Ileal Ulcers Research Articles

S2857 Intestinal Behcet’s Disease Involving Terminal Ileum

INTRODUCTION: Behcet’s Disease (BD) is a rare, chronic, inflammatory vasculitis that affects several organ systems. Gastrointestinal involvement occurs in 3 to 25% of patients, with prevalence of 1–2/1,000,000 in the United States. We present a case of a patient with BD developing abdominal pain, diarrhea, and weight loss. CASE DESCRIPTION/METHODS: 57-year-old man with known oral and genital BD presented with fever, 1-week 15lb weight loss, abdominal pain and non-bloody diarrhea. He had been on infliximab, colchicine and prednisone. Laboratory studies exhibited iron deficiency anemia and leukopenia. Abdominal CT showed wall thickening of terminal ileum with fat stranding consistent with terminal ileitis. Tuberculosis, Cytomegalovirus and Histoplasma on serum were negative. Colorectal surgery was consulted, and in light of refractory ileitis patient underwent laparoscopic right hemicolectomy with ileocolic anastomosis. Histopathology demonstrated acute ischemic necrosis with ileal ulceration. After surgery, he was continued on low dose prednisone and infliximab infusions with resolution of intestinal symptoms. DISCUSSION: Intestinal BD presents with abdominal pain, anorexia, vomiting, diarrhea, dyspepsia, and bloody/non-bloody stools. Mucosal ulcerations are thought to be the underlying factor behind the symptoms, likely secondary to a combination of vein and venule vasculitis and large vessel involvement leading to ischemia and subsequent infarction. Diagnosis can be challenging given clinical similarities with Inflammatory Bowel Disease (IBD), however findings of vasculitis on biopsy favors intestinal BD over IBD. Imaging modalities are useful in its diagnosis including barium swallow, CT, and MRI which demonstrate colonic wall thickening. Endoscopy often reveals large deep punched out ulcers with discrete margins usually in the ileocecal region. Treatment is similar to IBD, including medical and surgical modalities. First line agents are sulfasalazine, mesalamine and corticosteroids. Second line are infliximab and adalimumab. Colectomy is indicated if medical therapy fails or with presence of bowel perforation, fistulae or GI bleeding. After surgery, recurrence is seen up to 40–80% of cases, with 80% requiring re-operation. Keep in mind that patients with history of BD can develop colitis.Image 1.: Pre-operative CT showing the coronal sequence of images. Notice the circumferentially thickened, irregular terminal ileum in the right lower quadrant. There is secondary luminal narrowing and adjacent fat stranding compatible with transmural involvement.Image 2.: Pre-operative CT as above. Image series.

S2099 Initiation of Antiretroviral Therapy Leading to Idiopathic Terminal Ileal Ulceration

S2099 Initiation of Antiretroviral Therapy Leading to Idiopathic Terminal Ileal Ulceration

S2867 Mycophenolate Mofetil Induced Ileocolitis: A Complicated Case of Terminal Ileal Ulceration and Hemorrhagic Shock

S2867 Mycophenolate Mofetil Induced Ileocolitis: A Complicated Case of Terminal Ileal Ulceration and Hemorrhagic Shock

Typhoid ulcer related massive gastrointestinal bleeding successfully treated with endoscopic therapy

BackgroundTyphoid fever can manifest with a variety of gastrointestinal symptoms. However, in the present-day era, gastrointestinal bleeding related to bowel ulceration is becoming increasingly sporadic especially in the urban setting.Case presentationWe present a rare case of life-threatening gastrointestinal bleeding from a typhoid ileal ulcer that was successfully managed with endoscopic therapy.ConclusionThough rare, this infective cause of gastrointestinal bleeding should still be considered in differential diagnosis, especially in developing countries.

Ileal and Rectal Ulcer Size Affects the Ability to Achieve Endoscopic Remission: A Post hoc Analysis of the SONIC Trial.

