Jung Pil Suh

Regression of giant pseudopolyps in inflammatory bowel disease

Inflammatory pseudopolyps are formed in the regenerative and healing phases of ulcerated epithelium. Giant pseudopolyposis of the colon (pseudopolyp larger than 1.5 cm in size) is a very rare complication of inflammatory bowel disease and it may lead to colonic intussusception or luminal obstruction, but the more important clinical significance is that it can be endoscopically confused with a malignancy, although it is generally regarded as having no malignant potential. It has been reported that giant pseudopolyposis of the colon rarely regresses with medical management alone and this sometimes require surgical or endoscopic resection. This report illustrates 2 unusual cases of giant pseudopolyps associated with Crohns disease and ulcerative colitis, and these giant pseudopolyps were initially confused with villous adenoma or adenocarcinoma, but they showed regression after adequate medical therapy.

Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥ 30 mm) pedunculated colorectal polyp?

BACKGROUND: Snare polypectomy of a giant pedunculated colorectal polyp is sometimes technically demanding, and, therefore, piecemeal resection is inevitable, despite the relative risk of invasive cancer and postpolypectomy bleeding. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection in comparison with conventional snare polypectomy for giant pedunculated polyps DESIGN AND SETTINGS: We retrospectively reviewed the clinical outcomes and complications of endoscopic polypectomy for giant pedunculated polyps from October 2006 to November 2011. PATIENTS: All the patients who underwent endoscopic submucosal dissection (n = 23) or snare polypectomy (n = 20) for pedunculated polyps ≥3 cm were enrolled consecutively. In the case of a giant pedunculated polyp with 1) poor visualization of the stalk, 2) technical difficulties in snare positioning for en bloc resection, or 3) need for trimming of the head, we did not attempt piecemeal snare polypectomy, and we performed endoscopic submucosal dissection instead. (These were arbitrarily defined as “difficult” giant pedunculated polyps.) MAIN OUTCOME MEASURES: Data on the patient’s demography, endoscopic and histopathologic findings, clinical outcomes, and complications were analyzed. RESULTS: Among the 43 giant pedunculated polyps, 23 polyps were defined as “difficult” polyps and were removed with endoscopic submucosal dissection. Subpedunculated (stalk <1 cm) type was more common in the “difficult” polyp group (p = 0.01). The overall incidence of cancer was 18.6% (8/43). En bloc resection rates were 100% (23/23) in the endoscopic submucosal dissection group and 90% (18/20) in the snare polypectomy group. The procedure times of snare polypectomy and endoscopic submucosal dissection group did not differ significantly (41.7 ± 13.7 minutes vs 44.9 ± 35.6 minutes, p = 0.70). Postpolypectomy bleeding was noted in 1 case (4.3%) in the endoscopic submucosal dissection group and in 3 cases (15%) in the snare polypectomy group. CONCLUSIONS: Endoscopic submucosal dissection, as well as the snare polypectomy for giant pedunculated polyps, appeared to be effective without major complications and can be an alternative option to achieve en bloc resection, particularly for difficult cases, such as giant subpedunculated polyps.

Endoscopic submucosal dissection for nonpedunculated submucosal invasive colorectal cancer: is it feasible?

Background/aims There have been no definite indications for additional surgical resection after endoscopic submucosal dissection (ESD) of submucosal invasive colorectal cancer (SICC). The aims of this study were to evaluate the feasibility of ESD for nonpedunculated SICC and to determine the need for subsequent surgery after ESD. Patients and methods A total of 150 patients with nonpedunculated SICC in resected specimens after ESD were analyzed. Among them, 75 patients underwent subsequent surgery after ESD. Clinical outcomes of ESD and histopathological risk factors for lymph node (LN) metastasis were evaluated. Results The en-bloc resection and complete resection (R0) rates of ESD were 98% (147/150) and 95.3% (143/150), respectively. None of the patients had delayed bleeding after ESD. Perforations occurred in seven patients (4.7%), which were successfully treated by endoscopic clipping. After subsequent surgery for 75 patients, LN metastases were found in 10 cases (13.3%). The incidence of LN metastasis was significantly higher in tumors featuring submucosal invasion of at least 1500 &mgr;m, lymphovascular invasion, and tumor budding. Multivariate analysis showed that lymphovascular invasion (P=0.034) and tumor budding (P=0.015) were significantly associated with LN metastasis. Among the 150 patients, no local recurrence or distant metastasis was detected, except one patient with risk factors and who refused subsequent surgery, during the overall median follow-up of 34 months (range, 5–63 months). Conclusion ESD is feasible and may be considered as an alternative treatment option for carefully selected cases of nonpedunculated SICC, provided that the appropriate histopathological curative criteria are fulfilled in completely resectable ESD specimens.

