Colonic Stricture Research Articles

S2190 A Case of Colorectal Signet Ring Cell Carcinoma Presenting as Ulcerative Recto-Sigmoiditis and Stricture

Introduction: Signet ring cell carcinoma accounts for about one percent of all colorectal cancers. It is an aggressive subtype of adenocarcinomas with the tendency for intramural spread and peritoneal carcinomatosis. Here, we reported a middle-aged male with circumferential colonic stenosis and inconclusive histology, found to have stage 4 colorectal signet ring cell carcinoma (SRCC). Case Description/Methods: A 41-year-old male without significant past medical history was referred to a gastroenterology clinic with bright red blood per rectum. Colonoscopy showed ulcerative recto-sigmoiditis with rectal bleeding, and there was stricture in the rectum, in the recto-sigmoid colon, and from anus to descending colon (Figure A). Biopsy was obtained from the stricture. The pathology revealed granulation tissue and abundant fibrinopurulent exudate showing small clusters, and individual atypical cells stained positive for CDX-2 immunostain. Unfortunately, the patient subsequently lost follow-up. Three months later, the patient was hospitalized for small bowel obstruction. CT showed markedly enlarged heterogeneous and edematous rectum, an abnormal mass within the posterior pelvis/rectum, retroperitoneal and pelvic lymphadenopathy with thickening and nodularity of the peritoneum. Biopsy was obtained from an inguinal lymph node with histological examination showing metastatic adenocarcinoma composed of poorly cohesive signet-ring cells (Figure B). Immunostains revealed that the neoplastic cells were strongly and diffusely positive for CDX2 and CK20 while negative for CK7, confirming a colorectal primary. Accordingly, the diagnosis of colorectal signet ring cell carcinoma was made. Discussion: The colonoscopic findings of colorectal SRCC could be nonspecific as diffuse circumferential thickening, stricture, or ulcerations. Typical pathological features may not appear on the initial biopsy sample. Immunohistochemical testing could help increase diagnostic yield and early identification of cancer cells. Our case hallmarked the importance of close follow-up for abnormal diffuse stricture and ulcerations in the colorectal area. These lesions may need to be rebiopsied, co-screened with abdominal imaging, and undergo an immunohistochemical investigation to characterize pathology further.Figure 1.: A: Colonoscopy: An intrinsic inflammatory circumferential fibrosis friable severe stenosis measuring 20cm (in length) * 9 mm (inner diameter) was found in the rectum, in the recto-sigmoid colon, and from anus to descending colon. B: Hematoxylin & eosin stain of tissue from lymph node showed metastatic adenocarcinoma composed of poorly cohesive signet-ring cells.

A Case of Sigmoid Colon Stenosis after Inguinal Hernia Repair with a Mesh Plug

A Case of Sigmoid Colon Stenosis after Inguinal Hernia Repair with a Mesh Plug

A Young Man With Epigastric Abdominal Pain

A Young Man With Epigastric Abdominal Pain

Atypical Presentation of Shiga Toxin Haemolytic Uremic Syndrome (STEC-HUS)

Shiga-toxin producing Escherichia coli (STEC) infection is the most common cause of haemolytic uremic syndrome (HUS) in children. It should be noted that 5% of STEC-HUS patients have no prodromal diarrhoea, while it may be present in up to 30% of atypical HUS (aHUS) cases. In patients at risk for aHUS, STEC infection may act as a trigger rather than playing a causative role. Presently, eculizumab is the first-line therapy for children presenting with aHUS, whereas treatment of children with STEC-HUS is mainly supportive. We report the case of a child with STEC-HUS who had a severe presentation, requiring renal replacement therapy in the acute phase and surgical treatment for a colonic stricture that arose as a late extra-renal complication of the disease. We aim to review the diagnostic workup of children presenting with HUS, stressing the resources available in our setting. In Portugal, O157 E. coli isolation medium is widely available in clinical laboratories. Non-O157 STEC identification requires specific testing, which is increasingly relevant as non-O157 STEC is becoming a more common cause of STEC-HUS than serogroup O157. The National Health Institute Doutor Ricardo Jorge (INSA) has the capacity to identify verotoxin genes and to proceed to verotxin-producing E. coli (VTEC) pathogenicity assessment using multiplex polymerase chain reaction. Fresh stool samples must be obtained early in the disease course to be sent for culture in O157 E. coli isolation medium and for non-O157 E. coli identification assays.

