Cold Forceps Research Articles

1579 Rare Finding of Incidental Ascending Colon Ganglioneuroma in the Setting of Hematochezia

INTRODUCTION: Ganglioneuromas are slowing growing tumors that are rarely found in the colon. Patients with colonic ganglioneuromas may present with nonspecific symptoms such as abdominal pain, bleeding, or change in bowel habits, but these patients are usually asymptomatic. We present a case of hematochezia where an ascending colon ganglioneuroma was incidentally found on diagnostic colonoscopy. CASE DESCRIPTION/METHODS: 84 year old male with a past medical history of hypertension, chronic atrial fibrillation on rivaroxaban, COPD, and prostate cancer S/P radiation presented with hematochezia of two days duration. He had three loose bowel movements on the day of presentation with bright red blood and clots. This was associated with nausea and diarrhea, but patient denied abdominal pain, vomiting, hematemesis, melena, and weight loss. Last colonoscopy, around 7 years ago, was normal. On presentation, patient's vital signs were within normal limits. Physical exam revealed an irregularly irregular rhythm. Abdominal exam was within normal range. Rectal exam revealed dark red stools. No external hemorrhoids were seen. Laboratory findings revealed hemoglobin of 12.5 g/dl and an INR of 1.4 Rivaroxaban was stopped on presentation. Hemoglobin dropped to 11 g/dl then became stable. Colonoscopy was performed five days later. It showed a 3 mm polyp in the ascending colon, a 4 mm polyp in the descending colon, and diverticulosis in the descending colon. The 3 mm polyp in the ascending colon was removed with a cold biopsy forceps. Histological examination of the specimen showed ganglioneuroma. DISCUSSION: Ganglioneuromas are hamartomatous tumors that are rarely seen in the gastrointestinal tract, and are usually found incidentally. There are three different subtypes of ganglioneuromas: polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. The most common type is polypoid ganglioneuroma which is usually a small single polyp arising from the mucosa and submucosa. Definitive diagnosis of ganglioneuroma can only be done through pathological and histological examination. Treatment depends on their size, location, and subtype in addition to the patient's clinical history. Polypoid ganglioneuroma, which is present in this patient, is a benign lesion, so endoscopic resection using a biopsy forceps or a snare is usually curative. It may also be useful to perform a follow up colonoscopy to ensure complete excision of the lesion.

2894 The Gastrointestinal Phenotype of Cowden’s Syndrome and Effects of Surveillance

INTRODUCTION: Cowden’s syndrome is an autosomal dominant hamartoma syndrome characterized by germline mutations in the phosphatase and tensin (PTEN) homolog gene, the protein product of which negatively regulates the PI3K-AKT-mTOR pathway. Clinically, individuals develop multiple hamartomas in body tissues, including the stomach and colon, and have a high risk of developing cancer. To mitigate the risks, individuals undergo upper and lower endoscopic surveillance. The effectiveness of endoscopic surveillance and polypectomy remains unknown. METHODS: 17 individuals who met relaxed international Cowden consortium criteria and had undergone at least two upper or lower endoscopies were included. We describe polyp number, size, location, pathology, and interventions over the surveillance period. RESULTS: The average age was 69 (43-88). 6 were males and 11 females. Average number of upper and lower endoscopies was 2 (1-8) and 5 (2-14), respectively. The average interval between upper and lower endoscopies was noted to be 2.64 years (standard deviation = 1.53) and 3.03 years (standard deviation = 2.14). One patient developed a cancerous polyp that was identified on the second colonoscopy. The polyp was located in the transverse colon and removed via snare polypectomy. Pathology showed invasive adenocarcinoma. Patient underwent colectomy with ileocolic anastomosis without chemotherapy. 68.5% of upper and lower endoscopies had an intervention performed including polypectomy with cold biopsy forceps (n = 40), cold snare (n = 7), hot biopsy forceps (n = 16), and hot snare (n = 33). Polyp pathologies in the stomach and upper intestine included hamartomas (n = 4), hyperplastic (n = 6), adenomas (n = 2), and fundic gland polyps (n = 6). Polyp pathologies in the colon included hamartomas (n = 14), hyperplastic (n = 40), ganglioneuromas (n = 2), adenomas (n = 81), inflammatory (n = 4), and sessile serrated (n = 7). 3 patients had more than one upper endoscopy, 2 of whom had a decrease in polyp size while 1 had no change. In the colon, the sizes of the polyps decreased over time in 11 of the 17 patients, 4 did not change, and 2 had an increase in size. CONCLUSION: We show that the overall size of polyps decrease in both the stomach and colon with endoscopic surveillance. One patient had a malignant polyp treated with endoscopic polypectomy.

