A 48-years-old male patient with a history of familial adenomatous polyposis (FAP) underwent a prophylactic restorative proctocolectomy (RPC) and ileal-pouch anal anastomosis (IPAA) 16 years ago. He presented with rectal bleeding and the endoscopy revealed multiple coalescent polypoid lesions (T0-Is+IIa), circumferentially occupying the anal transitional zone and the surgical anastomosis. Biopsy specimens showed a tubulovillous adenoma withlow grade dysplasia with focal high grade dysplasia.