Primary colonic melanoma: a rare entity

Gastrointestinal melanoma is usually metastatic in origin, and primary melanoma within the gastrointestinal tract is rarely reported. Colon is considered to be an extremely uncommon site for primary melanomas. Herein, we report the first case of a large primary melanoma within the transverse colon with gastric involvement. CT scan found a mass within the colon, which seemed to connect to the gastric antrum. Esophagogastroscopy showed an ulcerated lesion in the greater curvature of the stomach. Subsequent colonoscopy identified a large ulcerated lesion rendering significant stenosis of the transverse colon. Biopsy following colonoscopy indicated a diagnosis of colonic melanoma based on pathological findings, which identified submucosal malignant melanoma cells with epithelioid and spindle features. Immunohistochemical stains were positive for S-100, HMB-45, Vimentin, and Melan-A. A series of clinical and imaging examinations revealed no suspicious primary cutaneous or ocular lesions. The diagnosis of primary colonic melanoma was considered. A radical transverse colectomy with subtotal gastrectomy were conducted subsequently. Definite diagnosis of primary colonic melanoma can be established after ruling out the possibility of being a metastasis from other more common primary sites. Primary colonic melanomas are a challenge to diagnose and often need a multidisciplinary treatment approach, including surgery, BRAF-targeted therapy, and immunotherapy.

Endoscopic Stenting in Crohn's Disease-related Strictures: A Systematic Review and Meta-analysis of Outcomes.

Crohn's disease (CD) is a chronic progressive condition that is complicated by intestinal or colonic stricture in nearly 30% of cases within 10 years of the initial diagnosis. Endoscopic balloon dilation (EBD) is associated with a risk of perforations and recurrence rates of up to 60% at 5 years. Endoscopic stenting has been used as an alternative to EBD, but data on its safety and efficacy are limited. We conducted a systematic review and meta-analysis to assess the outcomes of endoscopic stenting in CD-related strictures. A systematic and detailed search was run in January 2022 with the assistance of a medical librarian for studies reporting on outcomes of endoscopic stenting in CD-related strictures. Meta-analysis was performed using random-effects model, and results were expressed in terms of pooled proportions along with relevant 95% confidence intervals (CIs). Nine studies with 163 patients were included in the final analysis. Self-expanding metal stents (SEMS) including both partial and fully covered were used in 7 studies, whereas biodegradable stents were used in 2 studies. Pooled rate of clinical success and technical success was 60.9% (95% CI, 51.6-69.5; I2 = 13%) and 93% (95% CI, 87.3-96.3; I2 = 0%), respectively. Repeat stenting was needed in 9.6% of patients (95% CI, 5.3-16.7; I2 = 0%), whereas pooled rate of spontaneous stent migration was 43.9% (95% CI, 11.4-82.7; I2 = 88%). Pooled incidence of overall adverse events, proximal stent migration, perforation, and abdominal pain were 15.7%, 6.4%, 2.7%, and 17.9%, respectively. Mean follow-up period ranged from 3 months to 69 months. Endoscopic stenting in CD-related strictures is a safe technique that can be performed with technical ease, albeit with a limited clinical success. Postprocedure abdominal pain and proximal stent migration are some of the common adverse events reported.

A Trapped Colon

A Trapped Colon

Ascending colon stenosis caused by repeated diverticulitis that clinically mimicked advanced colon cancer: A case report.

