Indian Pediatrics 1998; 35:897-900 

Spectrum of Colonic Polyps

Procedure

The pediatric colonoscopies were carried out using pediatric fiberoptic colonoscope (PCF-20, Olympus Co., Japan). Polypectomy snare along with diathermy apparatus was used for endoscopic polypectomy using 3 joule blended current. Insufflation with CO2 gas was done during polypectomy in children in whom mannitol was used. Dormia basket or snare was used to retrieve the cut polyp.

All the procedures were carried out either in left lateral position or supine position in operation theatre without fluoroscopy. Manual compression of abdomen was done whenever there was difficulty in advancing the colonoscope. In one patient, the polyp was too small to be held by polypectomy snare. Heater probe (HPU, Olympus Co., Japan, 25 joules) was used to stop the bleeding from diminutive polyp.

All the polyps were retrieved either by dormia basket or from the stool by sieving. Resected polyps were subjected to histopathological examination.

Results

The endoscopist at the time of examination found clean, well prepared colon in 21 children. In the remaining 4, liquid stool matter was seen at a few places, however colonoscopy could be performed. Total colonoscopy was performed in 18 cases (72%). In the remaining 7 children, the colon up to splenic flexure was examined thoroughly.

Children's age ranged from 2 years to 15 years with a mean age of 7.58 years. Of the 25 children (male 19, female 6), 8 (32%) were less than 5 years; 8 (32%) were between 5 to 10 years and 9 (36%) were more than 10 years of age.

Eighty three children presented :with history of bleeding per rectum and one of them had an additional history of Something coming out per rectum. Twenty five children were found to have polyps in colon. The children were referred to our center with prior investigations including barium enema done in 21 cases. Eighteen out of 21 showed features suggestive of polyp on barium enema examination.

Colonoscopic examination showed a single polyp in 20 cases (80%) and two polyps in 3 (12%) cases. In the remaining 2 cases colonoscopy showed the whole colon to be studded with pulyps and these were the cases of multiple adenomatous polyposis coli.

The sites of polyp included; 15 (57.69%) in the rectum; 9 (34.62%) in sigmoid colon and 2(7.69%) in descending colon. Fifteen out of 26 (57.69%) polyps were pedunculated and the remaining 11 (42.32%) were sessile.

The average time period required for the procedure of polypectomy ranged from 15 to 60 minutes. One patient had perforation during polypectomy which was successfully managed surgically. None of the other patients had any anesthesia or procedure related complications.

In 20 (80%) children the polyp was retrieved either by Dormia basket or' from stool. All the specimens were subjected for histopathological examination. Juvenile polyp was seen in 15 (60%), adenomatous polyp in 2 (8%) and inflammatory polyp in 3 (12%) cases. In 5 (20%) patients, the polyp could not be retrieved.

Discussion

Colorectal polyp is the most common cause of bleeding per rectum in the children(2-4). Before the introduction of fiberoptic colonoscopy, the treatment of polyp beyond the sigmoid colon was surgical. Invention of fiberoptic colonoscope and technique of polypectomy using diathermy snare made a dramatic change in the treatment of such polyps(5). Results of earlier studies showed that colonoscopic polypectomy can be safely used in the children(6-8).

Most of the polyps in the children are located in the rectum and the sigmoid co- lon(3,4,9). In an Indian study(6), 60% of the polyps were in the rectum, 24% in the sigmoid colon, 8% in descending colon, 2% in splenic flexure, 2% in transverse colon and 2% in ascending colon while the colon was studded with polyps in 1 (2%) case. Our study revealed 57.7% of polyps in rectum, 34.6% in sigmoid colon, 7.69% in descending colon. Two cases were found to have multiple adenomatous polyposis coli.

Most of the polyps in the children are hamartomatous, usually juvenile(2,3,4,9). Various studies revealed that more than 90% of polyps are juvenile. Our study revealed juvenile polyps in 15 out of 20 cases, adenomatous polyps in 2, inflammatory polyp in 3 cases, in contrast to high prevalence of juvenile polyps at other centers. The cause of the inflammatory polyps could not be identified. On colonoscopy the colonic mucosa was normal except for the polyp. A single juvenile polyp has no ma- lignant potential. It has to be removed only if symptomatic. The most common symptom is bleeding per rectum.

Colonoscopy is safe, simple and very useful investigation in children presenting with bleeding per rectum. Colonoscopies picked up polyps in 3 additional children in our study, which was missed on barium enema examination. Moreover, brush cytology and biopsies can be collected from abnormal or suspicious area. Also, therapeutic procedure like polypectomy can be carried out in same sitting or later on.

Colonoscopic polypectomy is a safe procedure and can be carried out under sedation or general anesthesia. Earlier Indian workers have used intravenous sedation in majority of cases(6,7). However, some preferred general anaesthesia or intravenous ketamine(10). We prefer general anaesthesia in children to relax smooth muscles of colon and to avoid movement of child during the procedure. We used general anaesthesia in 21 children. Complications like perforations of colon and bleeding have been described in various studies(I,7). Except for the perforation in one case, there were no procedure related complications in our study.




 

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