To do or not to do: prolapsed, bleeding, rectal polyp, a dil
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A 40-year-old, female presented to the out-patient with breathlessness and extreme pallor, and her mother who accompanied her gave 5-year history of a reducible mass per rectum, which had become irreducible and was bleeding continuously for the past 6 days. She was having fainting attacks and was dripping serosanguinous fluid from her anal region. The only investigation she had was a hemoglobin report of 5 g% done 3 days back. She had no significant medical or family history.

On examination, she was grossly pale, had a tachycardia of 110/min, respiratory rate of 24 per min, and systolic blood pressure of 90 mm Hg. Her abdomen was scaphoid with no organomegaly or lump. Rectal inspection revealed a large villous mass (10 x 12 cm size) (Figs 1 and 2) with left anterolateral rectal wall prolapse (Fig. 2B). There was an area of injury (due to finger insinuation) with clot (Figs 1B, 2A and 2C) and the papillomatous polyp was having almost watery bleeding (Fig. 1B) and a thin mucoid discharge.

The possibility of getting blood and anesthesia for her immediately was nil, as she was from an extremely poor socio-economic background and had no relatives to arrange for blood, which is the routine pre-requisite for issuing blood in our hospitals. The necessity to stop her bleeding was the top priority, so with explained risks and consent she was given IV analgesia and on a slow drip of lactated ringer, cleaned and draped. The mass was resected with a centimeter margin all around from the visible base of 3 x 2 cm (Fig. 2B) (a third of the rectal circumference) and the rectal wall was sutured with 2-0 interrupted Vicryl. On repositioning of the redundant rectum, the suture line was felt 6–7 cm from the anal verge to the left.

Post-operative course was smooth, and she had no subsequent bleeding or prolapse and on insistence was discharged on the third post-operative day, after arranging and transfusing three units of blood. All her investigations carried out post-operatively were normal, except for an hemoglobin of 3.5 g% which increased to 7.0 g% following transfusions. Her histopathology reported a tubulo-villous adenoma with no evidence of dysplasia. She came back for follow-up after 15 days when her colonoscopy was performed which did not reveal any other polyps. However, she has been kept on regular follow up, and is asymptomatic for 1 year now.