It is unclear how baseline endoscopic characteristics in Crohn's disease (CD) affect the ability to achieve endoscopic remission (ER). We aimed to determine the endoscopic prognostic factors that influence achieving ER in CD. This post hoc analysis of SONIC (NCT00094458; YODA #2019-3980) evaluated baseline and week 26 endoscopy indices in 172 patients using the CD Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score for CD. The impact of baseline ulcer depth and size on achieving week 26 ER was assessed using multivariate logistic regression models adjusted for confounders. The ER rate of ileal ulcers was significantly lower than ER rates throughout the colon (P < 0.0001). Ileal ulcers >2 cm were less likely to achieve ER compared with smaller ulcers {odds ratio (OR) 0.31 (95% confidence interval [CI] 0.11-0.89), P = 0.03}. Similarly, rectal ulcers >2 cm were associated with reduced odds of week 26 ER (OR 0.26 [95% CI 0.08-0.80], P = 0.02). Ulcer size in other colonic segments did not affect the achievement of week 26 ER. Deep ileal and rectal ulcers >2 cm compared with smaller or superficial ulcers were even less likely to achieve week 26 ER (ileum: OR 0.10, 95% CI 0.02-0.68, P = 0.02; rectum: OR 0.12, 0.02-0.82, P = 0.03). High baseline Simple Endoscopic Score for CD (≥16) or CDEIS scores (≥12) did not affect achieving week 26 ER. Patients with larger and deep ulcers in the ileum or rectum may have difficulty achieving ER. Overall degree of endoscopic inflammation as measured numerically by endoscopic scores does not affect the likelihood of achieving week 26 ER.

P099 LEUKOCYTOCLASTIC VASCULITIS AFTER USTEKINUMAB INDUCTION IN CROHN’S DISEASE: A CASE SERIES AND SYSTEMATIC REVIEW

Abstract Ustekinumab (UST) is an effective treatment for Crohn’s disease (CD). Here we present two cases of leukocytoclastic vasculitis (LCV) in CD patients after UST induction therapy with a review of the literature. Patient #1: A 26 year old woman with a 14 year history of Crohn’s ileocolitis. She was previously treated with 6-mercaptopurine, infliximab, and vedolizumab without durable response. She ultimately underwent a left hemicolectomy due to development of a sigmoid stricture and was started on UST postoperatively. Thirty-six days after her initial UST intravenous (IV) infusion of 390 milligrams (mg) she developed new partially blanching, erythematous, non-tender, non-pruritic macules and papules over the right medial thigh, which later evolved into palpable purpura involving both lower extremities (Figure 1A). She reported no gastrointestinal (GI) or other symptoms. White blood cell (WBC) count and metabolic panel were normal. Antinuclear antibody (ANA) titer was 1:80. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) were positive. C-reactive protein (CRP) was elevated to 41.5 mg/liter (L). One lesion was biopsied, and pathology findings were consistent with LCV (Figure 1B). She was started on colchicine 0.6 mg daily with improvement in her rash and has received her second dose of UST without further complications. Patient #2: A 29 year old woman with a 6 year history of Crohn’s ileocolitis. Her prior treatments include budesonide, mesalamine, and infliximab. While on infliximab, she developed jejunal and ileal ulcers on video capsule endoscopy. Infliximab was discontinued, and UST was started. Three months following initial IV induction therapy of UST, she developed pink purpuric papules and hemorrhagic vesicles involving her bilateral shins, dorsal feet, calves, and bilateral extensor forearms. The appearance of the rash was consistent with LCV (Figure 2). She was started on prednisone at 60 mg daily for 1 week with taper resulting in complete resolution of her rash. UST was continued with no recurrence. WBC count and metabolic panel were normal. ANCA was negative, and ANA titer was 1:80. CRP was elevated to 13.2 mg/L. Literature review revealed only one prior published case report of a patient with inflammatory bowel disease developing LCV after administration of UST. In this case, UST was discontinued since re-administration caused the rash to return. Here we have two patients who developed LCV soon after initiating UST therapy, although after treatment with prednisone/colchicine, there was no recurrence with continuing UST. It is possible to develop LCV in association with CD alone; however, these patients had longstanding disease without occurrence of LCV until being started on UST. Moreover, patient #1, was in remission from a Crohn’s disease standpoint at the time of UST initiation and onset of the rash.

P058 ISOLATED TERMINAL ILEITIS AT COLONOSCOPY – WHAT FACTORS PREDICT A NEW DIAGNOSIS OF CROHN’S DISEASE?

