Chapter 22

An intestinal polyp is defined as a tissue mass that projects from the wall of the bowel into the lumen. It can be broadly classified into two main categories, neoplastic and non-neoplastic. Within each category, there are multiple potential types of lesions, some of which are associated with a syndrome including multiple polyps, some of which may carry a risk of cancer, and others which are less numerous and unlikely to cause future problems. The neoplastic polyps typically have an abnormal epithelial component resulting from abnormal proliferation. Non-neoplastic polyps can be either hamartomas, with involvement of all three germ layers, or inflammatory in nature.

A child with polyps typically presents with painless rectal bleeding, although larger polyps can be associated with pain if they cause obstruction, if motility-induced traction on the polyp results in stretching of mesenteric attachments, or if a polyp serves as a lead point for intussusception. Polyps may be encountered in any region of the intestine, although the region most commonly affected is the colon. They may occur sporadically, or there may be a strong familial component. It is therefore important to obtain a thorough family history of polyps and gastrointestinal cancers.

### Juvenile Polyps

#### Definition and Epidemiology

The most common of the intestinal polyps encountered in childhood is the juvenile polyp, a benign non-neoplastic tissue growth with a marked propensity for causing rectal bleeding.1 These are relatively common, with most cases occurring before age 10 years and peaking at around ages 2–5 years. Isolated juvenile polyps are not associated with a genetic disorder and therefore not typically associated with a family history of polyps. If such history exists, other conditions must be suspected.

#### Pathogenesis

The etiology of isolated juvenile polyps is not well understood. In contrast to juvenile polyposis, in which multiple similar polyps occur throughout the GI tract (see below), there is no associated known gene mutation. Similar-appearing polyps (inflammatory polyps) are seen in children and adults with intestinal inflammation, and it is therefore likely that these lesions are in some way related to an inflammatory process. Long-term follow-up of patients with isolated juvenile polyps reveals no evidence of increased risk of intestinal malignancy,2 which is in marked contrast to juvenile polyposis syndrome.

#### Clinical Features

Children with juvenile polyps typically present with recurring episodes of small-volume, bright red rectal bleeding, not associated with any abdominal discomfort or significant anemia. Bleeding appears to be caused by intestinal contents moving across the friable surface of these polyps, causing mechanical trauma and resulting in bleeding. Occasionally, more brisk bleeding can occur if the head of the polyp is avulsed from its stalk, creating a very brief and hemodynamically insignificant higher volume bleeding episode.

At endoscopy, no lesions are found in the upper gastrointestinal tract, and fewer than five polyps are seen during ...

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