|Year : 2014 | Volume
| Issue : 1 | Page : 20-23
Juvenile polyp in children in Kano Nigeria: Clinical presentation and management challenges
C Anyanwu Lofty-John1, M Mohammad Aminu1, U Ibrahim Mustapha1, T Atanda Akinfenwa2
1 Department of Surgery, Paediatric Surgery Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Pathology, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||7-Apr-2014|
C Anyanwu Lofty-John
Department of Surgery, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Background: Juvenile polyps are a common cause of low volume painless rectal bleeding in children. Most of these polyps are located within the sigmoid colon and the rectum. Objective: The aim of this study was to describe the clinical characteristics of children presenting with colorectal polyp in Kano, Nigeria and to document the challenges faced in their management. Materials and Methods: We undertook a retrospective review of the clinical records of all children aged 13 years or less who presented to our hospital with a colorectal polyp between January 2008 and December 2008, and also prospectively enrolled all those presenting between January 2009 and December 2010. Demographic, clinical and laboratory data were collected. Data were analysed using SPSS 15.0 (SPSS Inc, Chicago, IL). Results: There were 16 patients in all, with their ages ranging between 2.5 years and 9 years (mean 6.03 years). There were 8 boys and 8 girls (M: F = 1:1). Haematochezia was the most common presenting symptom, followed by a prolapsing rectal mass and rectal prolapse. In 13 of the patients, there was a solitary polyp, while 3 patients had 2 polyps each. All the polyps were located in the rectum within 7 cm of the anal verge. Only one patient had a sessile polyp, while all the others were pedunculated. Histopathology reported juvenile polyp without evidence of adenomatous change in all of them. Conclusion: A careful digital rectal examination is recommended for all children presenting with a bloody stool to rule out juvenile polyp.
Keywords: Challenges, haematochezia, juvenile polyp, rectum, sigmoidoscope
|How to cite this article:|
Lofty-John C A, Aminu M M, Mustapha U I, Akinfenwa T A. Juvenile polyp in children in Kano Nigeria: Clinical presentation and management challenges. Niger J Basic Clin Sci 2014;11:20-3
|How to cite this URL:|
Lofty-John C A, Aminu M M, Mustapha U I, Akinfenwa T A. Juvenile polyp in children in Kano Nigeria: Clinical presentation and management challenges. Niger J Basic Clin Sci [serial online] 2014 [cited 2019 Mar 20];11:20-3. Available from: http://www.njbcs.net/text.asp?2014/11/1/20/130162
| Introduction|| |
Juvenile polyps are the most common gastrointestinal (GI) polyps seen in children.  In preschool-aged children, it is a very common cause of recurrent low volume rectal bleeding, which is not associated with anal pain. ,
Juvenile polyps are lesions, which are typically solitary and commonly occur in the rectum or sigmoid colon. , A minimal and often recurrent rectal bleeding is commonly seen in about 85% of children with a juvenile polyp, although cases of massive lower GI bleeding have also been reported in children. 
Although total colonoscopy is recommended in children with a rectal bleed after infective causes have been ruled out, , the isolated juvenile polyp is the most common kind of polyp identified in children,  and often lies within the reach of a sigmoidoscope. ,,
Juvenile polyps are relatively rare lesions, and few studies have documented the pattern of its presentation in our region as in this study. Its presentation is usually dramatic, yet treatment is straight forward; diagnosis can be made easily with 'Digital Rectal Examination' (DRE), and it should be considered an important differential of haematochezia in children.
The aim of this study was to describe the clinical characteristics of children presenting with colorectal polyp in Kano, Nigeria and to document the challenges faced in their management.
| Materials and Methods|| |
We undertook a retrospective review of the clinical records of all children aged 13 years or less who presented to our unit with a colorectal polyp between January 2008 and December 2008, and also prospectively enrolled all those presenting between January 2009 and December 2010.
Demographic and clinical data were collected from patients' clinical records, and included age, gender, location and number of polyps, and the diameter of the polyps. Laboratory data retrieved included 'Packed Cell Volume' (PCV) on presentation, stool microscopy results and histopathology reports of the excised polyps. Each patient had a gentle digital rectal examination (DRE) done by a paediatric surgeon at the out-patient clinic. All patients had a stool microscopy test. Due to the non-availability of paediatric scopes in our centre, no patient had a lower gastrointestinal (GI) endoscopy. The patients were admitted a day before surgery for twice daily rectal wash outs with normal saline.
