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From question on page 1000
During menses, colonoscopy showed a large multilobulate polyp (3.5 cm in diameter) of the sigmoid colon with a hyperaemic and friable mucosa (fig 1). Histological examination showed a normal mucosa with the presence of some branched crypts and marked inflammation in the lamina propria.
During the intermenstrual period (on the eighth day of the cycle), polyp size had decreased; its surface appeared only slightly lobulate without friability and with hyperaemia, which was reduced at two red spots (fig 2). Histopathological evaluation showed the presence of endometriotic foci in the context of a mucosa containing branched crypts.
The patient was submitted to a gynaecological examination which was found to be normal. Pelvic and vaginal ultrasounds did not show evidence of endometriotic lesions. Magnetic resonance imaging detected a 1.8 cm area with a T1 hyperintense and T2 hypointense signal in the sigmoid wall.
Medical treatment with leuprolide acetate depot, a gonadotropin releasing hormone agonist (GnRH-a) (3.75 mg intramuscularly every four weeks for three months) was started. Abdominal pain and bloody diarrhoea promptly disappeared. At the four month follow up she was still free of symptoms and anaemia had reversed (haemoglobin 12.3 g/dl). At the one year follow up, colonoscopy showed a flat lesion without hyperaemia or friability at the site of the endometriotic polyp. Histological examination of multiple biopsies was normal and a magnetic resonance imaging showed complete disappearance of the previously detected lesion. After 18 months of follow up, the patient remains completely asymptomatic.
Endometriosis is defined as the presence of endometrial tissue in sites other than the uterus. The rectosigmoid is the most frequently involved site. Heterotopic endometrium generally adheres to serosal surfaces and may invade the bowel wall. However, appearance as a polyp is rarely reported. Infiltration of the mucosa is uncommon and therefore the endoscopic biopsy may not be diagnostic. The variable appearance on endoscopy is related to the cyclic endometrial tissue changes.
Surgical resection is indicated for massive rectal bleeding or obstruction but the role of surgery is less clear when the clinical course is not life threatening. Medical treatment with a GnRH-a is commonly used in pelvic endometriosis but studies on its efficacy in intestinal endometriosis are still lacking.
To our knowledge this is the first case reported in the literature showing that an endometriotic colonic polyp may be successfully treated by medical therapy with a GnRH-a. This case further illustrates that endometriosis may appear as a colonic polyp and that polypectomy is not curative.
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