Ascending Colon Leiomyoma: A Case Report of a Uncommon Case

A 52-year-old male who is known to have essential hypertension, which is controlled by medications (losartan 50 mg once daily), presented to gastroenterology clinic with concern of positive result of a fecal immunochemical test which was performed for screening purposes. The patient is otherwise well with no active gastrointestinal symptoms or constitutional symptoms. He has no family history of gastroenterological diseases or malignancies. He has been a smoker of shisha (tobacco pipe) for the past 30 years (1 shisha daily). He denied any alcohol intake. Physical examination was unremarkable. Laboratory tests including CBC, Creatinine, albumin, electrolytes, and liver enzymes were all within normal limits. After colon preparation with 2 liters of polyethylene glycol solution, a colonoscopy was performed, which revealed a 0.5 cm sessile polyp (Paris classification 0-Is) with a smooth surface located 2 cm distal to the ileocecal valve. The polyp was lifted with epinephrine/saline mixed solution (1:10,000), then resected with a hot snare and submitted to histopathology examination without immediate complications. The colonoscopy was otherwise normal. The histopathology report confirmed the size of the polyp (5 mm), single, firm, gray-white, polypoid 0.5 cm inflamed submucosal leiomyoma with inflamed and ulcerated surface [Figures 1 - 3 ]. No findings are suggestive of malignant changes. Section from grossly described polypoid tissue showing nodular and circumscribed submucosal proliferation of interlacing smooth muscle fibers obliterating the muscularis mucosal layer. Overlying mucosal epithelium is unremarkable. Low power (x40) magnification, hematoxylin and eosin staining Intermediate power (x200) microscopic view of H and E stain demonstrating smooth muscle spindle cells proliferation having round to oval nuclei and overlying unremarkable colonic epithelium High power (x400) microscopic view of the lesion showing a closer view of spindle cells lacking cytological atypia, mitoses, and necrosis Upon follow-up after 2 weeks, the patient was doing well with no active complaints. And CT was ordered to screen the rest of the gastrointestinal system for other lesions. A month later, a CT showed lipomatosis of the terminal ileum and ileocecal valve with diffuse intramural fatty infiltration Figure 4 . Abdominal computer tomography showed lipomatosis of the terminal ileum and ileocecal valve with diffuse intramural fatty infiltration. Coronal (a) and axial (b) plane (red arrow)

Well-differentiated smooth muscle cells, which can originate from the muscularis mucosa, muscularis propria, or vascular smooth muscle, make up colonic leiomyomas, which are benign proliferations. Although they can appear anywhere in the digestive tract, the stomach and small intestine are where they are most frequently encountered.[ 1 2 ] They are benign because they hardly ever show signs of cellular atypia or malignant potential, and they usually appear as unintentional observations on radiologic imaging or colonoscopy.[ 3 4 5 ] Colonic leiomyomas are very uncommon; they make up only 3% of gastrointestinal leiomyomas, and 1% of gastrointestinal neoplasms are rectum leiomyomas.[ 5 6 7 8 ] It frequently occurs after the age of 50 years, with male predominance of 2.4:1.[ 1 8 ] True gastrointestinal (GI) leiomyomas often affect the stomach or esophagus; however, they can also occasionally show up in the rectal region.[ 3 ] It is most commonly found in the descending and sigmoid colons, where it typically manifests as accessory little intraluminal polyps.[ 9 ] The majority of patients are asymptomatic and are only incidentally diagnosed during routine endoscopic and radiological tests; nevertheless, in the event that they do exhibit symptoms, they may manifest as constipation, abdominal pain, bleeding, intestinal obstruction, or palpably feel like they have large abdominal masses.[ 7 10 ] Histology is required for confirmation, but colonoscopy, radiologic imaging such as computed tomography (CT) with colonography, and magnetic resonance imaging (MRI) can be helpful diagnostic tools.[ 11 ] It is most commonly found in the descending and sigmoid colons, where it typically manifests as accessory little intraluminal polyps.[ 9 ] Colonic leiomyomas may manifest as adenomas, pedunculated polyps, or sessile polyps.[ 1 ] This case shows an unusual finding of a leiomyoma in the ascending colon, as colonic leiomyomas are usually detected in the rectum and sigmoid colon. Since ascending colonic leiomyoma is extremely uncommon, it is critical to report any cases that do occur to raise awareness among medical professionals. This case report highlights a 52-year Saudi man who presented with ascending colonic leiomyoma discovered during screening colonoscopy.

Colonic leiomyoma is a very uncommon benign tumor. CT can be useful in distinguishing between benign leiomyoma and leiomyosarcoma; nevertheless, tissue diagnosis is the gold standard. The most important diagnostic stage is histoimmunopathology. For small and big colonic leiomyoma polyps, respectively, snare polypectomy with complete removal and broad surgical removal with follow-up is adequate treatment. In some cases of leiomyosarcoma, the mainstay of treatment is surgical excision, with or without radiation and chemotherapy. Nil. There are no conflicts of interest.

During routine endoscopic assessments, a polyp discovered should be taken into consideration for the differential diagnosis of colonic leiomyomas.[ 1 ] Most GI polyps are epithelial in origin.[ 6 ] However, benign proliferations of nonepithelial cells, such as those originating from smooth muscle layers, are referred to as leiomyomas; these proliferations can happen in the colon and are usually discovered by accident.[ 12 ] The rectum and sigmoid colon are the primary locations of these tumors, which are primarily seen in males with a median age of 62 years, according to a study by Miettinen et al .[ 3 ] that examined 88 tumors of the muscularis mucosae of the colon and rectum. The patients in this case study were 52 years old. Colonic leiomyomas, which primarily affect males over 50, are typically benign and asymptomatic.[ 1 ] They may present in asymptomatic individuals on screening like our patient, but also can have accompanying symptoms including bleeding, abdominal pain, and intestinal obstruction.[ 1 ] The histopathology findings of an inflamed submucosal leiomyoma with no malignant changes are reassuring in terms of cancer risk. However, the presence of inflammation within the polyp raises questions about potential underlying causes, such as chronic irritation or other inflammatory conditions within the gastrointestinal tract. Given the patient’s smoking history and the inflammatory nature of the polyp, it is reasonable to consider whether smoking contributed to the inflammatory changes observed. Certain persons with leiomyomas present with symptoms such as bleeding, stomach pain, and intestinal blockage, whereas in other cases, the tumors are discovered incidentally during screening tests like endoscopy and cause no symptoms at all. Endoscopic leiomyomas might show up as intramural or pedunculated lesions.[ 6 ] In addition to endoscopy and colonoscopy, MRI and CT can also aid in diagnosis; nonetheless, histology remains the final arbiter of diagnosis.[ 11 ] Furthermore, the incidental finding of lipomatosis of the terminal ileum and ileocecal valve on CT scan adds another dimension to the case. While lipomatosis is often considered a benign condition, its presence raises the question of whether there are underlying metabolic or inflammatory processes contributing to its development. Additionally, the diffuse intramural fatty infiltration observed suggests a more systemic process affecting the gastrointestinal tract and further investigation into potential underlying conditions such as inflammatory bowel diseases.