Abstract Background Faecal calprotectin (FC) is a biomarker elevated in active inflammatory bowel disease (IBD). FC is more sensitive in colonic than small bowel IBD. Ileo-colonoscopy is usually performed to confirm a diagnosis of IBD. Isolated non-specific terminal ileitis is often inconclusive despite biopsy. We aimed to assess the factors that predict terminal ileal Crohn’s disease after ileitis is seen at colonoscopy. Methods A single centre retrospective study of all endoscopic cases of isolated terminal ileitis diagnosed at colonoscopy over a 4 year period (January 2015 – December 2018) was performed. Data was obtained from the Unisoft Endoscopy reporting software. Statistical analyses included chi-square, student t-test and binary logistic regression. Faecal calprotectin, CRP and histology were noted. &amp;gt;150μg/mg was used as a cut off for elevated FC. Results 139 cases were identified and exclusion criteria were applied (known Crohn’s disease, colonic disease). 74 cases were included for analysis. The mean age was 43.9. 44 (59.5%) of the cases were women. 38 (51.4%) had FC performed of which 27 (71.1%) had a FC &amp;gt;150μg/mg. 60 (81.1%) cases had macroscopic terminal ileum ulcers, 9 (15%) of these had histological evidence of ulceration. Subsequent diagnoses of Crohn’s disease were made in 15 (20.3%) patients. Odds ratio of 1.28 (p = 0.016, Cl 0.45-0.047) in the TI ulcers + FC &amp;gt;150μg/mg vs. no TI ulcers + FC &amp;lt;150μg/mg. Conclusion 1 in 5 patients with isolated terminal ileitis were subsequently diagnosed with Crohn’s disease. Almost 90% of these new cases had a faecal calprotectin &amp;gt;150μg/mg. There is poor correlation between endoscopic and histological terminal ileum ulceration. We conclude that terminal ileal ulceration in combination with faecal calprotectin &amp;gt;150μg/mg increases the likelihood of a new diagnosis of Crohn’s disease.

Massive Lower Gastrointestinal Bleeding Due to Cytomegalovirus-Related Ileal Ulcer

Massive Lower Gastrointestinal Bleeding Due to Cytomegalovirus-Related Ileal Ulcer

P752 A nationwide survey of chronic enteropathy associated with SLCO2A1 gene in Japan

Abstract Background Chronic enteropathy associated with SLCO2A1 gene (CEAS) is an autosomal recessive disease caused by mutations in the SLCO2A1 gene which encodes a prostaglandin transporter. It is a rare intractable disease characterised by persistent blood and protein loss due to the small intestinal ulcers. Because CEAS mimics Crohn’s disease (CD) concerning ileal ulcers and stenoses, it is often difficult to distinguish CEAS from CD based on gastrointestinal findings alone. Furthermore, SLCO2A1 gene mutations are also known to cause primary hypertrophic osteoarthropathy (PHO) and some CEAS patients manifest digital clubbing, periostosis, acroosteolysis, and thickened skin as extra-intestinal manifestations. Since little is known about the clinical features of CEAS, we conducted a nationwide survey in Japan. Methods All study participants provided written informed consent for genetic analysis. The present study was approved by the ethics committee of each institution. During the period between 2012 and 2019, 141 patients suspected of CEAS were enrolled in this study and checked to have SLCO2A1 gene mutations. We reviewed the clinical information of genetically confirmed CEAS patients. Results We confirmed 61 CEAS patients (21 males and 40 females) and found 14 different types of recessive SLCO2A1 mutations. The median age at disease onset and diagnosis was 18.5 (range 1–69) and 40 (range 7–70) years, respectively. Parental consanguinity was present in 16 patients (26%). Although anaemia was present in almost all patients, only two patients experienced gross haematochezia. The median haemoglobin and serum protein levels at diagnosis were 9.7 (range 2.3–13.7) and 5.2 (2.7–8.2) g/dl, respectively. Thirty-three patients (54%) had undergone intestinal surgery. They showed relatively low inflammatory markers in blood tests (median CRP, 2.9 mg/l). The most frequently involved gastrointestinal site was ileum (93%), but the terminal ileum was rarely involved (Figure). Mild digital clubbing or periostosis was found in 16 patients (26%), with six male patients fulfilling the major diagnostic criteria of PHO. The major manifestations of PHO were more frequently found in males than in females (digital clubbing 57% vs. 10%; periostosis 52% vs. 11%; pachydermia 62% vs. 0%). Conclusion Although CEAS frequently causes intestinal strictures like CD, its clinical features seem to be distinct from those of CD. Also, a gender difference in clinical symptoms needs to be considered, because concurrent PHO can be frequently seen especially in male patients with CEAS.