Gastroenterology: Acute mucosal injury of esophagus and stomach induced by sodium picosulfate/magnesium citrate for bowel preparation

A 68-year-old woman was admitted to our hospital because of heart burn and epigastric pain. The patient underwent an upper gastrointestinal endoscopy examination which revealed longitudinal vesicles with hemorrhagic content in the lower esophagus (Figure 1a–b). In addition, multiple longitudinal confluent ulcers coated with a thick yellow exudate was present on the greater curvature of the upper gastric body (Figure 1c–d). Exudative coatings was removable with biopsy forceps, and hyperemic streaks were exposed afterwards (Figure 1e–f). Histological examination of biopsies taken from the lesions showed inflammatory exudates with fibrin and inflammatory cell aggregates (Figure 2a, H&E staining, magnification, x200) and infiltration of inflammatory cells with extravasations of red blood cells in the mucosal layer (Figure 2b, H&E staining, magnification, x200). The history of the presentation included that a screening colonoscopy was been planned for this patient. The patient swallowed a bowel preparation of sodium picosulfate/magnesium citrate powder (Picolight, Pharmbio Limited, Seoul, Korea) without dissolving it in water as per recommendations. Thereafter, the patient swallowed only a small volume of water. Sodium picosulfate/magnesium citrate (PSMC) is a low volume bowel cleansing agent that has been available in Korea since 2011, although it has been used for more than 20 years in European countries. PSMC is generally well tolerated and considered pleasant to taste, thus potentially improving patient compliance. Moreover, this preparation was better accepted than polyethylene glycol in terms of a low volume of lavage solution. Recently, colonic mucosal inflammation has been reported in patients taking PSMC, however endoscopically proven esophageal or gastric mucosal inflammation induced by the inadvertent taking of PSMC powder has not yet been reported. The reason for esophageal or gastric mucosal injury due to PSMC is uncertain but may be due to heat that can be generated when a mixture of PSMC powder and small volume of water is inappropriately ingested. Direct thermal effect may be responsible for this injury. Therefore, thorough preparation instruction is important to prevent possible upper gastrointestinal mucosal injury from PSMC. Emphasis should be made to dissolve the PSMC powder in an adequate volume of water before ingestion.

Education and imaging. Gastrointestinal: Asymptomatic rectal perforation and massive pneumoretroperitoneum in patient with ulcerative colitis treated with mesalamine enemas.

A 76-year-old woman with a 4-year history of ulcerative proctitis presented with increased stool frequency of over 10 episodes of bloody diarrhea per day and lower abdominal pain. Physical examination revealed tenderness over the left lower abdomen. She was started on intravenous hydrocortisone. Sigmoidoscopy revealed diffuse hyperemic inflammation of the sigmoid colon and rectum (Figure 1a). Mesalamine enema was prescribed. A few days later, her diarrhea and rectal bleeding improved slightly, but lower abdominal discomfort continued. Two days later, a prearranged abdominal computed tomography (CT) scan was performed and it showed massive amount of air in the pelvic and presacral space and along the lateral border of the psoas muscle (Figure 1b). An urgent sigmoidoscopy revealed a 10 mm-sized deep laceration above the dentate line (Figure 2a). Surgical suturing of the laceration was performed and intravenous antibiotics were prescribed. The patient improved without development of sepsis, generalized peritonitis, or aggravation of her colitis. She was discharged home after a 10-day hospitalization. Two weeks later, a follow-up CT scan demonstrated complete disappearance of retroperitoneal air (Figure 2b). Pneumoretroperitoneum as the manifestation of colorectal perforation is a rare complication that mostly occurs after iatrogenic injury, trauma, infection, or colorectal cancer. While most indirect hydrostatic pressure-induced perforations occur in the sigmoid colon, direct perforations such as foreign bodies or accidental impalement mostly occur in the rectum. Plain radiograph showing retroperitoneal air, usually around the rectum or along the psoas muscles is useful in diagnosis. However, CT scan is the most sensitive and specific diagnostic tool to detect retroperitoneal free air and determine its extension. Although pneumoretroperitoneum is not as serious as intra-peritoneal perforation, prompt diagnosis and surgery may prevent serious pelvic abscess formation and sepsis. Care with the enema technique is required including adequate lubrication of the tip and gentle insertion. However, special attention is required in cases of proctitis, anorectal stricture, or hard extrinsic compressing lesions such as prostatic or uterine tumors. Injury of the rectal mucosa above the dentate line usually induces no pain, therefore diagnosis can be delayed. In addition, an elderly patient with ulcerative colitis, treated with a high dose steroid therapy like in this case should be treated with extra care, perhaps avoiding the use of enemas during active severe ulcerative proctitis.

