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wjg@wjgnet.com World Journal of Gastroenterology ISSN 1007-9327
doi:10.3748/wjg.15.3687 © 2009 The WJG Press and Baishideng. All rights reserved.

CASE REPORT

Obstructive ileus due to a giant fibroepithelial polyp of the

anus

Ioannis Galanis, Dimitrios Dragoumis, Michail Tsolakis, Konstantinos Zarampoukas, Thomas Zarampoukas,
Konstantinos Atmatzidis

Ioannis Galanis, Dimitrios Dragoumis, Michail Tsolakis,

Konstantinos Zarampoukas, Thomas Zarampoukas, INTRODUCTION
Konstantinos Atmatzidis, 2nd Surgical Clinic, Aristotle Fibroepithelial polyps of the anus, also referred to
University of Thessaloniki, “G. Gennimatas” District Hospital, as hypertrophied anal papillae, are structures formed
Ethnikis Aminis 41, Thessaloniki 54 635, Greece
Author contributions: Galanis I and Dragoumis D designed
by hyperplasia of connective tissue in the vicinity of
the study; Tsolakis M, Zarampoukas K and Zarampoukas T the anal columns. They are usually relatively small in
acquired, analyzed and interpreted the data; Atmatzidis K size and asymptomatic. Enlargement of anal papillae
revised and finally approved the final version. is thought to be due to a hyperplastic response of
Correspondence to: Ioannis Galanis, MD, PhD, 2nd Surgical the modified ectoderm to chronic irritation, injury or
Clinic, Aristotle University of Thessaloniki, “G. Gennimatas”
District Hospital, Ethnikis Aminis 41, Thessaloniki 54 635,
infection. Following repeated inflammatory episodes
Greece. galanis.ioannis@gmail.com they can hypertrophy into the rectum and be confused
Telephone: +30-2310-430149 Fax: +30-2310-430149 with adenomatous polyps. Fibroepithelial polyps of the
Received: March 17, 2009 Revised: April 24, 2009 anus should be included in the differential diagnosis of
Accepted: May 1, 2009 a smooth mass located near the anal verge, especially
Published online: August 7, 2009
in a patient with a history of chronic anal irritation or
infection. To our knowledge, this is the first case of a
giant fibroepithelial polyp of the anus complicated by
obstructive ileus: there is only one similar case study in
Abstract the medical literature regarding a giant hypertrophied
Fibroepithelial polyps or hypertrophied anal papillae anal papilla complicated by massive anal bleeding and
are essentially skin tags that project up from the prolapse[1,2].
dentate line and the junction between the skin and the
epithelial lining of the anus. They are usually small in
size, but sometimes they become enlarged, causing CASE REPORT
unexpected medical conditions. An extremely rare case A 67-year-old woman was admitted to the emergency
of a giant hypertrophied anal papilla complicated by
room with a diffuse, cramping abdominal pain of
obstructive ileus is reported. Fibroepithelial anal polyp,
progressive onset, tendency to vomit and constipation for
despite its size, should be included in the differential
diagnosis of a smooth mass located near the anal 5 d. She had experienced similar episodes of intermittent
verge, especially in a patient with a history of chronic abdominal pain, anal bleeding and persistent perianal pain
anal irritation or infection. due to long-standing hemorrhoidal disease over the last
7 years. Despite having been aware of the presence of
© 2009 The WJG Press and Baishideng. All rights reserved. chronic constipation, she had not sought timely medical
treatment. Her family history was unremarkable, as was
Key words: Anus; Fibroepithelial polyp; Hypertrophied her medical history, except for clonazepam intake due to
anal papillae; Ileus; Intestinal obstruction epileptic episodes during her childhood.
On physical examination, she had reduced bowel
Peer reviewer: Francis Seow-Choen, Professor, Seow-Choen
Colorectal Centre, Mt Elizabeth Medical Centre, Singapore, 3
sounds, while the upper abdomen was distended with
Mt Elizabeth Medical Centre #09-10, 228510, Singapore mild tenderness on palpation. Digital examination was
negative for the presence of blood in the rectum, but
Galanis I, Dragoumis D, Tsolakis M, Zarampoukas K, revealed a giant elastic mass with convoluted grooves
Zarampoukas T, Atmatzidis K. Obstructive ileus due to a giant on a smooth surface in the distal rectum. This lesion
fibroepithelial polyp of the anus. World J Gastroenterol 2009; was located 2 cm above the dentate line, obstructing the
15(29): 3687-3690 Available from: URL: http://www.wjgnet. intestinal lumen. Preoperative examinations, consisting
com/1007-9327/15/3687.asp DOI: http://dx.doi.org/10.3748/ of a full blood count, serum kidney and liver functions,
wjg.15.3687 as well as cancer markers (CEA, CA 19-9), were within

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 3688 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol August 7, 2009 Volume 15 Number 29

Figure 1 Computed tomography of the pelvis showing the mass in the B

rectum.