Endoscopic Treatment of Sessile Colorectal Polyp

Background: Endoscopic resection of sessile colonic polyps’ presents a number of unique challenges. Large sessile polyps are associated with the greatest risk of postpolypectomy bleeding, perforation and polyp recurrence, with massive submucosal scarring making subsequent attempts at endoscopic resection problematic. Objective: This study aimed to evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps. Patients and methods: This prospective study was carried out on forty (40) consecutive patients at General Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt between January 2014 and August 2016. All patients were subjected to clinical evaluation including history taking, general examination, abdominal and per-rectal examinations. Results: Of the 40 cases with removed polyps, 10 cases were excised by cold biopsy forceps, 4 cases were excised by cold snare, 12 cases were excised by hot snare and 14 cases were excised by EMR with mucosal lifting according to the size of the polyp. Complications included nonspecific abdominal pain in 5 patients (12.5%) that were treated conservatively and bleeding in 3 (7.5%), two cases during procedure while 1 case presented 7 th day post procedure. One case transferred into open surgery due to perforation. All cases were treated endoscopically. Post-polypectomy surveillance permitted the detection and treatment of recurrent polyps in 3 cases that treated endoscopically with piece meal excision. Conclusion: This study showed that polypectomy of benign sessile colorectal polyps performed by an expert endoscopist is feasible, effective, and safe, even on an outpatient basis.

3064 A Case of a Rectal Xanthoma: A Sessile Polyp in an Uncommon Place

INTRODUCTION: Xanthomas are benign collections of lipid bearing histiocytes that form a localized mass. While they are usually found in the soft tissue, they may also be found in the gastrointestinal (GI) tract. Within the GI tract, they are most commonly located in the stomach, and rarely within the rectosigmoid colon. These polyps are found within the mucosa and while usually asymptomatic, can rarely cause obstructive symptoms or pain if large enough. This case presents a rare finding of a rectal xanthoma. CASE DESCRIPTION/METHODS: A 55-year-old woman without any significant PMH presented for an initial screening colonoscopy. Physical exam and basic laboratory evaluation were unremarkable. Colonoscopy showed pan-diverticulosis, internal hemorrhoids, and a rectal polyp. The polyp was 4 mm, sessile, and yellow-white in color. It was removed with cold biopsy forceps. Pathology identified the polyp as a xanthoma. Given the benign nature of the polyp, patient was instructed to undergo screening colonoscopy in 10 years. DISCUSSION: During endoscopy, xanthomas are often overlooked as a differential diagnosis for a polypoid lesion, especially when found in an unlikely location. The exact incidence of rectal xanthomas is unknown and mostly limited to case reports alone. They can be seen in any age group, but tend to be more frequent with age. Colorectal xanthomas can present as flat, sessile, or pedunculated lesions. They are usually solitary and yellow-white in color. Xanthomas are typically confined to the lamina propria mucosa with pathology showing the characteristic foamy histiocytes in this location. Unlike cutaneous and tendinous xanthomas that often have a relation to hyperlipidemia, gastrointestinal xanthomas are usually not associated with an underlying disease (though this remains under investigation). The etiology of gastrointestinal xanthomas are poorly understood but it is believed that they arise in areas of damage, especially when they are found in the stomach. As xanthomas are benign and typically do not cause symptoms, there is no treatment necessary. Xanthomas continue to remain an important and rare finding within the GI tract that may eventually be found to have associations with certain systemic conditions.

361 WATS3D vs. Traditional Forceps Biopsy in Screening of Barrett’s Esophagus: A Community Hospital Experience

INTRODUCTION: Barrett’s esophagus (BE) is a pre-malignant condition of the esophagus currently diagnosed using systematic 4-quadrant cold forceps biopsies during endoscopy. Demonstration of intestinal metaplasia on histopathology and the degree of dysplasia is the cornerstone of BE diagnosis and management. This current method of biopsy is fraught with errors due to the randomness of sampling and experience of the operator. Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS3D) is an emerging technique to collect esophageal samples and improve detection of BE. We compared WATS3D with traditional biopsy as a screening tool in BE. METHODS: We reviewed the charts of adult patients that underwent BE screening by 3 of our gastroenterologists involved in the study with WATS3D and traditional cold forceps biopsy (FB) over the last year across community hospitals in Wichita, KS. The biopsy specimens were processed and analyzed by in-house pathologists while the WATS3D specimen were sent to CDX technology labs, NY. WATS3D specimens were obtained after FB in all instances. RESULTS: A total of 108 patients were identified to have undergone both WATS3D and FB at the same time for BE screening. FB detected 62 cases (57.4%) while WATS3D detected 83 (76%) cases of BE. This attributed to an absolute increase in 21 cases (18.6%) of incident BE detection by WATS3D. The number needed to test (to detect an additional patient with BE) with WATS3D was 5. We divided the sample into 4 groups – WATS3D+FB+, WATS3D+FB-, WATS3D-FB+, WATS3D-FB- to compare the agreement across the 4 groups (Table 1). Overall agreement by kappa statistic was 0.74 (good). There were 62 and 23 cases that were identified as positive and negative respectively by both methods. The pathologist read both cases of FB+ that was WATS3D- as intestinal metaplasia with no dysplasia. Of the 21 cases that were FB-, WATS3D identified 15 cases of goblet cell metaplasia, 4 cases of crypt dysplasia, 1 case of low-grade dysplasia and 1 case of adenocarcinoma. There were no immediate complications reported among the patients studied. CONCLUSION: WATS3D identified 20 cases of BE missed by FB, including 1 case of low-grade dysplasia and 1 case of adenocarcinoma. It is possible that the cases missed by WATS3D were due to the presence of an island of BE that was removed during FB. Overall, with no added increase in complications, WATS3D improved incident detection of BE compared to FB alone.