P546 Ileal ulcer size significantly impacts the ability to achieve endoscopic remission: a post-hoc analysis from the SONIC trial

Abstract Background Endoscopic remission (ER) is an important target of treatment for Crohn’s disease (CD). However, it is unclear how individual baseline endoscopic characteristics impact the ability to achieve ER. We aimed to determine endoscopic prognostic factors that influence the likelihood of achieving ER in CD. Methods This was a post-hoc analysis of SONIC (NCT00094458; YODA #2019–3980), where data from 172 patients who had endoscopic scores at baseline and at week 26 were evaluated. Individual components of the Crohn’s Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score for Crohn’s disease (SES-CD) indices were used to evaluate the impact of baseline ulcer depth (CDEIS) and size (SES-CD) on likelihood of achieving ER at week 26. Ileum and colon segments were evaluated separately. Multivariate logistic regression models were used to evaluate the relationship between baseline endoscopic findings and achievement of ER in each segment at week 26, after accounting for known confounders including disease duration and treatment allocation. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results The rate of ulcer improvement in the ileum was significantly lower than rates of healing throughout the colon (p &amp;lt; 0.0001) (see figure). Patients with ulcer size &amp;gt;2 cm in the ileum were less likely to achieve ER of the ileum compared with patients with ulcer size &amp;lt;2 cm (OR 0.31, 95% CI 0.11–0.89, p = 0.03). Ulcer size did not consistently impact likelihood of achieving week 26 ER in colonic segments. Patients with ileal ulcer size &amp;gt; 2 cm that were also deep were less likely to achieve ileal ER, when compared with patients with smaller or superficial ulcers (OR 0.10, 95% CI 0.02–0.68, p = 0.02). High baseline SES-CD score (&amp;gt;16) or CDEIS score (&amp;gt;12) did not impact the likelihood of achieving week 26 ER. Conclusion Ulcer size and depth, but not the overall degree of endoscopic inflammation, seem to impact likelihood of achieving week 26 ER. ER may be more difficult to achieve for patients with larger and deep ulcers in the ileum. These findings may have implications for recruitment into clinical trials and would support the importance of balancing these prognostic factors in trial arms. Further prospective data are needed to validate these findings.

3140 An Unfortunate Triad: GI Bleed Due to Refractory DLBCL Complicated by Occlusive Thrombus of the Inferior Vena Cava

INTRODUCTION: Ileal ulcers are circumscribed, inflammatory and necrotic erosive lesions on the mucosal surface of the ileum and can have specific etiologies such as Crohn's disease, NSAID-intake, intestinal tuberculosis and eosinophilic enteritis. Here, we report a symptomatic terminal ileal ulcer caused by a diffuse large B-cell lymphoma (DLBCL). CASE DESCRIPTION/METHODS: A 71 year-old male with a history of gastrointestinal bleeds (GIB) due to ulcers presented with weight loss and small bowel obstruction due to a terminal ileum mass and was diagnosed with an EBV-negative DLBCL after a right hemicolectomy. In the setting of refractory disease (RCHOP, Ibrutinib and Lenalidomide on trial, salvage with DHAX) he presented again with an active GIB with hematemesis and dark stools, an EGD was normal but a colonoscopy showed a lymphoma of the terminal ileum (TI). Clinical examination showed no abnormalities. Initial work up showed mild anemia and elevated creatinine (1.68). A CT abdomen and pelvis showed a progressive disease with new circumferential thickening of the small bowel in the right abdomen. A PET showed a progressive lymphadenopathy throughout the abdomen and pelvis. The GIB was managed with IV pantoprazole and sucralfate. A biopsy of the terminal ileum mass showed a recurrent DLBCL. The patient was considered for a regeneron trial but developed nearly occlusive deep vein thrombosis (DVT) that extended into his inferior vena cava (IVC) and led to a DVT in his left subclavian vein, so that he no longer was a candidate for trial. Given the active GIB, he was planned for the placement of an IVC filter, however, the occlusive thrombus in the IVC prevented the procedure. The goals of best supportive care were discussed with the patient. DISCUSSION: The gastrointestinal (GI) tract is the most common extranodal site involved by lymphomas. While GI tract involvement is usually secondary during progression of the disease, primary GI tract lymphoma is relatively rare. Diffuse large B-cell lymphomas are the most common lymphomas affecting the GI tract. GI lymphomas present with unspecific clinical features and are therefore difficult to distinguish from other conditions. The diagnosis is made by pathology. In this case, a biopsy was obtained from the TI mass confirming the diagnosis of refractory DLBCL with GI involvement. This patient developed an unfortunate combination of multiple complications interacting with the respective treatments.