IntroductionWe experienced a rare case of right-sided large bowl obstruction (LBO) of the colon caused by chronic diverticulitis, which was challenging to diagnose.Presentation of caseA young male was admitted to our department with a fever, diarrhea, and right-sided lateral abdominal pain for several days. CT showed a thickened ascending colon wall with stenosis and adjacent retroperitoneal inflammation without marked diverticula. The next day, he developed severe abdominal pain, and perforation was suspected. We chose the “interval definitive surgery”; at that time, intestinal decompression and laparoscopic drainage. Colonoscopy showed an edematous membrane, but no cancerous lesions or diverticula. Hemi-colectomy was performed after 10 days' nutritional therapy. No postoperative complication occurred. The histopathology showed that the pathogenesis was chronic diverticulitis.DiscussionThere have been few reported cases of right-sided LBO caused by diverticulitis, but it is important to be aware that benign disease, such as chronic diverticulitis, can cause LBO. Initial conservative therapy and nutritional therapy produced a correct diagnosis and good outcomes.ConclusionPerforming “interval surgery” allowed us to make an accurate diagnosis and may help to prevent surgical complications in rare cases of right-sided LBO due to diverticulitis.

Large bowel obstruction caused by a colonic polyp

A large bowel obstruction (LBO) is an emergency condition that requires early diagnosis and prompt treatment, and it is also crucial to identify the cause of the obstruction. Here, we describe a 76-year-old woman who presented to the hospital with a 1-day history of abdominal pain and vomiting and was diagnosed with LBO. Endoscopic findings showed that the cause of the LBO was initially determined to be a Bormann Type I tumour in the sigmoid colon. However, the surgery was performed later; the pathological findings led to the diagnosis of colonic obstruction caused by a colonic polyp in the sigmoid colon narrowed by chronic diverticulitis. Colonic polyps rarely cause LBO. Poor observation due to colonic stenosis can mask the morphology of the lesion. In cases of LBO, colonic polyps should be differentially diagnosed in addition to colon cancer.

Colon Cast in a Child With Graft Versus Host Disease.

A 4-year-old girl with juvenile myelomonocytic leukemia underwent a cord blood transplant 2 months post-diagnosis following a poor response to chemotherapy. One month after the transplant, she developed a skin rash, abdominal pain, and bloody diarrhea despite receiving oral tacrolimus and methotrexate to prevent graft versus host disease (GVHD). Administration of intravenous prednisolone relieved the skin rash but not the intestinal symptoms. Colonoscopy revealed marked redness and bleeding in the colonic mucosa. Neither corticosteroid enemas nor intravenous antibiotics improved her symptoms. Two months after the transplant, she excreted an approximately 6-cm colon cast, a full-thickness, infarcted colonic segment (Fig. 1). Colonoscopy and pathology showed a demucosed colon (Fig. 2). Hyperbaric oxygen (HBO) therapy was initiated with the suspicion of intestinal ischemia secondary to transplant-related thrombotic microangiography. Her symptoms improved within a week after therapy initiation.FIGURE 1.: The excreted colon cast.FIGURE 2.: Colonoscopic and histologic findings of the colon. Left) Colonoscopic examination revealed diffuse mucosal inflammation and peeling. Endoscopic examination could only be performed up to 15 cm due to colonic stenosis. Right) Histology of the sigmoid colon showed infiltrating lymphocytes and loss of mucous membrane.Follow-up colonoscopy performed 3 months after the HBO therapy revealed healed colonic mucosa. Giuseppe et al reported that 37% of patients experience gastrointestinal GVHD after allogeneic hematopoietic stem cell transplant (1). A colon cast is believed to be associated with mucosal ischemia because most cases are reported in patients with ischemic colitis (2,3). Although several cases in adults have been reported, the presumed first case of colon cast associated with ischemia in a child was reported in 2017 (4). Colon cast associated with GVHD is rare, with only one previously reported adult case (5). In our case, the patient had demucosed colon on colonoscopy, similar to previous cases, and showed immediate improvement after the HBO therapy. The HBO therapy may be a safe and effective treatment option for intestinal GVHD accompanied by a colon cast. Patient anonymity: this patient’s anonymity is carefully protected. There are no identifiable photographs of the patient included in this manuscript. ACKNOWLEDGMENTS T.M. wrote the initial draft of the manuscript. T.I. performed colonoscopy and hyperbaric oxygen therapy and assisted in preparing the manuscript. All other authors were involved in the treatment of juvenile myelomonocytic leukemia and critically reviewed the manuscript. All authors approved and agreed to be accountable for the manuscript.