3043 Not All Bumps Are Equal, Mucosal Schwann Cell Hamartoma a Rare Subtype

INTRODUCTION: Benign mesenchymal polyps are an interesting group of colonic polyps. There has been a surge in the number of these polyps identified since legislation modified Medicare and began reimbursement for screening colonoscopy in patients at an average risk for colorectal carcinoma. It is important to differentiate between the different types of mesenchymal polyps given that some have correlation with hereditary diseases. CASE DESCRIPTION/METHODS: 66 year old male patient with history of hypertension presents for routine colorectal cancer screening colonoscopy. He is asymptomatic and has no family history of cancer including colon cancer. During the colonoscopy a small 5 mm polyp was found in the rectosigmoid which was removed using cold forceps polypectomy. The pathology was read as a benign mesenchymal polyp. Further staining with S-100 and CD 68 was done which revealed that this polyp was in fact a Schwann cell hamartoma. DISCUSSION: There has been 10 reported cases of mucosal schwann cell hamartoma in literature. Using immunohistochemistry for S100 highlights tissue with neural differentiation expanding the lamina propria of the colonic biopsy and CD68 highlights muciphages. These polyps resemble spindle cell proliferation and other neuronal tumors and are usually limited to the mucosa of the colon with no submucosal extension. They are usually solitary and patients do not have symptoms though a couple of cases reported finding them in the process of workup for diarrhea. Gibson and Hornick supplied the necessary name in 2009 in an attempt to differentiate it from other Schwann cell proliferation which is seen in entities like neurofibroma and ganglioneuroma. The importance of this entity is its lack of association with hereditary cancer syndromes, specifically neurofibromatosis type 1 (NF1) and multiple endocrine neoplasia 2B (RET) which is seen with neurofibromas. Also ganglioneuromatous polyposis and diffuse ganglioneuromatosis are seen in Cowden syndrome, Juvenile polyposis syndrome, MEN2B and NF1 however solitiary ganglioneuroma are not associated with hereditary diseases. It is important to differentiate this entity from others to prevent unnecessary and aggressive testing and treatment. Pathologists should include this differential as part of S 100 positive spindle cell proliferative lesions and gastroenterologists should be aware of the benign nature of this pathology.

3229 Helicobacter pylori-Negative Gastric Mucosa-Associated Lymphoid Tissue Lymphomas: A Challenge in Treatment Options

INTRODUCTION: Primary gastric lymphoma is a rare entity of which the specific variant, mucosa-associated lymphoid tissue (MALT) lymphomas may be the best recognized given its association with Helicobacter pylori (H. pylori) infection. It has been thought that repetitive immune stimulation from underlying infection is influential in the pathogenesis of this tumor. However up to 10% of gastric MALT lymphomas are diagnosed without a concomitant H. pylori infection. The pathogenesis and management of H. pylori-negative gastric MALT lymphomas remains uncertain. CASE DESCRIPTION/METHODS: 65 year old woman with Celiac disease and GERD presented with worsening severe reflux and epigastric pain. She underwent EGD which revealed multiple superficial ulcers in the cardia with notable nodularity, ulceration, and friability. Cold forceps biopsies of the abnormal mucosa demonstrated diffuse atypical small B-Cell lymphoid infiltrate with features compatible with low grade MALT lymphoma. Of note, immunostain for H. Pylori was negative. Subsequent H. pylori stool antigen assay as well H. pylori IgG, IgM, and IgA were all negative. Given her negative antibodies indicating she truly had no exposure to H. Pylori, the patient has been referred to oncology for multidisciplinary management. DISCUSSION: This case of early stage gastric MALT lymphoma without evidence of active H. pylori infection elucidates that there is limited literature for the management for these patients. Studies have suggested that H. pylori eradication therapy can be efficacious for a proportion of H. pylori-negative gastric MALT lymphomas, possibly due to a false negative detection by biopsy. Local radiation therapy with curative intent and single agent rituximab therapy rather than H. pylori eradication have also been explored as alternate options. The data stems from retrospective studies and single agent prospective trials. Thus, there may be a role for future research directly comparing treatment strategies for optimal management of this clinical entity.

