Abstract. Pseudopolyps are a frequent finding in the course of
inflammatory bowel disease. They are non-neoplastic lesions
resulting from a regenerative and healing process that leaves
inflamed colonic mucosa in polypoid configuration. Data about
their management is lacking. "Giant" pseudopolyps can be
mistaken for adenocarcinomas and, as they rarely regress with
medical management alone, a surgical resection is often required.
A case of giant pseudopolyposis treated non-surgically, in a patient
with concomitant ulcerative colitis and chronic hepatitis B, is
reported, representing a co-morbidity complicating an eventual
conservative treatment. The clinical implementation of topical
budesonide was originally tested, resulting in clinical, endoscopic
and histological remission. Budesonide seems a promising therapy
for IBD, particularly when a comorbidity with viral hepatitis exist.
The term pseudopolyp (or inflammatory polyp) is used to
describe non-neoplastic polypoid lesions resulting from a
regenerative and healing process that leaves inflamed colonic
mucosa in polypoid configuration (1). The formation of
pseudopolyps in the course of inflammatory bowel disease
(IBD) and particularly of ulcerative colitis (UC) is frequent,
with a reported incidence in older series varying from 12.5%
to 74% (2). They grossly appear as small filiform lesions and
very rarely as giant protruding colonic masses mimicking
adenocarcinomas. Histologically, they are characterized by
minimal alterations related to the underlying inflammation.
Data about the management of inflammatory polyps is
unsufficient. Giant pseudopolyps rarely regress with medical
management alone and often require surgical resection (3). To
our knowledge, this is the first report of giant pseudopolyposis
in a patient with concomitant IBD and chronic hepatitis B,
representing a co-morbidity complicating an eventual
A 45-year-old male patient was admitted to our service in July
2002 for acute rectal bleeding. All laboratory tests were
normal, except an increase of aminotransferases level (>10 N)
and a serological profile consistent with acute hepatitis B or a
flare of chronic hepatitis B (HbsAg +, HbsAb –, HbeAg –,
HbeAb +, HbcAb-IgM +). The patient underwent lower
gastro-intestinal endoscopy and multiple biopsies were taken
from a bulky rectal mass lesion (Figure 1). Histological study
revealed alterations compatible with inflammatory bowel
disease (IBD) with no dysplasia (Figure 2). Because of the
atypical macroscopic features and the high suspicion of rectal
adenocarcinoma, repeated endoscopic and histological studies
were subsequently performed, which established the diagnosis
of a giant pseudopolyp with no dysplasia, in a patient with IBD
and acute or HBeAg-negative chronic hepatitis B.
The patient was initially given 5-aminosalicylate (5-ASA)
both orally (2 g/d) and in enemas (4 g/d) for 6 weeks, resulting
in both clinical and endoscopic failure. Budesonide enemas
(2.3 g/d) replaced the initial therapy of 5-ASA for 6 more
weeks, resulting in control of bleeding with both macroscopical
and histological remission (Figure 3). The patient is followed-
up annually and receives topical treatment with 5-ASA in
suppositories (500 mg tiw).
In January 2003, both the initial serological profile and the
abnormal aminotransferases levels persisted, thus imposing a
liver biopsy. Chronic hepatitis with moderate fibrosis and
moderate necroinflammatory activity was microscopically
evidenced (Figure 4). The patient was given lamivudine
(100 mg/d) orally and responded biochemically. Twenty months
after his hospitalization, the patient maintains the above-
mentioned therapy and remains asymptomatic with normal liver
Inflammatory polyps complicating IBD are more commonly
found in cases of pancolitis than left-sided colitis and seem
related to the chronicity of the disease (4, 5). From this point
of view, the case reported herein, with giant pseudopolyps as
the primary anatomical expression of limited proctitis, is
Correspondence to: Dr. Charalampos Pilichos, Bouboulinas 27-
15341, Ag Paraskevi, Athens, Greece. Tel/Fax : +30 210 6524097,
Key Words: Inflammatory polyps, pseudopolyps, ulcerative colitis,
ANTICANCER RESEARCH 25: 2961-2964 (2005)
Topical Budesonide for Treating Giant Rectal Pseudopolyposis
CHARALAMPOS PILICHOS1, ATHENA PREZA1, MARIA DEMONAKOU2,
DIMITRIOS KAPATSORIS1and CONSTANTINOS BOURAS1
1First Department of Internal Medicine and 2Department of Pathology, Sismanogleion Hospital, Athens, Greece
ANTICANCER RESEARCH 25: 2961-2964 (2005)
Figure 1. Endoscopic view of rectum: giant pseudopolyp partially obstructing rectal lumen.