Utility and safety of the self-expandable metallic colonic stent in Japanese patients who received systemic chemotherapy or palliative treatment for obstructive primary advanced colorectal cancer: A retrospective single-center medical chart evaluation.

Background and AimThe present study aimed to compare the utility and safety of the colonic self‐expandable metallic stent between patients with obstructive primary colorectal cancer who underwent chemotherapy or palliative treatment care and patients bridging for surgery.MethodsThe cases of 71 patients with colonic obstructive stenosis and in‐dwelling stents who were hospitalized between May 2012 and April 2020 at Karatsu Red Cross Hospital were retrospectively analyzed. The patients were classified into three groups: bridging for curative surgery (group I), receiving systemic chemotherapy (group II‐A), and receiving only palliative treatment (group II‐B). Technical and clinical success rates and complication rates after stenting were evaluated.ResultsNo significant differences were observed in the technical (procedure) success rates (group I: 100%; group II, 97.6% [II‐A: 100%; II‐B: 95.8%]). The total clinical success rate was 85.9% (61/71) and did not vary significantly among the groups (group I: 82.8%; group II 88.0% [II‐A: 83.3%; II‐B: 91.6%]). No significant differences were observed in the early complication rates between groups I and II and in the late complication rates between groups II‐A and II‐B. Nutrition status, general condition, tumor staging, and 1‐year survival were poorer in group II than in group I.ConclusionThe findings show that colonic stenting for malignant obstruction was performed successfully and safely both in patients who received systemic chemotherapy or palliative therapy and in patients bridging for curative surgery, regardless of risk status for malnutrition, poor general condition, cancer stage progression, and short survival.

Characteristics of primary signet ring cell carcinoma of colon and rectum: a case control study

BackgroundPrimary signet ring cell carcinoma of the colon and rectum (PSRCCR) is rare, usually diagnosed at advanced stage with poor outcomes. We aimed to find possible diagnostic clues in order to help diagnosis.MethodsA retrospective study of PSRCCR patients from 1993 to 2018 was reviewed at a single tertiary center. Colorectal adenocarcinoma patients as control group with 1:4 ratio was also enrolled.Results18 patients with PSRCCR were identified. The prevalence rate was 0.16% (18 of 11,515). The mean age was 50.2 years-old in PSRCCR group and 63 years-old in non-SRCC colorectal cancer patients (p < 0.001). Diagnosis tool depends on colonoscopy were much less in PSRCCR group than control group (44.4% vs 93%, p < 0.001). SRCC patients had higher level of CEA (68.3 vs 17.7 ng/mL, p = 0.004) and lower level of Albumin (3.4 vs 4.3 g/dL, p < 0.001). The majority of PSRCCR tumor configuration was ulcerative and infiltrative. More PSRCCR pathology presented as high-grade carcinoma (66.7 vs 1.4%, p < 0.001) and lymphovascular invasion (77.8 vs 44.4%, p = 0.011) than control group. More PSRCCR patients were diagnosed at advanced stage (88.8 vs 40.3%, p = 0.001). Higher mortality was also noticed in PSRCCR group than control group (72.2 vs 20.8%, p < 0.001).ConclusionFor young patients with long segment colonic stenosis and ulcerative/ infiltrative mucosa but endoscopic biopsy failed to identify malignant cells, earlier operation or non-colon site biopsy is suggested for diagnosing the PSRCCR.