1668 A Rare Cause of Cyclical Rectal Bleeding: Sigmoid Endometriosis

INTRODUCTION: Endometriosis can frequently involve the bowels with rectosigmoid involvement being the most common. Although serosal infiltration is not uncommon, mucosal involvement is rare, hence presentation with rectal bleeding is rare. Diagnosis without pathology is difficult given symptoms frequently mimic IBS, IBD or malignancy. Here, we present a case of a woman with a history of breast cancer who presented with rectal bleeding ultimately found to have infiltrating sigmoid endometriosis. CASE DESCRIPTION/METHODS: A 40-year-old woman with a history of ER+/PR-/HER2+ breast cancer in remission on maintenance tamoxifen presented with worsening rectal bleeding for one year. Interestingly, hematochezia occurred cyclically every month seemingly coinciding with menses. It was associated with dyschezia, abdominal pain, loose stools, and dysmenorrhea. Hemoglobin and rectal exam were normal. Due to her history of breast cancer, a CT scan was done which demonstrated a focal area of sigmoid wall thickening and luminal narrowing with a 3 cm × 4 cm filling defect. Primary colonic malignancy and metastatic lesions were considered in the differentials. Colonoscopy revealed an area of extreme tortuosity in the sigmoid colon that could not be traversed. Several hypervascular polypoid lesions were noted in the proximal sigmoid colon at the site of narrowing. Cold forceps biopsy of the lesions showed endometriosis on pathology. Immunohistochemical stains positive for CD10 and estrogen receptor further supported the diagnosis. The patient was treated with Goserelin acetate with complete resolution of her rectal bleeding. After a year, she discontinued Goserelin due to side effects of fatigue and joint pains and has been on Danazol suppositories. Surgery was deferred as she did not have colonic obstructive symptoms. DISCUSSION: Here, we report a rare case of sigmoid endometriosis presenting as cyclical rectal bleeding with a lesion that masqueraded as malignancy on CT scan. Gastroenterologists should be aware of this differential in women in their reproductive years and be familiar with its unusual endoscopic appearance. This case also emphasizes good history taking, where the cyclical nature of rectal bleeding coinciding with menses is a clue for diagnosis. While symptoms of colonic endometriosis are typically chronic, late diagnoses can lead to unfortunate sequelae including acute bowel obstructions. Early diagnosis is clinically important to attempt medical therapies before complications necessitate surgical intervention.

1496 Visceral Involvement as the Initial Presentation of Kaposi Sarcoma Carries a Worse Prognosis

INTRODUCTION: AIDS-related Kaposi sarcoma (KS) is a vascular tumor associated with infection by the human herpesvirus-8 (HHV-8) that most commonly affects mucocutaneous sites. In its disseminated form, it can also involve lymph nodes and visceral organs, in particular the respiratory and gastrointestinal tract. Visceral involvement as the initial manifestation of KS is extremely rare and carries a worse prognosis. We present a case of a 54-year-old Male with disseminated KS with rectal involvement presenting with cough and chills. CASE DESCRIPTION/METHODS: 54-year-old Male with a past medical history significant for HIV, not adherent with HAART therapy, who presented to the Emergency Department (ED) with a chief complaint of cough and subjective chills of three days duration. He later endorsed recent sick contacts, bloody diarrhea, and a 40 lb weight loss over the last year. In the ED, he was hypotensive and tachycardic and found to have a CD4 13 with a viral load of 3 million copies/ml. A CT Chest showed evidence of bilateral pleural effusions for which he was started on broad spectrum antibiotics. He underwent bronchoscopy with BAL which showed small nodules suspicious for KS versus Lymphoma. His hospital course was complicated by microcytic anemia (Hb 6.1 on admission) with a positive fecal occult test requiring multiple blood transfusions. Gastroenterology was consulted and the patient underwent colonoscopy which showed evidence of a large, non obstructing, fungating mass in the distal rectum. The mass had a purple hue, was noncircumferential, and was confluent with multiple scattered oozing purple sessile nodules. Biopsies were taken with cold forceps for histology. The rectal biopsy was positive for Human Herpes Virus 8 (HHV-8) and he was diagnosed with disseminated KS. He was subsequently transferred to the National Institutes of Health Clinical Center in Maryland after failed initial treatment for further management and care. DISCUSSION: Visceral involvement as the initial presentation of KS is rare and carries a worse prognosis. While gastrointestinal KS lesions are usually asymptomatic, they may also cause a wide array of symptoms including nausea and vomiting, weight loss, upper or lower gastrointestinal bleeding, and abdominal pain. Because visceral involvement is rare as the initial presentation, the possibility of disseminated KS in an immunocompromised patient is often over looked and thus, a high index of suspicion is required.

1353 Beware of When a Pancreatic Cyst Is Not a Cyst: Endoscopic Ultrasound Guided FNB of Neuroendocrine Tumor in the Pancreas