Patients with a PCV of <28% (i.e. Haemoglobin <9.3 g/dl) on admission had blood transfused before surgery to raise their PCV to a minimum of 30% (Haemoglobin of 10 g/dl) according to the unit's protocol.
Under general anaesthesia in the theatre, DRE was repeated before manual polypectomy was done. None of the patients had a snare polypectomy. The location, number and characteristics of the polyps were recorded. All polyps were sent for histopathologic evaluation. Data were analysed with SPSS version 15.0 for Windows (2006 SPSS Inc.).
| Results|| |
A total of 16 children were included in the study. Their ages ranged from 2.5 years to 9 years with a mean of 6.03 years (SD 1.79 years). There were 8 boys and 8 girls (M: F = 1:1). The most common presenting symptom was haematochezia. This was seen in all the patients, and was often accompanied with mucoid stools. Only 3 patients had diarrhoea (18.75%). One patient (6.25%) had a rectal bleeding with significant blood loss, which required blood transfusion for resuscitation. She was transfused before referral to our hospital. Four patients in all (25%) with a PCV of <28% on admission had pre-operative blood transfusion. Other presenting symptoms were a prolapsing rectal mass (n = 15) and a prolapsed rectum (n = 6). Of the 6 (37.5%) patients with a rectal prolapse, one had a complete rectal prolapse and required a 'Thiersch stitch' [Figure 1]. A total of 19 polyps were identified in the 16 patients. There were 3 patients (18.75%) with 2 polyps each. All the polyps were located within 7 cm of the anal verge in the rectum. There were 18 (94.73%) pedunculated polyps and only 1 (5.26%) sessile polyp. The largest polyp had a diameter of 4 cm (range 1-4 cm), and the mean polyp diameter was 2 cm (SD 0.86). The average Packed Cell Volume (PCV) was 29.25% (range 21-37%; SD 4.3%). Of the 7 patients whose stool microscopy result was available, ova of helminthes were identified in 2 (28.57%). Another patient gave a history of passage of worms in stools. All patients had manual polypectomy except one (6.25%) who had an autoamputation of the polyp, but had an uneventful recovery. None of the patients had a family history of rectal polyps. Histopathology report was that of juvenile polyp without evidence of adenomatous change in all the patients [Figure 2].
|Figure 2: Polyp (H and E ×100). Photomicrograph showing dilated mucous glands in inflamed oedematous lamina propria|
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The longest duration of follow up was 2 years, and none of the patients has represented with a recurrent polyp.
| Discussion|| |
Juvenile polyps are commonly believed to be hamartomatous lesions with a low possibility for malignant transformation.  They comprise 95% of colorectal polyps seen in children.  Juvenile polyps are most often diagnosed in the first decade of life, with a peak incidence between the ages of 2 years and 6 years,  and the patients being predominantly males. ,,
Our patients had a mean age of 6.03 years, with the youngest being 2.5 years old. We, however, had an equal sex distribution of the disease in our series.
Juvenile polyps are believed to be the commonest childhood bowel tumours, occurring in about 1-3% of children. , The incidence of this condition in sub-Saharan African children is not known due to paucity of data on it from the sub-region. Juvenile polyps commonly present with a painless intermittent fresh rectal bleeding, which may streak the stool or is passed at the end of a stool. , All our patients had a history of haematochezia. Sometimes, a massive bleeding episode requiring blood transfusion may occur. , This was the case in 1 (6.25%) of our patients who had rectal bleeding with significant blood loss requiring transfusion for resuscitation at the referring hospital. Her PCV on admission was 21% and she was re-transfused pre-operatively to raise her PCV to 30% before surgery. This is similar to the findings of Ukarapol et al., who had reported that nearly 10% of their series of Thai children developed massive lower GI bleeding that required blood transfusion. 
Our unit's protocol is to transfuse all patients with an admitting PCV of <28% to raise their PCV to a minimum of 30% before surgery. We also would transfuse to resuscitate a patient if an acute blood loss resulted in hemodynamic instability.