3214 Acute Extensive Jejunal Ulceration Following Single Balloon Enteroscopy

INTRODUCTION: Small bowel ulceration can be difficult to diagnose and maybe confused with perforation or intestinal obstruction. The differential considerations for small bowel ulceration include inflammatory causes: PUD, isolated terminal ileal ulcers, drug induced, Crohn's disease. Vascular disorders: vasculitis, Behcet's, vascular dysplasia, microangiopathic ischemic ulcers, veno-occulsive. Other causes: ischemia, neoplasia and more. We are reporting a case of diffuse jejunal ulceration after episode of hypotension diagnosed by capsule endoscopy (CE). CASE DESCRIPTION/METHODS: 75 yo male veteran with IBS-C, CAD, CHF, A fib on ApixabanPatient admitted for acute CHF exacerbation. Hgb was decreased to 8.1 g/dl (baseline 13 g/dl). Patient denied hematemesis, hematochezia, melena Due to patient cardiac issues, we used CE to evaluate for possible GI bleed. CE findings noted for AVM in early jejunum, distal jejunal polyp, bleeding ileal AVM. He was transferred to another facility for single balloon enteroscopy (SBE) with ablation of 4 areas of AVM's. A tattoo was placed to the most distal area of the jejunum reached. The jejunal polyp wasn't seen on SBE. Post procedure he developed hypotension, and started on pressor for blood pressure (BP) support. The patient was transferred back to our facility after 2 weeks. We were asked to evaluate if the jejunal polyp was missed on SBE. A repeat CE showed: multiple areas of severe, large circumferential ulceration throughout the jejunum. Jejunal polyp was noted distal to the tattoo, bleeding AVM in the ileum again. Anticoagulation was held and started iron supplement. DISCUSSION: Patients needing pressor support for BP control are at risk for CV events such as intestinal ischemia. Given the acute changes in the small bowel seen on the CE, likely due to either the hypotensive episode or use of vasoactive drugs to support the patient's BP. In our literature search, we didn't find any reports on acute extensive jejunal ulceration following a hypotensive episode or after use of vasoactive drugs. This entity may be under reported due to patients' hemodynamic instability preventing endoscopic eval. In general, unless targeted the small bowel is not routinely evaluated. We propose using CE, which requires minimal prep and no anesthesia, to help reveal the diagnosis of ileal ischemia in patients with pressor support or hypotension that aren't responding to supportive measures in order to alter the clinical intervention. This can be done as a future prospective study in ICU patients.

657 Ulceration of the Pre-Pouch Ileum in Patients With Ulcerative Colitis Following Proctocolectomy With Ileal Pouch-Anal Anastomosis: An Analysis of Pouchoscopies From 272 Patients