Figure 2 Clinical appearance of the giant fibroepithelial anal polyp. A: The

clinical aspect of the mass during surgery; B: The gross macroscopic specimen.

B vessel sealer (LigaSure Precise®). The histological assay

of the resected specimen showed fibrous tissue covered
by multilayered squamous epithelium, many small dilated
vessels filled with red blood cells, scattered smooth
muscle fibers and a superficial ulceration of the fibrous
stroma (Figure 3). In all immunohistochemical sections
from the giant fibroepithelial polyp, spindle and stellate
mononucleated stromal cells were positive for CD34,
SMA (Smooth Muscle Actin) and desmin (Figure 4).
The histological and immunohistochemical findings
therefore established the diagnosis of fibroepithelial
polyp of the anus. The patient presented no postopera-
tive complications and was discharged after 3 d of hos-
Figure 3 Histological features of the fibroepithelial polyp. A: pitalization.
Photomicrograph of resected polyp showing fibrous tissue covered by squamous
epithelium, small vessels and the ulceration of fibrous stroma (HE, × 100); B:
Deeper layer of the polyp showing scattered smooth muscle fibers within the DISCUSSION
fibrous stroma (HE, × 100).
Fibroepithelial polyps of the anus, also known as
hypertrophied anal papillae, are common lesions that
normal limits. Plain abdominal X-rays revealed the have attracted little attention in the medical literature.
presence of dilated small intestine with air-fluid levels. They are enlarged, benign, polypoid projections of
A computed tomography of the abdomen and pelvis the anal squamous epithelium and the subepithelial
demonstrated the presence of a mass in the rectum connective tissue. These lesions are present in 45% of
(Figure 1). Anal examination under anesthesia was patients who undergo proctoscopic examination and
carried out. A giant (measuring 15 cm × 12 cm) smooth are considered to be acquired triangular protrusions that
mass attached to a wide pedicle extending over the entire arise from the base of the rectal columns of Morgagni at
posterior wall of the anal canal, above the dentate line, the dentate line[2]. As regards our patient, this is a report
was easily observed (Figure 2). During the proctoscopy, of a unique case of a very oversized fibroepithelial polyp
biopsy specimens and frozen section analysis confirmed of the anus which finally led to intestinal obstruction.
the benign nature of the lesion. Clinically, these polyps may have the appearance of
The huge mass was uneventfully removed by local hemorrhoids, but they do not display thick-walled veins
excision with the the aid of an electrothermal bipolar or any evidence of hemorrhage and organizing thrombi.

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 Galanis I et al . Giant fibroepithelial polyp of the anus 3689

