Management of a Large Pedunculated Colon Polyp in a Young Female with Severe Health Anxiety

Case at a Glance

A 34-year-old female with a history of severe health anxiety underwent a colonoscopy that revealed a 3cm pedunculated polyp. The case highlights the management of the polyp itself and the concurrent need to address the patient's profound psychological distress during the diagnostic waiting period.

Patient's Story

The patient is a 34-year-old mother of a toddler who presented for a colonoscopy with extreme pre-procedural anxiety. Following the procedure, she was informed that a large, 3cm pedunculated polyp and a second, smaller polyp were found and removed. The patient's anxiety escalated significantly upon hearing the endoscopist mention observing 'changes' in the larger polyp. Despite reassurance from the clinical team about clear margins and that the 'threat is gone,' the patient experienced intrusive thoughts and catastrophic fears about a potential cancer diagnosis, specifically worrying about invasion down the polyp's stalk. This anxiety became all-consuming, affecting her daily functioning and exacerbating her distress over the 1-2 week wait for pathology results, particularly as she and her partner were hoping to conceive another child soon.

Initial Assessment

The patient presented as a well-nourished 34-year-old female for a scheduled colonoscopy. A significant history of generalized anxiety disorder with a focus on health was noted in her chart. Pre-procedural assessment confirmed her heightened state of anxiety regarding the procedure and potential findings. The indication for the colonoscopy was based on an evaluation for non-specific gastrointestinal symptoms.

The Diagnostic Journey

During the colonoscopy, a 3cm pedunculated polyp was identified in the sigmoid colon. The polyp had a long stalk, and the head of the polyp showed some surface irregularities and subtle color changes concerning for dysplasia. A second, smaller polyp (approximately 5mm) was found in the transverse colon. Both polyps were successfully removed in their entirety via snare polypectomy and retrieved for histopathological analysis. Post-procedure, the endoscopist communicated the findings to the patient, expressing confidence that the polypectomy was complete and margins appeared clear. However, the patient fixated on the possibility of malignancy and was unable to be fully reassured, demonstrating significant emotional distress while awaiting the pathology report.

Final Diagnosis

Histopathology report confirmed the 3cm polyp as a 'Tubulovillous adenoma with high-grade dysplasia, completely excised.' The margins of the resection, including the stalk, were free of dysplastic cells. The smaller polyp was diagnosed as a 'Tubular adenoma.' The final diagnosis was the successful endoscopic removal of pre-cancerous lesions, preventing progression to adenocarcinoma.

Treatment Plan

The primary treatment was the completed therapeutic polypectomy. Upon receiving the pathology results, the patient was contacted and scheduled for a follow-up consultation to discuss the findings in detail. The plan included:

1. Gastroenterological Management: Reassurance that the high-grade dysplasia was fully contained within the polyp and that the removal was curative. A surveillance colonoscopy was scheduled in 3 years, per standard guidelines for large adenomas with high-grade dysplasia.
2. Psychological Support: A formal referral was made to mental health services for cognitive-behavioral therapy (CBT) to address her severe health anxiety. The importance of developing coping mechanisms for managing uncertainty during surveillance periods was emphasized.

Outcome and Follow-up

At her follow-up appointment, the pathology results were explained thoroughly to the patient. The physician stressed that the colonoscopy had successfully prevented the development of colon cancer. While relieved by the news, the patient acknowledged the profound impact the anxiety had on her well-being. She agreed to pursue counseling to better manage her health anxiety. Her family planning discussions were able to resume without the immediate fear of a cancer diagnosis. She is scheduled for her next surveillance colonoscopy in three years.