal polyps were confirmed by colonoscopy/laparotomy and histopathology. Among all 288 patients, solitary polyps were identified in 278 patients (96.52%), and multiple polyps were identified in 10 patients (43 polyps) (3.48%) by colonoscopy/laparotomy and histopathology.By ultrasonic examination, 264 cases (264/278) were detected as solitary polyp and 9 cases (9/10) as multiple polyps (31 polyps). In 278 solitary polyps, 180 (64.74%) were detected by ultrasonic examination without a colon preparation. Following glycerine enema (10-20 mL) treatment, 264 (94.96%) cases were detected by ultrasonic examination. The sensitivity and specificity of ultrasonography with glycerine enema for the detection of colorectal polyps were 94.96% and 100%, respectively. Colon preparation significantly increased the proportion of polyps identified by ultrasonography (P < .0001), as well as the diagnostic rate of polyps in rectum, sigmoid colon and descending colon (P < .05).Ultrasonography can be the primary diagnostic method for screening colorectal polyps in children on the strength of its safety, validity, and accuracy. Basic colon preparation with glycerine enema is recommended for children, which enable the detection of intraluminal lesions before ultrasonic examination.

Clinical, endoscopic, and pathologic characteristics of colorectal polyps in Indian children and adolescents

OBJECTIVES

Colorectal polyps are among the common causes for rectal bleeding in children. We studied the clinical, colonoscopic, and histopathological features of colorectal polyps and polyposis syndrome in Indian children and adolescents.

METHODS

Medical records of children and adolescents with colorectal polyps and polyposis syndrome were retrospectively reviewed from 2001 to 2014 at Department of Gastroenterology, in large tertiary care center of Mumbai.

RESULTS

A total of 120 patients were found to have colonic polyps during study period. Mean age of presentation in children was 7.31 ± 4.05 years (range 2 to 19 years), with male-to-female ratio of 2.16:1. Rectal bleeding was presenting symptom in 95.8 % with mean duration of 12.6 ± 15 months. Majority of polyps (77.5 %) were juvenile, and 97.2 % were located in left colon. Solitary polyps were seen in 76.6 %, multiple polyps in 11.6 %, juvenile polyposis syndrome in 6.6 %, familial adenomatous polyposis in 4.2 %, and Peutz-Jeghers syndrome in 0.8 % of the children. The polyposis syndrome group had higher age at presentation (p = 0.00006), greater likelihood of anemia, abdominal pain, and diarrhea (p = 0.0001, 0.0002, and 0.0051, respectively). Likelihood of adenomatous change in polyps was higher in polyposis syndrome group (p = 0.0003). Left colonic polyps were more common in non-polyposis group, whereas pan-colonic polyps were more common in polyposis syndrome group (p < 0.00001).

CONCLUSION

Presence of anemia, abdominal pain, diarrhea, higher age at presentation (more than 10 years), and history of polypectomy are clinical indicators of polyposis syndrome.

Colorectal polyps in children: a retrospective study of clinical features and the value of ultrasonography in their diagnosis

BACKGROUND

Colorectal polyps are common in children. The purpose of this report was to describe a clinical experience with colorectal polyps at the Beijing Children's Hospital and to evaluate the diagnostic value of ultrasonography in screening colorectal polyps in children.

METHOD

This was a retrospective medical record review of 487 children with colorectal polyps managed at the Beijing Children's Hospital between August 2003 and April 2010.

RESULTS

The mean age at presentation was 4.7 ± 2.5 years, with a male predominance (M/F ratio, 1.9:1). Most children (n = 458, 94%) presented with hematochezia associated with other symptoms, such as recurrent abdominal pain (n = 42, 8.6%), prolapse of the polyp from the anus (n = 43, 8.8%), and diarrhea (n = 10, 2.1%). Anemia was observed in 33 (6.8%) children, 4 of whom required a blood transfusion before the colonoscopy. Among the 487 patients, 352 (72.3%) patients underwent ultrasonography before the colonoscopy. Polyps were detected on 345 of 352 ultrasonographic examinations in which patients subsequently underwent colonoscopy and were found to have colonic polyps. The most common polyp locations were the sigmoid colon (n = 212, 46.1%) and the rectum (n = 174, 37.8%). Solitary polyps were identified in 421 patients (88.4%), and multiple polyps were identified in 55 (11.6%) patients. Colonoscopy complications were rare, with colonic perforation observed in 2 patients and postcolonoscopy hemorrhage observed in 1 patient. The available pathology records showed that the most frequent histological type was juvenile polyps (n = 435, 91.8%), followed by Peutz-Jeghers polyps (n = 17, 3.6%), juvenile polyposis (n = 14, 3.0%), hamartomas (n = 6, 1.3%), familial adenomatous polyposis (n = 1, 0.2%), and inflammatory polyps (n = 1, 0.2%).