Colonic tuberculosis masquerading as ascending colon carcinoma in a patient of FIGO Stage IIB cervical carcinoma following chemo-radiotherapy: A case report

Introduction and importanceColonic tuberculosis may masquerade colonic carcinoma. Also, intestinal tuberculosis may mimic colonic carcinoma, Crohn's disease, ulcerative colitis, etc.Case presentationA 40 years female was diagnosed with cervical carcinoma FIGO Stage IIB underwent chemo-radiotherapy. She was symptom-free for a few months and then she developed right-sided abdominal pain and abdominal fullness for 4 months. She underwent a colonoscopy that showed ulcerative growth and friable tissue in hepatic flexure of colon and histopathology and immunohistochemistry findings suggested non-Hodgkin's lymphoma or poorly differentiated carcinoma. Then right standard hemicolectomy was performed and histopathology showed tuberculosis. The patient received medications for tuberculosis and the patient improved.Clinical findings and investigationsPreoperatively suspected colonic carcinoma in developing countries (where the prevalence of tuberculosis is high) may sometimes come out as colonic tuberculosis in histopathology. The biopsy sample taken from colonoscopy was examined by histopathology, which showed nonspecific results, and the case was mistakenly thought of as colonic carcinoma preoperatively.Interventions and outcomesThe case underwent right standard hemicolectomy and to the surprise, the excised specimen came out as tuberculosis. The patient received anti-tubercular drugs and the patient is symptomatically better.Relevance and impactColonic tuberculosis can mimic colonic carcinoma. Histopathology will confirm colonic tuberculosis and response to anti-tuberculosis drugs will verify the diagnosis. Though a patient undergoing chemotherapy may develop lymphoma, colonoscopic biopsy may not be conclusive. In any symptomatic patient with colonic stricture, surgery is the treatment of choice.

Systematic review with meta-analysis: incidence and factors for progression to advanced neoplasia in inflammatory bowel disease patients with indefinite and low-grade dysplasia.

Due to limited research on the natural history of indefinite for dysplasia (IND) and low-grade dysplasia (LGD) in inflammatory bowel disease (IBD), the management of these patients is controversial. This systematic review and meta-analysis aimed to estimate the incidence and identify the risk factors for advanced neoplasia in IBD patients with IND and LGD. PubMed, Embase and Cochrane Central Register of Controlled Trials were searched until 24 December, 2021, to identify studies that reported pathological results of follow-up colonoscopy or surgery in IBD patients with IND and LGD. The main outcomes were the incidence and risk factors for advanced neoplasia in IBD patients with IND and LGD. Based on the analysis of 38 studies, the pooled incidences of advanced neoplasia in IBD patients with IND and LGD were 9.9% (95% CI 4.4%-15.4%) and 10.7% (95% CI 7.0%-14.4%) respectively. The risk factors for advanced neoplasia in IND patients were primary sclerosing cholangitis (PSC) and aneuploidy. The risk factors for advanced neoplasia in LGD patients included male, PSC, previous IND, colonic stricture, index lesion ≥1cm, distal location, multifocal lesions, distal and flat lesions, nonpolypoid/flat lesions and invisible lesions. The incidence of advanced neoplasia was similar between IND and LGD in IBD patients, as high as one in ten, so more rigorous surveillance is also suggested in IND patients. Since the effects of most factors were derived from the pooled results of only two to three studies, further research was needed to confirm our results.

P455 Aminosalicylates in Ulcerative Colitis: old but gold?

