Giampaolo Iacopini

Heterotopic gastric mucosa in the anus and rectum: first case report of endoscopic submucosal dissection and systematic review

Background: Heterotopic gastric mucosa (HGM) is the most reported epithelial heterotopia, but it is very rare in the rectum and anus. Methods: The first case of an asymptomatic adult male with a large nonpolypoid HGM in the low rectum underwent complete resection by endoscopic submucosal dissection (ESD) is reported. The systematic review was based on a comprehensive search of MEDLINE, EMBASE and Google Scholar. Studies on humans were identified with the term ‘heterotopic gastric mucosa in the rectum and /or anus.’ Results: The search identified 79 citations, and 72 cases were evaluated comprising the present report. Congenital malformations were observed in 17 (24%) patients; rectal duplication accounted for most of the cases. The HGM was located in the anus and perineal rectum in 25 cases (41%) and low, middle and proximal pelvic rectum in 20 (33%), five (8%) and 11 cases (18%), respectively. Morphology was nonpolypoid in 37 cases (51%), polypoid in 26 cases (36%) and ulcerated in nine cases (13%). Specific anorectal symptoms were reported by 50 (69%) patients of the whole study population, and by 33 (97%) of 34 patients ≤ 18 years. Complications were observed in 23 cases (32%). The HGM was excised in 50 cases (83%). Endoscopic resection was performed in 17 cases (34%); resection was piecemeal in five of 12 lesions ≥15 mm, required argon plasma coagulation in two cases and was associated with residual tissue in two (17%). Intestinal metaplasia and an adenoma with low-grade dysplasia were described in three adults (4%). Discussion: This systematic review shows that the HGM in the rectum and anus may be associated with specific rectal symptoms and serious complications, mainly in the pediatric population, and a risk of malignancy in adults. Its complete excision should be recommended, and the ESD can overcome the technical limits of conventional endoscopic snare resection and avoid unnecessary surgery.

Colorectal endoscopic submucosal dissection: predictors and neoplasm-related gradients of difficulty

Background and study aim  The role of colorectal endoscopic submucosal dissection (ESD) is standardized in Japan and East Asia, but technical difficulties hinder its diffusion. The aim was to identify predictors of difficulty for each neoplasm type. Methods  A competent operator performed all procedures. ESD difficulty was defined as: en bloc with a slow speed (< 0.07 cm 2 /min; 30 × 30 mm neoplasm in > 90 min), conversion to endoscopic mucosal resection, or resection abandonment. Pre- and intraoperative difficulty variables were defined according to standard criteria, and evaluated separately for the rectum and colon. Difficulty predictors and gradients were evaluated by the multivariate logistic regression model. Results  A total of 140 ESDs were included: 110 in the colon and 30 in the rectum. Neoplasms were laterally spreading tumors – granular type (LST-G) in 85 cases (61 %); the median longer axis was 30 mm (range 15 – 180 mm); a scar was present in 15 cases (11 %). ESD en bloc resection and difficulty rates were 85 % (n = 94) and 35 % (n = 39) in the colon, and 73 % (n = 22) and 50 % (n = 15) in the rectum ( P  = 0.17 and 0.28, respectively). The scar was the only preoperative predictor of difficulty in the rectum (odds ratio [OR] 12.3, 95 % confidence interval [CI] 1.27 – 118.36), whereas predictors in the colon were: scar (OR 12.7, 95 %CI 1.15 – 139.24), LST – nongranular type (NG) (OR 10.5, 95 %CI 1.20 – 55.14), and sessile polyp morphology (OR 3.1, 95 %CI 1.18 – 10.39). Size > 7 – ≤ 12 cm 2 (OR 0.20, 95 %CI 0.06 – 0.74) and operator experience > 120 procedures (OR 0.19, 95 %CI 0.04 – 0.81) were predictors for a easy procedure. No intraoperative predictors of difficulty were identified in the rectum, whereas predictors in the colon were: severe submucosal fibrosis (OR 21.9, 95 %CI 2.11 – 225.64), ineffective submucosal exposure by gravity countertraction (OR 12.3, 95 %CI 2.43 – 62.08), and perpendicular submucosal dissection approach (OR 5.2, 95 %CI 1.07 – 25.03). When experience was /= 90, preoperative gradient of colonic ESD difficulty was the highest for LST-NGs (scar positive and negative up to 47 % and 20 %, respectively), intermediate for sessile polyps with scar (up to 23 %), and the lowest for LST-Gs (< 8 %). Different difficulty gradients between neoplasm types persisted with increasing experience: LST-NG rate up to 14 % after 120 procedures. Conclusions  Colonic and rectal ESD difficulty has qualitative differences. Preoperative predictors should be considered to identify the difficulty gradient of each neoplasm type and the appropriate setting for ESD.

7148 Two young patients with a primary form of pneumatosis cystoides intestinalis.

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of submucosal or subserosal gas-filled cysts within the bowel wall. From 1985, we have observed five cases of PCI; we present two of these cases, that can be considered atypical in some way. In the first patient, a 20-year-old white male, disease was localized to the right colon. He had a history of chronic abdominal pain, with no findings at physical examination. A colonoscopy showed the presence of multiple rounded bluish masses in the right colon; puncture of these polypoid lesions with an endoscopic injection needle caused them to collapse, so confirming the diagnosis.A barium enema was then performed, with final definition of the case. An accurate evaluation excluded any associated condition and patient received no specific therapy. Three months later, follow-up endoscopy documented a complete resolution of the lesions. The second patient, a 23- year-old female, presented a disease localized to the left colon. She was referred for a recent history of abdominal pain and change in bowel habits; for this reason, patient underwent a colonscopy showing the presence of multiple typical lesions of PCI in the descending-sigmoid colon. Again, no associated condition was found. Follow-up endoscopy, performed after four months, revealed disappearance of gas collections without specific treatment. We conclude that the peculiarity of these two cases of PCI consists in the following aspects: 1)appearance in young patients; 2)absence of associated conditions (primary or idiopathic form); 3)differential diagnosis with inflammatory bowel disease; 4)spontaneous and rapid resolution of lesions.

Acute intestinal ischemia in a young patient with cocaine abuse and polycythemia

A 29-year-old patient was admitted to our hospi tal with hematemesis, hematochezia and abdominal pain. He was affected by polycythemia (basal hemoglobin level: 18.5 g/dL) and referred cocaine abuse. Physical examination showed mild diffuse abdominal tenderness, hypotension, tachycardia and postural changes. Laboratory data documented a severe anemic condition (hemoglobin: lO g/dL). Therefore, an upper gastrointestinal endoscopy was performed showing blood clots in the fundic area and a gastric ulcer with non bleeding visible vessel, undergone to injection therapy (epinephrine 1:10000, total amount 8 ml); in addition, mucosa of the distal duodenum appeared frankly ischemic. A colonoscopy was negative for mucosal lesions but revealed the presence of red blood. Subsequently, an arteriogram of mesenteric vessels documented occlusion of the superior mesenteric artery. Therefore, patient underwent surgical intervention with extensive jejunal and limited ileal resection. We present a case of acute intestinal ischemia in a young man with polycytemia and cocaine abuse. The combination of the above conditions is rare. Nevertheless, mesenteric ischemia should be considered in the differential diagnosis of abdominal pain syndrome in patients with cocaine abuse.