inside the anal verge should suggest the possibility of a

A
fibroepithelial polyp, especially in a patient with a history
of chronic anal irritation or locoregional infection[2,3].
Endoscopically, a fibroepithelial polyp can be easily
distinguished from an adenomatous polyp by several
distinctive characteristics: (1) its mucosa is whitish
compared with the reddish appearance of an adenomatous
polyp, (2) the “stalk” of a hypertrophied anal papilla
originates from the squamous side of the dentate line,
(3) closure of the biopsy forceps on a fibroepithelial
polyp results in pain, and (4) biopsy of these structures
always demonstrates squamous epithelium. On the other
hand, radiographic demonstration (on barium enema
B
examination or computed tomography) of a fibroepithelial
polyp is uncommon and occurs only when it becomes
large enough to prolapse into the rectum. The differential
diagnosis should always include internal hemorrhoids,
rectal polyp, anal carcinoma and submucosal anorectal
tumor[4,5].
Groisman et al[6] studied the histological, immunohisto­
chemical and ultrastructural features of a series of 40
fibroepithelial polyps of the anus. The authors concluded
that fibroepithelial polyps of the anus are benign lesions
characterized by the presence of mononucleated and
multinucleated, sometimes atypical, CD34+ stromal cells
C
showing fibroblastic and myofibroblastic differentiation.
They also suggested that polyps harboring atypical cells
are those of large size. The morphologic resemblance
between these lesions and normal anal mucosa supports
the hypothesis that fibroepithelial polyps may represent
a reactive hyperplasia of the subepithelial connective
tissue of the anal mucosa. Mast cell infiltration, by means
of their fibrogenic, fibrolytic and angiogenic activities,
may play an important role in the pathogenesis of these
structures.
The presence of smooth muscle bundles and hyalin-
ized vascular changes at the base of anal fibroepithelial
Figure 4 Immunohistochemical analysis of the polyp. A: Stromal cells polyps has also been reported. The rectal muscularis mu-
strongly express SMA; B: Stromal cells strongly express desmin; C: Stromal cosa may be found in the upper part of the anal transi-
cells strongly express CD34.
tional zone. An increase in smooth muscle bundles could
be the result of the hyperplastic response which caused
In persons with poor anal hygiene, local disease or bowel anal fibroepithelial polyps to form a central core, and
dysfunction, these structures may become inflamed and to become enlarged[7]. In our case study, the presence
edematous. They are usually small in size, asymptomatic of abundant smooth muscle fibers in the stroma merely
and can be regarded as normal anatomic variations. Most emphasizes the extreme enlargement of the polyp.
anal papillae are 2-5 mm at their greatest dimension, Another prominent histological feature of fibroepi-
although rarely they may exceed 2 cm. Enlargement of thelial polyps of the anus, but of uncertain significance,
a fibroepithelial polyp to more than 3 cm in diameter is is the eosinophilic epithelial vacuolation. This is char-
rare, and it is therefore necessary to differentiate such acterized by the accumulation of PAS-positive homog-
lesions from malignant tumors including leiomyosarcoma, enous eosinophilic material in superficial keratinocytes.
anorectal carcinoma and malignant lymphoma. This change may be a non-specific reaction to mechani-
Hypertrophied anal papillae are liable to trauma cal trauma, particularly given its propensity to afflict the
during the passage of stools and may become inflamed. apex of polyps. Pathologists should be very careful to
Furthermore, they produce symptoms by projecting at avoid a misdiagnosis of extramammary Paget disease or
the anal orifice during defecation and sometimes require oral white sponge nevus, which may sometimes affect
digital repositioning, strongly simulating a rectal prolapse. anal epithelium[8].
Pruritus, foreign body sensation, mucus discharge, A fibroepithelial polyp that starts projecting into
sense of incomplete evacuation and discomfort while the anal canal requires attention and proper therapeutic
sitting are the prevailing symptoms associated with this strategy. Complete removal by crushing of the base and
medical condition. The location of a smooth mass just excision after using an electrothermal bipolar vessel

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 3690 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol August 7, 2009 Volume 15 Number 29

sealing system (EBVS-LigaSure), electrocauterization or anal papillae and fibrous anal polyps. Bratisl Lek Listy 2005;
ultrasonic energy (Harmonic Scalpel) has been suggested 106: 30-33
3 Gupta PJ, Kalaskar S. Removal of hypertrophied anal
by many authors. Some other surgeons have found papillae and fibrous anal polyps increases patient satisfaction
that the use of radio frequency devices is a quick, easy after anal fissure surgery. Tech Coloproctol 2003; 7: 155-158
and significantly complication-free procedure for these 4 Heiken JP, Zuckerman GR, Balfe DM. The hypertrophied
pathological entities. This type of device can ablate anal papilla: recognition on air-contrast barium enema
the papillae instantly, while the fibrous polyps can be examinations. Radiology 1984; 151: 315-318
excised after coagulation of the bases and thereafter the 5 Hizawa K, Sakamoto K, Nakahara T, Inuzuka S, Akagi
K, Shimono R, Iwai K, Matsumoto T. Endosonographic
pedicles[9]. demonstration of a giant fibrous polyp of the anus.
Although in our case we had no other option but to Gastrointest Endosc 2001; 53: 824-825
remove this giant polyp due to the intestinal obstruction it 6 Groisman GM, Polak-Charcon S. Fibroepithelial polyps
caused, in general, complete removal of these structures, of the anus: a histologic, immunohistochemical, and
regardless of the method used, offers definite therapeutic ultrastructural study, including comparison with the normal
anal subepithelial layer. Am J Surg Pathol 1998; 22: 70-76
benefits and results in improved patient satisfaction.
7 Sakai Y, Matsukuma S. CD34+ stromal cells and hyalinized
vascular changes in the anal fibroepithelial polyps.
Histopathology 2002; 41: 230-235
REFERENCES 8 Beer TW, Carr NJ. Fibroepithelial polyps of the anus with
1 Kusunoki M, Horai T, Sakanoue Y, Yanagi H, Yamamura epithelial vacuolation. Am J Surg Pathol 1999; 23: 488-489
T, Utsunomiya J. Giant hypertrophied anal papilla. Case 9 Gupta PJ. Hypertrophied anal papillae and fibrous anal
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2 Gupta PJ. A study of the symptomatology of hypertrophied surgery? World J Gastroenterol 2004; 10: 2412-2414

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