Abstract Background The clinical course of ulcerative colitis (UC) is characterized by periods of exacerbation and remission. 5-aminosalicylic acid (5-ASA) remains the treatment of choice in patients with mild-to-moderate UC, due to its beneficial effect in preventing relapse. Treatment options (immunomodulators [IMM] and biological agents) have increased, so it is important recognizing patients at risk of medical therapy failure that can appropriately optimize treatment escalation for better control of the disease. Little is known about the long-term course of the disease among patients in remission with 5-ASA. Aims To assess long-term efficacy of 5-ASA (no IMM, biological therapy or colectomy) and to identify predictive factors of non-response. Methods An observational, retrospective, single-centre, case-control study was performed. All consecutive patients with UC followed in our Hospital from January 2000 until June 2020 initially treated with 5-ASA (±steroids) with a minimum follow-up of 1 year were screened for eligibility. Exclusion criteria were 5-ASA toxicity/intolerance or initial treatment with IMM/biologic agents.Time until step-up was recorded. Demographic, clinical, endoscopic, biochemical, and histological variables at the diagnosis were recorded and a Cox regression was performed to identify predictive factors for step-up strategy. Results 218 patients (mean age 41,4±14,6 years; 54,5% female; mean follow-up10,1±1,9 years) were analysed, 28% needed treatment with biologics or IMM, mainly due to steroid-dependence. Among “5-ASA responders”, 72% and 48% had sustained endoscopic and histological remission, respectively. The probability of step-up at 1 year, 5 years and 10 years was 10, 18 and 25%, respectively. “Step-up patients” had higher rates of hospitalization, disease extent progression, extraintestinal manifestations and colonic stenosis and/or pseudo-polyps (p&amp;lt;0,05). Montreal E3 (HR:2,31;95% CI: 1,12-4,68), steroids at first flare (HR:3,45;95% CI: 1,26-7,29), lower 5-ASA maintenance dose (HR: 1,97;95%;CI:1,12-3,29), lower haemoglobin level (HR:1,45;95% CI: 1,11-3,24) and DUBLIN Score≥4 (HR:1,81;95% CI: 1,269-4,59) were factors associated with the step-up strategy, in multivariate analysis. Conclusion 5-ASA is an effective maintenance therapy; a satisfactory response was achieved in 72% of the patients after a mean time of follow-up of 10 years. Extensive colitis, higher DUBLIN Score, lower doses of 5-ASA, need for steroid and anaemia can predict a worse prognosis at the initial diagnosis and are associated with higher therapeutic requirements. These findings may be used in our clinical practice to identify patients that might benefit from an early step-up approach and minimize the morbidity associated with uncontrolled disease.

Removal of Large Urinary Stone Using Percutaneous Nephrolithotomy in a Patient with Crohn’s Disease

&lt;p&gt;Extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD) is approximately 36%. Of genitourinary complications as an EIM of Crohn’s disease (CD), nephrolithiasis is the most common urinary complication in patients with CD. CD patients have been shown to have decreased urinary volume, pH, magnesium, and excretion of citrate, all of which are significant risk factors for nephrolithiasis. Genitourinary complications often occur in case of a severe longstanding disease and are associated with, the activity of bowel disease, especially in those who have undergone bowel surgery. As uncontrolled nephrolithiasis could impair renal function as well as adversely affect quality of life, proper monitoring, early detection, and prevention of the occurrence of urologic complications in CD is crucial. Few data are available about urolithiasis in patients with CD. Herein we report a case of a successful removal of a 2.7 cm calcium oxalate stone using percutaneous nephrolithotomy from a patient with long-standing CD with a previous surgery for small intestinal and colonic stricture.&lt;/p&gt;

P077 Incidence of Colonic Strictures - A Systematic Review and Meta-analysis.

Intestinal strictures are a complication of the inflammatory bowel diseases (IBD, including ulcerative colitis (UC) and Crohn's disease (CD)) that can lead to bowel obstruction and therapy failure. Intestinal strictures occurring after long-standing tissue damage and repair are more frequently reported in CD, but colonic strictures can occur in UC. However, there is a paucity of literature that comprehensively summarizes the available information regarding the incidence and etiology of colonic strictures in UC. The aim of this study was to perform a systematic review and meta-analysis of published reports on the incidence of colonic strictures in UC patients. Four independent reviewers performed a comprehensive review of all original articles describing the incidence of colonic strictures in UC published from inception to June 2021. Primary outcomes were (1) overall incidence of colonic strictures; (2) 10-year incidence of colonic strictures; and (3) incidence of colonic strictures containing high-grade dysplasia (HGD) or colorectal cancer (CRC). Subgroup analysis was performed to compare the outcomes between the pre-biologic era and post-biologic era. The meta-analysis was performed and the statistics were 2-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test. Eleven studies reporting on a total of --- patients with colonic strictures were included in the analysis after comprehensive search. This yielded a pooled colonic stricture incidence rate of 5.4% (95% confidence interval (CI) 3.7-7.8). The incidence rate of colonic strictures was lower in the post-biologic era compared to the pre-biologic era but the difference was not statistically significant (2.6% vs 6%; p = 0.14). The pooled 10-year colonic stricture rate was 3.2% (95% CI 1.5-6.8). The pooled 10-year incidence rate of colonic strictures was lower in the post-biologic era compared to the pre-biologic era but the difference was not statistically significant (1% vs 1.8%; p = 0.1). The pooled incidence of strictures with associated high-grade dysplasia (HGD) or colorectal cancer (CRC) was 21.9% (95% CI 12.2-36.5). The incidence rate of HGD or CRC in colonic strictures was higher in the post-biologic era compared to the pre-biologic era but the difference was not statistically significant (23.6% vs 20.4%; p = 0.79). This systematic review and meta-analysis on the incidence of colonic strictures in UC showed that the overall pooled incidence and 10-year incidence of colonic strictures in UC are low. There was a trend towards lower incidences of UC strictures in the post-biologic era, although the differences did not reach statistical significance. While the overall incidence of colonic strictures, in UC is low, a high proportion of colonic strictures are associated with HGD or CRC, even in the biologic era. Therefore, this study provides further support for importance of stricture biopsy and surgical evaluation for colectomy in the UC patient with colonic stricture.