Polyps have been documented to prolapse in 4% of patients.  Wajeehuddin, however, reported that 14 (31.11%) children had a prolapsed polyp in their series.  Prolapse of the polyp was seen in 15 (93.8%) of our patients. The polyps may also autoamputate, sometimes leading to severe bleeding. ,, Autoamputation occurred in only 1 (6.3%) of our patients. Rectal prolapse (complete or partial) is a not commonly reported manifestation of rectal polyps. This was seen in 6 (37.5%) of our patients, one of who had a complete rectal prolapse and required a Thiersch stitch.
'Juvenile' refers not to the age of onset of the polyp, but to the histological type.  Histologically, the juvenile polyp is composed of a prominent lamina propria, cystically dilated mucus filled glands and a dense inflammatory cell infiltration. , Various terminologies used to describe juvenile polyps based on the dominant histological finding include - retention polyps, inflammatory polyps and hyperplastic polyps. 
Juvenile polyps most commonly occur as solitary lesions in the rectum or sigmoid colon,  being pedunculated in 90% of cases, and measure between 1 cm and 3 cm in their widest diameter.  The largest polyp in our series measured 4 cm (mean 2 cm), and 94.7% of them were pedunculated. All of our polyps were located within the rectum.
Although the aetiology of juvenile polyps is unknown, they are generally believed to be hamartomatous. , Some workers, however, believe that they may result from a spontaneous or iatrogenic local inflammation of the mucosa of the colon or rectum, which leads to granulation tissue formation that may be subsequently covered by regenerating epithelium, which lines haemorrhagic cavities and mucus lakes to form irregular, elongated and cystic glands, which are characteristic of juvenile polyps.  Intestinal helminthes, are a common cause of gastrointestinal mucosa injuries.  In our country, as much as 60% of the children in some communities may be afflicted with ascariasis.  Ova of helminthes were identified in 2 out of the 7 patients in our study whose stool microscopy results were available. Another of our patients, however, gave a history of passage of worms in his stools.
For the child with a painless rectal bleeding, lower GI endoscopy is recommended after infective causes have been ruled out. , Sigmoidoscopy is widely used, as majority of colorectal polyps are easily visualised by this instrument. ,,, Various workers, however, have reported that as many as 22-40% of polyps occur proximal to the sigmoid colon. , Total colonoscopy is now believed to be the gold standard in evaluating children with suspected polyps.  Other modalities which have proved effective in the evaluation of colorectal polyps include double contrast barium enema , and hydrocolonic ultrasonography.  None of our patients had lower GI endoscopy due to the non-availability of paediatric scopes in our hospital. All the polyps in our series were located in the rectum by a gentle DRE only, and all were within 7 cm of the anal verge. Although there is a paucity of literature on the distribution of colorectal polyps in children in sub-Saharan Africa, the absence of a recurrence of the initial presenting symptoms following polypectomy suggests that no other synchronous polyps had been missed out in the children. Wajeehuddin had earlier reported on their series in Pakistani children that they located 97.77% of the polyps by DRE.  Population-based studies will be needed to ascertain the distribution of colonic polyps in our environment to know if it differs from other regions.
Although the solitary juvenile polyp is considered to have little malignant potential, polypectomy is usually recommended.  The presence of more than 5 polyps or an associated family history of juvenile polyps is indicative of juvenile polyposis syndrome (JPS) - A rare condition with neoplastic potential. , Also, if an adenomatous change is identified in a polyp in an individual younger than 30 years, familial polyposis should be considered.  None of our patients had more than 2 polyps, and no family history of colorectal polyps was identified in any of them. None of the polyps in our series showed an adenomatous change.
It is commonly believed that in the absence of a family history of colorectal polyps in the child with one or two juvenile polyps, polypectomy (endoscopic or manual) with histopathologic review of the polyps is usually sufficient treatment, and a long-term follow up is not necessary. ,, We, however, followed up our patients since we had not objectively ruled out the presence of a more proximal synchronous polyp.
| Conclusion|| |
Colorectal polyps are an important cause of a painless rectal bleeding in children. Although total colonoscopy remains the gold standard for evaluating such a child, a gentle DRE in resource-challenged settings would locate majority of the polyps.
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[Figure 1], [Figure 2]