INTRODUCTION: Colectomy is required in up to 30% of patients with ulcerative colitis (UC) due to medically refractory disease or development of dysplasia/cancer. In such cases, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgery of choice. However, pouchitis may occur in up to 80% of patients and significantly impairs quality of life. Pouchitis usually spares the pre-pouch ileum, however, a subset of patients develops discrete ulcerations in the pre-pouch ileum despite a firm preoperative UC diagnosis. The prevalence of such findings and predictive factors have not been adequately studied. We report a large cohort of patients undergoing pouchoscopies and describe the prevalence of pre-pouch ileal ulcerations. METHODS: This is a retrospective single-center study of adult patients with UC who had a total proctocolectomy with IPAA and subsequently underwent pouchoscopy between January 2007 and August 2018. At our institution, pouchoscopies are performed using a standard operating protocol. These reports include detailed descriptions of the mucosa as well as high definition images of the different areas of the pouch, the pre-pouch ileum, the pouch inlet, forward view of the pouch, a retroverted view of the pouch, and the rectal cuff. Based on these images and descriptions, we characterized pouch phenotypes and ulcer locations. Patient demographic and clinical data were also assessed. RESULTS: We reviewed the pouchoscopies of 272 patients who underwent proctocolectomy with IPAA for a pre-operative diagnosis of UC. Characteristics of the patients included median age 39 years (IQR 30.2-50.7), median BMI 25 (IQR 22.5-28.6), 90% Caucasian, 59% men, 23% ex-smokers and 83% extensive colitis prior to colectomy. 18% of our patients had discrete ulcerations in their pre-pouch ileum. In a multivariate analysis including age, sex, BMI, disease extent, race, ex-smoking status, prior treatment with anti TNFs or immunomodulators, history of PSC and previous infection with C. diff, none of these factors were associated with pre-pouch ileal ulcers (Table 1). CONCLUSION: Despite a firm diagnosis of UC prior to colectomy, 18% of patients at our tertiary center were found to have discrete ulcers in their pre-pouch ileum. We did not identify predictive factors in this patient cohort, but the potential impact of these findings suggests that proactive post-operative monitoring may be helpful.

Etiology of isolated terminal ileal ulcers in symptomatic patients

Introduction: Isolated terminal ileal ulcers (ITIUs) are being frequently encountered by the clinicians with the increasing numbers of ileal intubation during colonoscopies. This study was aimed at finding the etiologies of these ulcers in symptomatic patients and their association with various clinical features.&#x0D; Methods: This was a hospital based prospective, observational, descriptive study performed on all consecutive patients who underwent ileocolonoscopy for various gastrointestinal symptoms between 1 July 2018 and 30 June 2019. Clinical, endoscopic and histopathological findings were analyzed to determine the etiology of ITIUs in symptomatic patients. Statistical analysis was done by SPSS 20.&#x0D; Results: Among 60 (7.67%) of 782 symptomatic patients who had ITIUs on ileocolonoscopy, specific etiologies were established in 28 (46.67%) of them. Intestinal TB was the most common specific diagnosis, which was seen in 18 (30%) patients. Chronic abdominal pain with or without chronic diarrhea was the most common indication for ileocolonoscopy.&#x0D; Conclusions: Specific etiologies like tuberculosis, Crohn’s disease, NSAID-induced ulcer and intestinal spirochetosis were seen in 28 (46.67%) of patients with isolated terminal ileal ulcers. The most common clinical features were chronic abdominal pain (65%) and abdominal pain with diarrhea (16.7%). No clinical presentation was significantly associated with any specific etiology, thus emphasizing the need for routine ileal intubation and tissue sampling for histopathological examination in all symptomatic patients undergoing colonoscopy.

Proteomics Highlights Common and Distinct Pathophysiological Processes Associated with Ileal and Colonic Ulcers in Crohn's Disease.

Based on genetics and natural history, Crohn's disease can be separated into two entities, an ileal and a colonic disease. Protein-based approaches are needed to elucidate whether such subphenotypes are related to distinct pathophysiological processes. The proteome of ulcer edges was compared with that of paired control tissue samples [n = 32 biopsies] by differential proteomics in the ileum and the colon of Crohn's disease patients [n = 16]. The results were analysed using a hypothesis-driven approach [based on the literature] and a hypothesis-free approach [pathway enrichment analyses] to determine common and segment-specific pathophysiological processes associated with ileal and colonic CD ulcer edges. To confirm the involvement of a key pathway highlighted by proteomics, two proteins were also studied by immunochemistry. In the ileum and the colon, 4428 and 5204 proteins, respectively, were identified and quantified. Ileal and colonic ulcer edges differed in having a distinct distribution of proteins associated with epithelial-mesenchymal transition, neutrophil degranulation, and ribosomes. Ileal and colonic ulcer edges were similarly characterized by an increase in the proteins implicated in the endoplasmic reticulum protein-processing pathway and a decrease in mitochondrial proteins. Immunochemistry confirmed the presence of endoplasmic reticulum stress in the mucosa of ileal and colonic ulcer edges. This study provides protein-based evidence for partially distinct pathophysiological processes being associated with ileal and colonic ulcer edges in Crohn's disease patients. This could constitute a first step toward the development of gut segment-specific diagnostic markers and therapeutics.