CONCLUSION

Ultrasonic examination is a valid, accurate, and safe technique for screening colorectal polyps in children; and a full colonoscopy should be performed to remove the polyp(s) as soon as possible.

Sonographic diagnosis of juvenile polyps in children

The aim of this study was to assess the diagnostic value of ultrasonography for juvenile polyps in children and their sonographic characteristics. A retrospective analysis was performed of the ultrasound findings in 27 children who were diagnosed preoperatively with juvenile polyp within the intestinal tract by ultrasonography and then confirmed by colonoscopy, laparotomy and histopathology. The ultrasonic finding common to all polyps was an isolated intraluminal nodular or massive protrusion, associated with multiple mesh-like fluid areas of different sizes. In 25 children, surrounding pedicle-like low echoes of varying lengths were seen connecting with the polyps to form "mushroom" sign. The color Doppler showed abundant blood flow signals within all polyps and pedicles in a shape of a branch or an umbrella. For seven children with an intussusception, the polyp shadow was detected in the cervical part or interior of the intussusception. Ultrasonography is, thus, considered to be a feasible method for diagnosing intestinal juvenile polyp.

Polyps in children

Children with polyps usually present with bleeding or pain. Most pediatric intestinal polyps are sporadic and are not associated with malignancy. Polyposis syndromes are also well described in children. Peutz-Jeghers syndrome is the most common hamartomatous polyposis condition. Although the polyps are not thought to be premalignant in most patients, there is an increased risk of other cancers. Familial adenomatous polyposis is also seen in childhood and is associated with a very high risk of malignant transformation as well as extracolonic adenomas and malignancy. The diagnosis and management of sporadic juvenile polyps, Peutz-Jeghers syndrome, and familial adenomatous polyposis, as well as rarer conditions associated with intestinal polyps are reviewed in this article.

Gastrointestinal polyps in children

BACKGROUND

Gastrointestinal polyps are common in children. The purpose of this study was to review the clinical manifestations, diagnostic procedures, endoscopic findings, management, pathology, and recurrence of gastrointestinal polyps in children at Mackay Memorial Hospital.

METHODS

We retrospectively reviewed the charts of 50 children with a diagnosis of gastrointestinal polyps managed at Mackay Memorial Hospital between January 1984 and April 2007. Demographic data; clinical features; polyp size, number and location; endoscopic findings; management; pathology; and information on recurrences were extracted from the clinical records.

RESULTS

The distribution of polyps in the 50 patients included gastric (4 patients), duodenal (2), ileocecal (4) and colorectal polyps (40). All patients with gastric polyps presented with vomiting, and three of the four patients with ileocecal polyps presented with intussusception. The mean age of the 40 patients with colorectal polyps was 6.8 years. The majority of those polyps were in the rectosigmoid colon; 36 patients presented with hematochezia. Solitary polyps were identified in 33 patients and multiple polyps were identified in seven patients. Most of the colorectal polyps were less than 2cm in diameter. Histologically, the most frequent type was juvenile polyp.

CONCLUSION

Gastrointestinal polyps in children are usually benign. Pediatricians treating a child with a gastrointestinal polyp should pay attention to the immediate complications of the polyps, such as intussusception or bleeding, the extraintestinal manifestations and long-term risk for malignancy.

Epidemiology and management options for colorectal cancer in children

Colorectal carcinoma (CRC), although primarily a disease of adulthood, accounts for 2% of malignancies in adolescents and has been reported in children as young as 9 months of age. Our knowledge of CRC in pediatrics is based on a handful of case series and case reports. Apart from one small clinical trial, there has been a lack of prospective clinical studies in this age group. Based on these published reports, most CRC in children is sporadic, but it can also arise in the setting of predisposing conditions, such as gastrointestinal polyposis syndromes, nonpolyposis familial cancer syndromes, and inflammatory bowel disease. Despite some similarities to adult disease, CRC in childhood may be intrinsically different biologically, because it differs from adult-onset CRC in several respects. Childhood CRC tends to be diagnosed at an advanced stage, is largely of mucinous histology, and (probably because of these features) tends to have a poorer outcome. As a result of its rarity in children and the lack of prospective pediatric studies, recommendations for therapy are primarily extrapolated from adult clinical trials. A review of pediatric case series in the English literature emphasizes the prognostic significance of stage of disease, as well as extent of surgical resection. As in adults, early detection is critical in an effort to capture the disease at less advanced stages. Complete surgical resection with aggressive lymph node dissection is essential for cure, and neoadjuvant chemotherapy may be used in an effort to render unresectable lesions resectable. Active agents in adults with CRC include fluorouracil, folinic acid (leucovorin), oxaliplatin, and irinotecan. Furthermore, newer targeted therapeutic agents, such as bevacizumab and cetuximab, have added additional efficacy to the standard chemotherapy backbone. Collaborative multi-institutional pediatric clinical trials are needed to evaluate the prognosis, optimal treatment response, and the basic biology of childhood onset CRC.