INTRODUCTION: We present a case of pancreatic NET was assessed by EUS guided FNB at our institution during 2018 presenting initially as an incidental cyst on cross sectional imaging. Further evaluation was performed via EUS after patient sought a second opinion. EUS imaging characteristics favored a solid mass rather than a cyst. FNB of a 9.0 mm × 10.5 mm in the head of the pancreas was performed. CASE DESCRIPTION/METHODS: A 73 year old female was referred after having an incidental finding on recent CT and MRI indicating abnormal cyst in the head of the pancreas. Her symptoms included dyspepsia, fatigue, and dizziness. She has a past medical history of hypothyroidism, hypertension, hypercholesterolemia, gout, and neuropathy. Initial CT scan done showed an incidental cystic mass in the head of the pancreas which was “benign cyst versus cystic neoplasm,” and an MRI was recommended. Further evaluated through an MRI to be a “cystic neoplasm – possible IMPN.” We performed a history and physical exam in the office and then proceeded with an EGD which showed esophageal candida confirmed by cold forceps biopsy that showed PAS and GMS stained positive for invasive fungi Candida esophagitis. We then proceeded with an EUS which revealed a hypoechoic, heterogeneous solid mass in the neck of the pancreas measuring 9.0 mm × 10.5 mm in size and in the head of the pancreas adjacent to the pancreatic duct (Figure 1). The mass was not cystic. The remainder of the pancreatic parenchyma without ductal dilation, normal biliary system, gallbladder, and liver. We performed EUS guided FNB rather than aspiration in order to obtain a large core of histologic tissue. Pathological analysis of the mass reveals a diagnosis of well-differentiated neuroendocrine tumor, grade 1 at a rate of less than 2 mitoses/2 mm2. T1N0M0, grade 1 neuroendocrine tumor was confirmed at tumor board review. DISCUSSION: In conclusion, PNETS are increasing in incidence due to increased use of EUS and cross sectional imaging. Pancreatic cysts have also become a common incidental finding. The complexity arises in determining which cysts seen on cross sectional imaging require further evaluation. Some “cysts” or hypodense pancreatic structures on imaging may not be cystic in nature. EUS provides a greater sensitivity and specificity than high resolution CT scans, and allows for tissue sampling. The shift from EUS-FNA to EUS-FNB has allowed for improved tissue acquisition and true histology via EUS and disgnosis of even subcentimeter lesions.

2697 Gastrointestinal Stromal Tumor Mimicking a Small Lymphocytic Lymphoma

INTRODUCTION: Gastrointestinal stromal tumors (GIST) have been associated with synchronous or metachronous secondary malignancies in up to 43% cases. The occurrence between GIST and hematological malignancies is approximately 7%. Here, we present a case of a GIST mimicking Small Lymphocytic Lymphoma (SLL). CASE DESCRIPTION/METHODS: A 70-year-old male presented with a one-month history of bilateral axillary lymphadenopathy. Physical exam revealed a conglomerate of lymph nodes of both axillary regions. CT of the chest-abdomen-pelvis showed diffuse axillary, mesenteric, retroperitoneal and inguinal lymphadenopathy. In addition, it showed a 40 mm mass in the lesser curvature of the stomach (Figure 1). FNA of the axillary region showed findings consistent with SLL. Upper endoscopy showed a large subepithelial mass in the stomach (Figure 2). Biopsies were taken with cold forceps showing reactive white blood cells, this was suspected to be lymphoma. The patient was diagnosed with Stage IV SLL and started on Ibrutinib. Three months after therapy was started, CT revealed significantly improved on adenopathy but an increase in the size of the gastric mass. A repeat upper endoscopy with endoscopic ultrasound (EUS) showed a hypoechoic, heterogeneous round mass with well-defined borders, originating from muscularis propria layer (Figure 3). Fine needle biopsy (FNB) was performed and showed clusters of neoplastic cells, positive for CD117 and DOG1, negative for CK7, CK20, and CDX2, consistent with a GIST. DISCUSSION: Little is known about the coexistence of GIST and other metachronous tumors of different anatomic location. Several theories have been proposed to explain this link. These theories include pro-oncogenic changes in the tissue microenvironment, carcinogenic effect by chemotherapy and desmoid-type fibromatosis after trauma or surgery. When located in the stomach, GISTs most commonly present as subepithelial lesions. Since mucosal biopsies have a false negative rate of almost 50%, additional evaluation with EUS and EUS guided tissue acquisition is of essential importance. Obtaining core samples by FNB is useful for tissue architecture evaluation and immunohistochemistry assessment of the sample. In this particular case, EUS was not performed initially; instead, mucosal biopsies were obtained leading to a false negative result. This case highlights the rare association between GISTs and other malignancies, as well as, the importance of EUS for the evaluation and accurate diagnosis of different subepithelial lesions.

