Journal of Surgery (ISSN: 2575-9760)

case report

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Case Report: Cap Polyposis in Advanced Pelvic Floor Dysfunction - Stronger Evidence of a Mechanical Prolapse-Related Pathology

Adrian Sebastian1*, Chris Gillespie1,2

1Functional Colorectal Unit, Queen Elizabeth II Hospital, Brisbane, Australia

2University of Queensland, St Lucia QLD 4072, Australia

*Corresponding author: Adrian Sebastian, Functional Colorectal Unit, Queen Elizabeth II Hospital, Brisbane, Australia

Received Date: 07 November, 2022

Accepted Date: 14 November, 2022

Published Date: 17 November, 2022

Citation: Sebastian A, Gillespie C (2022) Case Report: Cap Polyposis with Advanced Pelvic Floor Dysfunction: Stronger Evidence of Mechanical Prolapse-Related Pathology. J Surg 7: 1623. DOI: https://doi.org/10.29011/2575-9760.001623

Abstract

We describe a case of diffuse rectal involvement with cap polyposis, manifesting as a protein-losing colopathy and occurring in the setting of advanced mechanical pelvic floor dysfunction. A 59-year-old male with a 5-year history of persistent excessive flatulence, defecatory difficulties and diarrhoea was diagnosed with extensive cap polyposis of the entire rectum. His symptoms progressed to severe faecal incontinence with mucus leakage, pelvic pain, weight loss, and hypoalbuminemia. Clinical examination exhibited severe perineal descent, a large rectocoele, poor anal squeeze, and a poor defecatory technique. After a trial of non-operative therapies addressing his defecatory dysfunction and Helicobacter Pylori eradication, surgical resection was offered due to severe symptoms with ongoing incontinence and protein loss with no other reasonable option. A robotic perineal resection with a permanent colostomy was performed, followed by an uncomplicated recovery. Our observation of coexisting mechanical pelvic floor dysfunction floor changes in this patient lends weight to the concept of prolapse-related floor changes in the pathophysiology of this rare condition.

Keywords: Cap polyposis; Case report; Faecal incontinence; Pelvic dysfunction

Introduction

Cap polyposis is a rare, benign, intestinal condition characterised by erythematous, inflammatory polyps covered by a ‘cap’ of fibrinopurulent mucous. It was initially described by Williams et al, and to date, has been followed by under 100 case reports/series in English literature [1-4]. It affects patients of both genders in a wide age range, usually in the 5th decade, but can also affect the paediatric population [2,4]. Cap polyps may be found throughout the colon, most commonly localised in the rectum and rectosigmoid area. The most common symptoms include abdominal pain, rectal bleeding, and mucoid diarrhoea [1,5] and severe cases of cap polyposis can lead to protein-losing enteropathy [6]. The pathogenesis of cap polyposis remains unclear and is debated between infectious, inflammatory, and mucosal prolapse aetiologies. We describe a case of diffuse rectal involvement with cap polyposis leading to profuse mucus leakage, faecal incontinence, and protein-losing colopathy in a patient with advanced mechanical pelvic floor dysfunction.

Case Presentation

A 59-year-old male presented with initial complaints of excessive flatulence. He was well apart from having a history of Gastro-Oesophageal Reflux Disease (GORD) and renal calculi. He was an ex-smoker and had moderate alcohol consumption. His regular medication was pantoprazole. The patient described a 5-year history of mixed obstructive defecation symptoms, faecal urgency, and flatus incontinence that worsened gradually over time. He tried a low FODMAP and dairy-free diet but had persisting symptoms.

A diagnosis of cap polyposis was made on colonoscopy, with 5-10mm polypoid lesions extending from the anorectal junction proximally to the sigmoid colon, mainly affecting the rectum with diffuse involvement (see Figure 1). Histology confirmed innumerable erythematous polyps with mucus caps, hyperplastic crypts and expanded, inflamed lamina propria. Clinically he exhibited signs of advanced pelvic floor dysfunction with significant perineal descent, a palpable rectocele, poor anal squeeze, and a poor defecatory technique. He was treated with dietary alteration, regular laxatives, biofeedback therapy, and a course of H.Pylori eradication.