Figure 2. Histological features of the colonic mucosa before treatment: epithelial ulceration with prominent crypt distortion, cryptic abscesses and
Pilichos et al: Topical Budesonide for Treating Giant Rectal Pseudopolyposis
Figure 3. Histological restitution "ad integrum" (regression of all lesions) of the colonic mucosa after 12 weeks of topical treatment.
Figure 4. Liver histology before lamivudine treatment. Active viral replication with moderate fibrosis and moderate necroinflammatory lesions.
exceptional. Clinically, inflammatory polyps may be quiescent,
manifested by symptoms related to the underlying IBD or even
complicated by partial or complete colonic obstruction or
intussusception requiring emergency surgery (3-7). The above-
mentioned factors (extension, chronicity and acute
complications) make total coloproctectomy with ileoanal
anastomosis the most reasonable therapeutic choice, while
some authors have performed local excision of the
pseudopolyp, in a bowel-sparing method (6). However, in the
reported patient whose IBD was limited to the rectum, in
whom pseupoloyposis was the first manifestation of UC and
who presented without a life-threatening complication, total
coloproctectomy seemed disproportional to the severity of the
disease. It was our opinion that a non-surgical treatment would
be more appropriate.
Lesions located more distally than splenic flexure are
accessible to local treatment. Topical formulations of
mesalamine have proven efficacy and may be used as a first-line
therapy (8). Non-response to local mesalamine is, however,
possible and a second-line therapy of orally- or rectally-
administered corticosteroids might be an adequate alternative
(9). Because of the co-morbidity of UC and HBV infection,
priority was given to rectal formulations. Budesonide, being the
only corticosteroid available in enemas in Greece, induced both
clinical and endoscopic remission in 6 weeks.
The co-morbidity of UC and chronic hepatitis B was the
major problem in the management of our patient. Despite
their proven effectiveness in treating distal colonic disease,
various molecular forms of topical corticosteroids preserve
various degrees of colonic absorption and thus their
administration is not devoid of systemic side-effects, such as
immunosuppression (10). The use of corticosteroids (even in
topical formulations) in cases of viral hepatitis should be with
caution, since they may lead to an enhanced viral replication
and the widespread infection of hepatocytes (11). This is a
concern, particularly in cases of concomitant IBD and hepatitis
B, in which a fulminant liver failure is possible at the time of
steroids withdrawal. Conversely, interferon (IFN-·) treatment
for chronic viral hepatitis could exacerbate the clinical course
of an IBD (12). This risk is more than theoretical, as
Mavrogiannis reported a case of UC exacerbation following
interferon treatment for chronic hepatitis C (13). Nevertheless,
despite these concerns, in eight patients with concomitant
Crohn’s disease and chronic hepatitis C, Biancone et al.
showed that corticosteroids (as well as other immuno-
suppressors) and IFN-· do not counteract and should be both
integrated in the same therapeutic strategy (14).
Being devoid of the immune modulating properties of
IFN-·, lamivudine was chosen as an initial antiviral therapy.
In cases of chronic HBV infection by a pre-core mutant, which
is commonly found in Greece, there is indeed growing
evidence supporting the efficacy, the safety and the excellent
tolerability of lamivudine (15).
However, although topical budesonide and lamivudine are
both proven safe and effective as first-line treatment, classic
therapies including systemic corticosteroids and IFN-· still have
a place in the therapeutic arsenal and might be subsequently
implemented, in case of clinical aggravation or viral flare.
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Received January 10, 2005
Revised May 24, 2005
Accepted May 26, 2005
ANTICANCER RESEARCH 25: 2961-2964 (2005)