2735 Phlegmonous Gastritis

INTRODUCTION: Phlegmonous gastritis (PG) is a rare cause of abdominal infection with a mortality rate up to 42%. PG presents a diagnostic and therapeutic challenge given the low incidence and non-standardized treatment options. We present a case of PG successfully treated with early antibiotic therapy. CASE DESCRIPTION/METHODS: A 47-year-old man with uncontrolled type 2 diabetes mellitus presented with four days of subjective fevers, abdominal pain, and vomiting. The patient was tachycardic (122 beats/min) and had epigastric tenderness without guarding or rebound. Initial studies revealed leukocytosis (30,000/mm³) and Gram-positive bacteremia, later identified as ß-hemolytic group A Streptococcus. The stomach was diffusely thickened to 16 mm on contrast-enhanced computed abdominal tomography (Figure 1). Endoscopy revealed diffuse gastric thickening with erythema and a nonbleeding 6 mm ulcer on the lesser curvature of the gastric body. Deep biopsy of the ulcer by cold forceps produced a purulent drainage (Figure 2). Subsequent endoscopic ultrasonography (EUS) found a 12 mm thickened gastric wall involving the deep mucosa, thus further biopsy was obtained. The biopsies from both endoscopy and EUS showed acute neutrophilic inflammation with micro-abscesses; Helicobacter pylori was not identified. The patient received three days of piperacillin/tazobactam followed by seven days of ampicillin/sulbactam, with resolution of symptoms. DISCUSSION: PG is a rapidly progressive and frequently fatal bacterial infection of the gastric wall. The etiology of PG remains unclear, but can be caused by local or hematogenous spread of infection. Streptococcusspp. accounts for 70% of cases, and up to one-third of infections are polymicrobial. Risk factors include gastric mucosal injury, diabetes mellitus, and alcoholism. Diagnosis is commonly delayed as clinical manifestations are nonspecific. High clinical suspicion and early radiographic testing are important to identify gastric wall thickening, which is supportive of the diagnosis. PG primarily affects the gastric submucosa but may extend to deeper layers. Histopathology is of limited benefit, as standard forceps biopsy collects insufficient submucosal tissue. Optimal treatment is not known. When diagnosis is delayed, surgical intervention is often required. Medical therapy alone has been associated with increased mortality rates; however, in cases of early diagnosis and empiric antibiotic treatment, medical therapy alone may be sufficient.

1719 Esophageal Adenocarcinoma Arising From <1 cm of Intestinal Metaplasia at the Gastroesophageal Junction: Is <1 cm Actually Low Risk?

INTRODUCTION: Barrett’s esophagus (BE) is defined by length, which has been shown to correlate with the risk for esophageal adenocarcinoma (EAC). Although long-segment (>3 cm) and short-segment (between 1 and 3 cm) BE are well-established definitions, current ACG practice guidelines recommend against defining columnar goblet-cell metaplasia in the distal esophagus <1 cm as BE. This specific variation of metaplasia disease has been officially defined as “specialized IM of the esophagogastric junction” (SIM-EGJ) over alternatives such as ultra-short segment BE. Given the relatively low incidence of EAC in this group and the high degree of inter-observer variability in defining metaplasia of this length, current guidelines recommend against biopsy in this setting. Individual cases in practice however have demonstrated reasons to question this paradigm. CASE DESCRIPTION/METHODS: A 42 year old white man with obesity and 10 years of reflux symptoms was diagnosed with a GE junction nodule on index endoscopy. Cold forceps biopsy of the nodule revealed high grade dysplasia, prompting referral to the BE Treatment Center at Thomas Jefferson University Hospital (TJUH). His repeat EGD revealed salmon-colored mucosa suggestive of intestinal metaplasia in an area less than 1 cm in length (Z-line at 39 cm). An 8 mm nodule was identified in the area of abnormal mucosa and removed by endoscopic mucosal resection. Pathology of the nodule revealed a T1a moderately differentiated intramucosal adenocarcinoma arising in BE. All margins were negative for invasive carcinoma, dysplasia, and intestinal metaplasia. The patient patients underwent endoscopic eradication therapy (EET) with radiofrequency ablation at the GE junction and in subsequent endoscopy achieved complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D). DISCUSSION: Although current guidelines advise against biopsying <1 cm of variability in Z line given its status as a relatively low risk lesion, data used to generate many of these risk predictions for EAC exclude visible lesions in their studies. Therefore in practice there may be under-evaluation of SIM-EGJ, potentially missing advanced dysplastic or cancerous disease. This case illustrates that the consideration BE risk factors and all endoscopic findings, such as nodules, need to be taken together when assessing abnormal mucosa at the GE junction, even with <1 cm variability of the Z line.

Morphologic Clues Identify Muscularis Propria at Colonic Biopsy and Warn of Potential Perforation

Abstract Objectives Perforation is currently believed to be a rare but potentially serious complication of colonic biopsies performed with cold forceps. Most reported cases have occurred in the setting of colitis. The presence of muscularis propria in specimens from colonic biopsies might portend increased risk of perforation. However, identifying muscularis propria at time of biopsy is difficult for many reasons, including histologic overlap with muscularis mucosa. Incidental muscularis propria obtained in this manner has yet to be studied. We hypothesized that differences in nuclear density could distinguish muscularis propria from muscularis mucosa. Methods We retrospectively reviewed 3 specimens from colonic biopsies performed with cold forceps for which muscularis propria was presumed to be visualized based on the presence of smooth muscle with lower nuclear density compared to areas known to be muscularis mucosa. All patients were adults clinically suspected to have colitis. These specimens were then compared to a full-thickness section from normal colonic tissue obtained via colectomy that served as control to confirm whether nuclear density or other features could distinguish muscularis propria from muscularis mucosa. Results Muscularis propria in the control tissue had lower nuclear density, more cytoplasmic pallor, greater maximal thickness, and smoother texture than the corresponding muscularis mucosa in the control tissue. The constellation of these features was consistently seen in all three specimens obtained via biopsy and therefore confirmed the presence of muscularis propria in all three specimens, although all patients lacked perforation clinically. Surprisingly, all three specimens had histologically normal mucosa. Conclusion We showed that several morphologic features, including low nuclear density, identify muscularis propria at time of colonic biopsy and alert endoscopists to the possibility of perforation, and we showed that muscularis propria can accompany normal mucosa obtained via biopsy with cold forceps. Additional studies are necessary to further validate these findings.