Low incidence of colonic complications after severe Shiga toxin-producing E. coli O104:H4 infection.

In summer 2011, Shiga toxin producing Escherichia coli (EHEC) serotype O104:H4 caused the most severe EHEC outbreak in Germany to date. The case of a previously recovered patient with symptomatic postinflammatory colonic stenosis following EHEC- infection prompted us to conduct a prospective study to assess the macro- and microscopic intestinal long-term damage in a cohort of patients who had suffered from severe EHEC colitis. Following EHEC infection in 2011, 182 patients were offered to participate in this study between January 2013 and October 2014 as part of the post-inpatient follow-up care at the University Medical Center Hamburg-Eppendorf and to undergo colonoscopy with stepwise biopsies. Prior to colonoscopy, medical history and persistent post-infectious complaints were assessed. Out of 182 patients, 22 (12%) participated in the study, 18 (82%) were female. All patients had been hospitalized due severe EHEC enterocolitis: 20 patients (90%) had subsequently developed hemolytic uremic syndrome (HUS), 16 patients (72%) had additionally required dialysis. On assessment prior to colonoscopy, all patients denied any abdominal complaints before EHEC-infection but 8 (36%) patients reported persistent post-infectious symptoms. According to the ROME IV criteria, 4 (18%) patients met the definition for post-infectious irritable bowel syndrome (PI-IBS). In all patients with persistent symptoms, colonoscopies and histological examination were unremarkable. Only in one symptom-free patient, biopsy revealed a locally limited cryptitis of the caecum, while all patients without complaints had inconspicuous histological and endoscopical findings. Following infection colonic stenosis is a serious but rare long-term complication in patients who had suffered from severe enterocolitis. However, a significant proportion of these patients develop PI-IBS.

Complete Colonic Diaphragm-Like Stricture After Ileostomy and Sigmoidectomy for Sigmoid Colon Perforation With Diverticulitis.