Sonographic diagnosis of intestinal polyps in children

Although colonoscopy is the modality of choice for the diagnosis of intestinal polyps, sonography may be the first diagnostic modality in the evaluation of children with this pathology. Graded compression sonography of the small and large bowel may be useful in diagnosing intestinal polyps. A specific diagnosis is possible in many cases as most polyps have a characteristic appearance. Although sonography is not intended to replace endoscopy in the diagnostic work-up of intestinal polyps, it is important for radiologists to be aware of this appearance as they can be the first in making the diagnosis of intestinal polyps using sonography.

Multicenter experience with upper gastrointestinal polyps in pediatric patients with familial adenomatous polyposis

BACKGROUND

Familial adenomatous polyposis (FAP) is a hereditary cancer syndrome that includes gastro-duodenal involvement, polyposis, and a propensity to adenocarcinoma necessitating endoscopic surveillance. There are few data describing pediatric upper gastrointestinal FAP resulting in conflicting screening recommendations.

OBJECTIVES

To characterize pediatric gastroduodenal FAP and to investigate the association between symptoms at endoscopy and APC mutation analysis with endoscopic-histologic findings warranting surveillance.

METHOD

A retrospective chart review was performed, including all children with FAP who underwent upper endoscopy (EGD) at two institutions; (UNMC: 1992-2002, JHH: 1983-2002), all biopsies were reviewed and the APC mutations present in the cohort of patients were correlated to the pattern of severity of endoscopic findings and the frequency of APC mutations identified through commercially available testing for FAP (Labcorp: 1998-2002).

RESULTS

Twenty-four patients from 21 families underwent 49 EGDs. Eighty-three percent were asymptomatic at the time of endoscopy. The most common finding was fundic gland polyposis (FGP) (51%), of which 42% and 15% harbored dysplasia and changes indefinite for dysplasia, respectively. Periampullary duodenal adenomata were present in 41% of patients with one patient necessitating ampullectomy. Symptoms at endoscopy were not predictive of premalignant changes. In 15 patients where the APC mutation was known patients with dysplastic FGP, gastric, or duodenal adenoma were more likely to harbor a mutation between codons 1225-1694 than the reference population (p= 0.006).

CONCLUSIONS

All pediatric patients with FAP warrant upper gastrointestinal screening and surveillance endoscopy from the time of initial colonoscopy irrespective of referable symptoms. Patients with APC mutation between codon 1225-1694 may be more susceptible to aggressive gastroduodenal involvement in FAP.

Benign Fibroblastic Polyps of the Colon

Mesenchymal proliferations presenting as mucosal polyps are relatively uncommon and are represented by gastrointestinal stromal tumors, smooth muscle and neural tumors, and inflammatory fibroid polyps. In this report, we describe the clinicopathologic features of a distinctive type of mucosal polyp composed of cytologically bland spindled cells with fibroblastic features. Fourteen cases with histologic features of"fibroblastic polyps" were identified from our case files from January 2000 to December 2003. The clinical and endoscopic findings were reviewed. Immunohistochemistry using a panel of antibodies (vimentin, smooth muscle actin, desmin, CD31, CD34, Bcl-2, c-Kit, S-100, and epithelial membrane antigen) was performed in all cases, and electron microscopy was performed in two cases. The lesions were solitary in all cases and not associated with an identifiable polyposis syndrome. Associated adenomata and/or hyperplastic polyps at different sites were present in 10 cases and hyperplastic polyps were seen in close association in 3 cases. These polyps were characterized by a monomorphic spindle cell proliferation in the lamina propria, without necrosis or mitotic activity. The lesions were intimately associated with the muscularis mucosae and resulted in wide separation and disorganization of the colonic crypts. Immunohistochemical analysis revealed strong and diffuse positivity for vimentin only. Weak and focal reactivity was noted in 2 cases for CD34 and smooth muscle actin, while staining for other antibodies was negative. Electron microscopy revealed sparse cytoplasmic organelles and many intermediate filaments. The histology and ultrastructural and immunohistochemical findings are suggestive of fibroblastic differentiation of these spindle cells. In summary, these lesions represent a distinctive type of colonic mucosal polyp that should be distinguished from other stromal polyps of the gastrointestinal tract.