Disagreement between high confidence endoscopic adenoma prediction and histopathological diagnosis in colonic lesions ≤ 3 mm in size.

Diminutive colorectal polyps resected during colonoscopy are sometimes histologically interpreted as normal tissue. The aim of this observational study was to explore whether errors in specimen handling or processing account in part for polyps ≤ 3 mm in size being interpreted as normal tissue by pathology when they were considered high confidence adenomas by an experienced endoscopist at colonoscopy. One endoscopist photographed 900 consecutive colorectal lesions that were ≤ 3 mm in size and considered endoscopically to be high confidence conventional adenomas. The photographs were reviewed blindly to eliminate poor quality images. The remaining 644 endoscopy images were reviewed by two external experts who predicted the histology while blinded to the pathology results. Of 644 consecutive lesions ≤ 3 mm in size considered high confidence conventional adenomas by a single experienced colonoscopist, 15.4 % were reported as normal mucosa by pathology. The prevalence of reports of normal mucosa in polyps removed by cold snare and cold forceps were 15.2 % and 16.0 %, respectively. When endoscopy photographs were reviewed by two blinded outside experts, the lesions found pathologically to be adenomas and normal mucosa were interpreted as high confidence adenomas by endoscopic appearance in 96.9 % and 93.9 %, respectively, by Expert 1 (P = 0.15), and in 99.6 % and 100 %, respectively, by Expert 2 (P = 0.51). Retrieval and/or processing of tissue specimens of tiny colorectal polyps resulted in some lesions being diagnosed as normal tissue by pathology despite being considered endoscopically to be high confidence adenomas. These findings suggest that pathology interpretation is not a gold standard for lesion management when this phenomenon is observed.

Appendix orifice polyps: a study of 691 lesions at a single institution.

Data on the management of appendix orifice lesions are limited. We present our experience on the management of appendix orifice lesions focusing on the range of size, histology, treatment, and outcomes for polyps at the appendix orifice. Retrospective descriptive study at a tertiary referral center. Those having appendix orifice lesion removed and sent for histology between 2000 and 2017. Polypectomy, surgery. Polyp size, shape, histology, treatment. In total, 691 patients matched our inclusion criteria. Screening was the most common indication for colonoscopy (49.1%). Mean size was 10.1mm. The most common excision method was cold biopsy forceps (36.3%), followed by hot snare (9.3%), cold snare (8.5%), jumbo cold forceps (6.7%), hot biopsy (6.8%), and endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) (4%). Recurrence was seen in 19/184 (10.3%) patients. Index polyps ≥ 10mm had a significantly higher risk of recurrence compared to those ≤ 5mm (odds ratio 3.2 95% CI 1.1-9.2, p = 0.027). None of the patients had complications. Surgery was performed in 45/691 (6.5%). Polyps > 5mm (41/45) were more likely to require surgery than polyps ≤ 5mm (4/45 6.67%), p < 0.001. Retrospective study. Appendix orifice polyps can usually be managed by conventional endoscopic polypectomy methods without the need for ESD.

Local recurrence of diminutive colorectal polyps after cold forceps polypectomy with jumbo forceps followed by magnified narrow-band imaging: a multicenter prospective study.

Cold polypectomy has been increasingly used to remove diminutive colorectal polyps. We evaluated the local recurrence rate of diminutive polyps at the 1-year follow-up after cold forceps polypectomy (CFP). In a prospective, multicenter, observational cohort study, patients with diminutive colorectal polyps ( ≤ 5 mm) were treated by CFP using jumbo forceps followed by magnified narrow-band imaging (NBI). Patients were assessed for local recurrence at 1-year follow-up. Risk factors associated with local recurrence were analyzed using logistic regression analysis. Overall, 955 lesions were resected in 471 patients who completed the 1-year follow-up. The endoscopic complete resection rate was 99.4 %. Immediate and delayed bleeding occurred in 0.8 % and 0.2 % of cases, respectively, with no perforations observed. Local recurrence occurred in 2.1 % of cases at the 1-year follow-up. Univariable analyses indicated that polyps > 3 mm (P < 0.01) and immediate bleeding (P = 0.04) were significantly associated with local recurrence. A trend was observed for patients ≥ 65 years (P = 0.06) and fractional resection (P = 0.09). Multivariable analyses confirmed that lesions > 3 mm were significantly associated with local recurrence (odds ratio 3.4, P = 0.02). CFP with jumbo forceps followed by NBI-magnified observation had a low local recurrence rate and is an acceptable therapeutic option for diminutive colorectal polyps. Although we recommend limiting the use of CFP with jumbo forceps to polyps ≤ 3 mm in size, future comparative studies are needed to make recommendations on cold polypectomy using either forceps or snares as the preferred approach for diminutive polyp resection.