CASE REPORT Anastomotic strictures occur in up to 22% of patients after colorectal resection, and up to 70% of them will eventually require surgical intervention.1,2 Traditionally, the approach taken in such cases has included endoscopic balloon dilation, self-expandable metal stent insertion, or surgical intervention; however, balloon dilation remains the primary modality because of its efficacy and safety profile.1–3 A 61-year-old Japanese woman underwent loop ileostomy creation and then sigmoidectomy for refractory sigmoidovesical fistula because of sigmoid colon perforation with diverticulitis (Figures 1 and 2). We performed a colonoscopy from both the anal and oral stoma sides before ileostomy closure surgery. We identified a complete diaphragm-like stricture in the sigmoid colon that was similar to the end of a blind loop during colonoscopy, and the region of complete construction was whitish and surrounded by a few xanthomas (Figure 3). Therefore, we performed an endoscopic intervention to treat the complete colonic stricture.Figure 1.: Abdominal computed tomography showing (A and B) sigmoidovesical fistula (A; arrow) with an inflammatory fibrous tissue (B; arrowhead) because of sigmoid colon perforation with diverticulitis.Figure 2.: The schema of operation site of this patient. Red circle is loop ileostomy as first operation, and blue slashes are sigmoidectomy as secondary operation.Figure 3.: (A) Colonoscopy from both the anal and oral sides revealing a complete diaphragm-like stricture in the sigmoid colon. (B) An endoscopic injection needle was used to penetrate the contralateral oral side of the colon. (C) An endoscopic catheter was used to investigate the opposite site with a 0.025-inch guidewire. (D and E) A through-the-scope sequential balloon dilator (8 mm) was used to dilate the stricture, and (F) Amidotrizoic acid was advanced into the opposite anal side.First, a 23-G endoscopic injection needle was used to penetrate the center of the blind lumen from the oral side, and then, a pinhole was made in the stricture (Figure 3). The contrast medium was then injected through the needle. After the position of the proximal lumen was confirmed, an endoscopic catheter was inserted into the pinhole that had been made in the stricture, with a 0.025-inch guidewire (Figure 3). Finally, a through-the-scope sequential balloon dilator (8 mm) was used to dilate the stricture, and Amidotrizoic acid was advanced into the opposite site (Figure 3). This intervention led to positive outcomes. Eight days later, the colonic stricture improved. However, the endoscope could not pass through; therefore, we performed balloon dilatation (12.5 mm) again (Figure 4). After 2 sessions, the patient showed improvement and underwent ileostomy closure (Figure 4).Figure 4.: Endoscopy showing (A) the colonic stricture had improved but did the endoscope could not pass through the site of the stricture. (B) A balloon dilator (12.5 mm) is used to dilate the stricture. (C) After 2 sessions, the patient improved.We encountered a colonic diaphragm-like stricture after performing a sigmoidectomy because of perforated colonic diverticulitis. Although anastomotic strictures of the colon are common complications after colorectal surgery, such a complete diagram-like membrane stenosis is rarely seen.4 In this case, we considered that because the loop ileostomy did not allow the passage of stool to the anastomotic site, a complete membrane stenosis had formed. Despite improvements in technology and surgical techniques, the incidence of colorectal anastomotic complications remains stable and substantial, and the detection and treatment of anastomotic complications remain a challenge.5 Our endoscopic intervention was effective in treating a diaphragm-like stricture characterized by complete circular stenosis. DISCLOSURES Author contributions: K. Soga wrote the manuscript and is the article guarantor. H. Mukai and N. Akamatsu edited the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.

EP.TU.688The fate of the rectal stump following subtotal colectomy for acute colitis

Abstract Aims Acute severe colitis requires surgery in approximately thirty percent of cases. Subtotal colectomy with end ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Controversy surrounds the optimal short and long-term management of the distal rectal stump. This study reviews the clinical outcomes and the fate of the rectal stump in this patient cohort. Methods Analysis of prospective data of patients who underwent emergency subtotal colectomy for severe acute colitis between 2010 and 2020 in a tertiary referral centre. Results Sixty-six patients underwent subtotal colectomy (median age, 40years; M:F, 1.3:1). Subtotal colectomy was performed for failure of medical therapy during an acute episode of severe colitis (56%), for fulminant colitis (40%), or for colonic strictures (4%). In 98% percent of patients the rectal stump was closed at the level of the recto-sigmoid junction and in 2% a mucous fistula was formed. 73% of patients opted for no further surgery, but 27% underwent a completion proctectomy, most commonly performed because of rectal stump bleeding. The median follow-up was 6.25years, during which 17% of those with a completion proctectomy underwent an ileo-pouch anal anastomosis (IPAA). Conclusions Subtotal colectomy with closed rectal intra-peritoneal stump and end ileostomy is the procedure of choice in severe acute colitis refractory to maximal medical therapy or fulminant colitis. Given the patient dissatisfaction and morbidity associated with mucous fistula, this procedure should be abandoned. Pelvic dissection should not be performed at the time of the emergency subtotal colectomy given the risk of morbidity.