Pyogenic granuloma of the rectum and stomach at the site of a previous rectal mucosectomy and gastric biopsy

A 54-year old male presented with a history of haematochezia. Subsequent endoscopy revealed a large rectal polyp. Endoscopic ultrasound and a MRI scan demonstrated confinement to the mucosal layer. Accordingly, a transanal mucosectomy was performed with uneventful recovery. Histopathologic exam confirmed complete resection of a tubulo-villous adenoma with high-grade dysplasia. Six weeks postoperatively, an immobile, broad-based, friable polyp was found fixed to the site of the previous polypectomy. Biopsy resulted in the histopathological diagnosis of a pyogenic granuloma, which was removed by snare polypectomy. Of note, the patient also had an esophagogastroduodenoscopy with biopsies which was repeated after six weeks. It then showed a tongue-like reddish lesion at the gastroesophageal junction that again was biopsied. Histopathological confirmed a pyogenic granuloma.

Pyogenic granuloma describes a benign vascular lesion occurring on skin, the oral and nasal cavity and rarley other parts of the gastrointestinal tract. The cause is postulated to be traumatic, an infectious (‘pyogenic’) component was not demonstrated, despite its misleading name(1). This hypothesis is supported by our case, where in the same patient, after mucosal surgical trauma, a pyogenic granuloma formed de novo. In the literature, 15 cases of the colon(2), 12 of the stomach(3), 2 of the rectum and rarely of the oesophagus and small intestine are reported. Usually, gastrointestinal bleeding leads to diagnosis. Endoscopically, the lesions can have a malignant aspect due to their irregular shape, reddish or polypoid appearance tendency of contact bleeding. The differential diagnosis includes inflammatory polyps, angiosarcoma, angiomatous variant of Kaposi-sarcoma and bacillary angiomatosis. Treatment requires complete removal of the lesion, though some cases of successful photoablation are described. The natural history in the intestinal tract is not known. As differential diagnosis this entity is important for pathologists, endoscopists and surgeons in order to avoid overtreatment as a malignant vascular tumour by bowel resection.