Gastrointestinal: Asymptomatic rectal perforation and massive pneumoretroperitoneum in patient with ulcerative colitis treated with mesalamine enemas

A 76-year-old woman with a 4-year history of ulcerative proctitis presented with increased stool frequency of over 10 episodes of bloody diarrhea per day and lower abdominal pain. Physical examination revealed tenderness over the left lower abdomen. She was started on intravenous hydrocortisone. Sigmoidoscopy revealed diffuse hyperemic inflammation of the sigmoid colon and rectum (Figure 1a). Mesalamine enema was prescribed. A few days later, her diarrhea and rectal bleeding improved slightly, but lower abdominal discomfort continued. Two days later, a prearranged abdominal computed tomography (CT) scan was performed and it showed massive amount of air in the pelvic and presacral space and along the lateral border of the psoas muscle (Figure 1b). An urgent sigmoidoscopy revealed a 10 mm-sized deep laceration above the dentate line (Figure 2a). Surgical suturing of the laceration was performed and intravenous antibiotics were prescribed. The patient improved without development of sepsis, generalized peritonitis, or aggravation of her colitis. She was discharged home after a 10-day hospitalization. Two weeks later, a follow-up CT scan demonstrated complete disappearance of retroperitoneal air (Figure 2b). Pneumoretroperitoneum as the manifestation of colorectal perforation is a rare complication that mostly occurs after iatrogenic injury, trauma, infection, or colorectal cancer. While most indirect hydrostatic pressure-induced perforations occur in the sigmoid colon, direct perforations such as foreign bodies or accidental impalement mostly occur in the rectum. Plain radiograph showing retroperitoneal air, usually around the rectum or along the psoas muscles is useful in diagnosis. However, CT scan is the most sensitive and specific diagnostic tool to detect retroperitoneal free air and determine its extension. Although pneumoretroperitoneum is not as serious as intra-peritoneal perforation, prompt diagnosis and surgery may prevent serious pelvic abscess formation and sepsis. Care with the enema technique is required including adequate lubrication of the tip and gentle insertion. However, special attention is required in cases of proctitis, anorectal stricture, or hard extrinsic compressing lesions such as prostatic or uterine tumors. Injury of the rectal mucosa above the dentate line usually induces no pain, therefore diagnosis can be delayed. In addition, an elderly patient with ulcerative colitis, treated with a high dose steroid therapy like in this case should be treated with extra care, perhaps avoiding the use of enemas during active severe ulcerative proctitis.

Gastrointestinal: Asymptomatic rectal perforation and massive pneumoretroperitoneum in patient with ulcerative colitis treated with mesalamine enemas: Education and Imaging

A 76-year-old woman with a 4-year history of ulcerative proctitis presented with increased stool frequency of over 10 episodes of bloody diarrhea per day and lower abdominal pain. Physical examination revealed tenderness over the left lower abdomen. She was started on intravenous hydrocortisone. Sigmoidoscopy revealed diffuse hyperemic inflammation of the sigmoid colon and rectum (Figure 1a). Mesalamine enema was prescribed. A few days later, her diarrhea and rectal bleeding improved slightly, but lower abdominal discomfort continued. Two days later, a prearranged abdominal computed tomography (CT) scan was performed and it showed massive amount of air in the pelvic and presacral space and along the lateral border of the psoas muscle (Figure 1b). An urgent sigmoidoscopy revealed a 10 mm-sized deep laceration above the dentate line (Figure 2a). Surgical suturing of the laceration was performed and intravenous antibiotics were prescribed. The patient improved without development of sepsis, generalized peritonitis, or aggravation of her colitis. She was discharged home after a 10-day hospitalization. Two weeks later, a follow-up CT scan demonstrated complete disappearance of retroperitoneal air (Figure 2b). Pneumoretroperitoneum as the manifestation of colorectal perforation is a rare complication that mostly occurs after iatrogenic injury, trauma, infection, or colorectal cancer. While most indirect hydrostatic pressure-induced perforations occur in the sigmoid colon, direct perforations such as foreign bodies or accidental impalement mostly occur in the rectum. Plain radiograph showing retroperitoneal air, usually around the rectum or along the psoas muscles is useful in diagnosis. However, CT scan is the most sensitive and specific diagnostic tool to detect retroperitoneal free air and determine its extension. Although pneumoretroperitoneum is not as serious as intra-peritoneal perforation, prompt diagnosis and surgery may prevent serious pelvic abscess formation and sepsis. Care with the enema technique is required including adequate lubrication of the tip and gentle insertion. However, special attention is required in cases of proctitis, anorectal stricture, or hard extrinsic compressing lesions such as prostatic or uterine tumors. Injury of the rectal mucosa above the dentate line usually induces no pain, therefore diagnosis can be delayed. In addition, an elderly patient with ulcerative colitis, treated with a high dose steroid therapy like in this case should be treated with extra care, perhaps avoiding the use of enemas during active severe ulcerative proctitis.