Pyogenic Granuloma Masquerading as an Ulcerated Sigmoid Polyp: 1480

A 60 year-old asymptomatic male presented for routine screening colonoscopy and a semi-pedunculated, friable, polypoid lesion measuring 15 mm was found in the sigmoid colon, for which four cold forceps biopsies were taken. Pathology showed “mucosal ulceration, with focal epithelial atypia.” A second colonoscopy with saline assisted endoscopic mucosal resection as performed two weeks later. There was substantial bleeding that was successfully treated with epinephrine and a hemostasis clip. Pathology this time revealed a “benign vascular proliferation of capillaries and granulation tissue” consistent with a pyogenic granuloma. A third colonoscopy was performed 4 weeks later with residual tissue found at the site which was ablated using argon plasma coagulation. Pyogenic granulomas are benign vascular neoplasms made up of lobules consisting of clusters of endothelial cells with variation of the lumina. The characteristic feature is the capillary lobule, which is a central branching vessel absent of red blood cells, surrounded by proliferation of neoformed endothelial and perithelial cells. The superficial portions have the possibility of undergoing secondary changes including edema of the stroma, capillary dilation, inflammation, and presence of granulation tissue which can be easily mistaken for a polyp. Because of its high vascularity, the areas are prone to bleeding with polypectomy. Review of the literature demonstrates that they are most commonly found in the nasal/oral mucosa or skin, and rarely the GI tract (15 reported cases), with the colon being the least common location. They can occur at any age; however, those that occurred within the gastrointestinal tract yielded a mean age of 54.8 years, with a span of 26 to 80 years. Usually, because of its malignant-appearing presentation, it is usually described as a colon cancer mimic, with differential including but not limited to: inflammatory polyp, angiosarcoma, angiomatous variant of Kaposi sarcoma, bacillary angiomatosis, and vascular proliferation related to intussusception/mucosal prolapse. Diagnosis is made after biopsy or resection. Cure is typically achieved with an average of three endoscopic sessions and recurrence has been reported as low. Improved endoscopic identification, because of the high risk of bleeding secondary to vascular proliferation, would potentially improve procedure outcomes and decrease adverse events prior to polypectomy.Figure 1Figure 2Figure 3