BEST POLYPECTOMY TECHNIQUE FOR SMALL AND DIMINUTIVE COLORECTAL POLYPS: A SYSTEMATIC REVIEW AND META-ANALYSIS.

Polypectomy of colorectal polyps is the mainstay of colorectal cancer prevention. Identification of the best polypectomy technique is imperative. This review aims at comparing efficacy of nine different resection methods for small colorectal polyps (<10 mm). We searched and selected only randomized controlled trials. Primary outcome was complete resection rates of small polyps by histological eradication. Secondary outcomes were: adverse events, retrieval tissue failures rates and duration of procedure. Eighteen trials including 3215 patients and 5223 polyps were analysed. Overall, cold polypectomy had a significantly shorter time of procedure than hot polypectomy (RD -5.92, 95%CI -9.90 to -1.94, P<0.05), with no statistical difference on complete histological eradication (RD 0.08, 95%CI -0.03 to 0.19, P>0.05). Regarding cold polypectomy techniques, cold snare was found superior to cold forceps on complete and en-bloc resection rates and less time consuming. When comparing endoscopic mucosal resection (EMR) with hot-snare and cold-snare, the latter showed no-inferiority on histological eradication, adverse events or retrieval tissue failure rates. Cold polypectomy is the best technique for resection of small colorectal polyps. Among cold methods, dedicated cold snare was found superior on histological eradication. Cold snare endoscopic mucosal resection might be considered an option for polyps from 5 to 9 mm.

Management and risk factors for incomplete resection associated with jumbo forceps polypectomy for diminutive colorectal polyps: a single-institution retrospective study.

Cold forceps polypectomy is simple and widely used in clinical practice. However, there are concerns about the risk of incomplete resection using this technique. In recent years, it has been reported that polypectomy with jumbo forceps (JF) is an effective treatment modality for diminutive polyps (DPs) because JF are able to remove large tissue samples with the combined advantage of a higher complete histological resection rate for DPs than standard forceps. To our knowledge, no studies have evaluated the risk factors for incomplete resection when polypectomy with JF is performed for DPs. From among 1129 DPs resected using JF at Hiroshima City Asa Citizens Hospital between November 2015 and December 2016, we retrospectively evaluated the clinical outcomes of 999 tumors with known histopathology and investigated the relationship between incomplete resection and clinicopathological factors. Most lesions [985 (87%)] were low-grade dysplasia and 14 (1%) were high-grade dysplasia. The en bloc resection rate was 92% (918/999) and the histological en bloc resection rate was 78% (777/999). Multivariate analysis showed that the significant independent predictors of incomplete resection were tumor size ≥ 4mm [odds ratio (OR) 3.8; 95% confidence interval (CI) 2.65-5.37; p < 0.01], non-tangential direction of forceps in relation to the tumor (OR 1.73; 95% CI 1.21-2.45; p < 0.01), and lack of muscularis mucosae in the pathological specimen (OR 15.7; 95% CI 9.16-27.7; p < 0.01). This study identified significant independent predictors of incomplete resection of DPs which may be helpful when planning polypectomy with JF.

Efficacy and safety of cold forceps polypectomy utilizing the jumbo cup: a prospective study.

Background/AimsThere are few prospective studies on cold forceps polypectomy (CFP) using jumbo cup forceps. Therefore, we examined patients with diminutive polyps (5 mm or smaller) treated with CFP using jumbo cup forceps to achieve an adenoma-free colon and also assessed the safety of the procedure and the recurrence rate of missed or residual polyp after CFP by performing follow-up colonoscopy 1 year later. MethodsWe included patients with up to 5 adenomas removed at initial colonoscopy and analyzed data from a total of 361 patients with 573 adenomas. One-year follow-up colonoscopy was performed in 165 patients, at which 251 lesions were confirmed. ResultsThe one-bite resection rate with CFP was highest for lesions 3 mm or smaller and decreased significantly with increasing lesion size. Post-procedural hemorrhage was observed in 1 of 573 lesions (0.17%). No perforation was noted. The definite recurrence rate was 0.8% (2/251 lesions). The probable recurrence rate, which was defined as recurrence in the same colorectal segment, was 17%. Adenoma-free colon was achieved in 55% of patients at initial resection. Multivariate analysis revealed that achievement of an adenoma-free colon was significantly associated with number of adenomas and years of endoscopic experience. ConclusionsCFP using jumbo biopsy forceps was safe and showed a high one-bite resection rate for diminutive lesions of 3 mm or smaller. The low definite recurrence rate confirms the reliability of CFP using jumbo biopsy forceps. Number of adenomas and years of endoscopic experience were key factors in achieving an adenoma-free colon.