Retrograde Device Assisted Enteroscopy as a Salvage Procedure for Failed Colonoscopy: The Experience of a large Australian Centre

Aim: Failed caecal intubation occurs in 4-25% of colonoscopies. The primary objective was to assess the technical success of retrograde Device Assisted Enteroscopy (rDAE) after failed colonoscopy. Secondary aims were to describe the diagnoses and interventions, and to identify factors affecting technical success.Methods: Retrospective review of consecutive patients undergoing retrograde DAE at our institution between November 2004 and May 2016. Data were collected on: demographics, technical success, bowel preparation, diagnoses, interventions and adverse events.Results: In total, 277 patients underwent retrograde DAE. Of these, 86 procedures were performed on 82 patients for incomplete colonoscopy, primarily in redundant colons. Cecal intubation was achieved in 80 procedures (93%). Incomplete procedures were caused by unsatisfactory preparation in 5 cases (6%) and by colonic herniation in 1 case (1%). Of the 80 completed procedures, 2 were non-diagnostic due to poor bowel preparation and 20 showed no abnormalities. In the remaining 58 procedures, 66 diagnoses were made: adenomatous polyps (n=25), inflammatory bowel disease (n=14), angioectasias (n=7), colonic diverticulosis (n=6), strictures (n=5), laterally spreading tumours (n=3), adenocarcinomas (n=3), and ileal ulcers (n=2). Interventions performed were: snare polypectomy (n=29), biopsy (n=17), argon plasma coagulation (n=8), endoscopic mucosal resections (n=3), dilatation (n=3) and endoscopic clipping (n=4). No reported adverse events.Conclusion: Salvage retrograde DAE has a high technical success in redundant colons and important diagnostic findings. DAE should be recommended in preference to repeat standard colonoscopy or CT colonography. There should be a strong focus on optimising bowel preparation, as it was the major factor influencing technical success and diagnostic yield.

Intussussception and Ileal Ulceration: A Case of Recurrent Near-Tetraploid Diffuse Large B-Cell Lymphoma of the Small Intestine

Diffuse Large B-Cell Lymphoma (DLBCL) presents extranodally in nearly 40% of cases. In patients with polyploidy, however, extranodal presentation is far less common. To date, no primary gastrointestinal cases of polyploid DLBCL have been reported. We present a case of DLBCL with polyploidy diagnosed as intussusception in the terminal ileum with recurrence as an ileal ulcer. A 71-year-old man with history of an inguinal hernia repair and empyema presented to our hospital with two weeks of back pain with periumbilical radiation, non-bilious emesis, inability to tolerate food by mouth, ten pound weight loss, and decreased stool caliber. His last colonoscopy over ten years ago was normal. CT imaging revealed a small bowel obstruction with circumferential wall thickening at the terminal ileum causing 4-cm of intussusception (Figure 1). He underwent exploratory laparotomy and right hemicolectomy with side-to-side ileocolic anastomosis. Pathology revealed a non-germinal center DLBCL with a near-tetraploid karyotype. Resection margins were negative. After positron-emission tomography CT (PET-CT) revealed no evidence of disease, he received six cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Following treatment, repeat PET-CT revealed normal bowel with adjacent newly avid peritoneal and mesenteric nodules (Figure 2). Given radiographic recurrence, he was treated on a clinical trial with a combination of ibrutinib, lenalidomide and rituximab. During his first cycle, he re-presented with anemia and dark, guaiac-positive stool. Although EGD was unremarkable, colonoscopy revealed a solitary, non-bleeding, 10-mm ulcerated polyp in the neo-terminal ileum with surrounding healthy mucosa proximal to the site of the prior end-to-end ileocolic anastomosis (Figure 3). Pathology revealed recurrent DLBCL and imaging confirmed progressive disease. Treatment with salvage chemotherapy was ineffective. He was transitioned to hospice and died two weeks later. To our knowledge, this is the first reported case of gastrointestinal DLBCL with polyploidy. In addition to reduced infiltration of extranodal sites, these karyotypes carry an unfavorable prognosis and poor overall survival. Early identification and attention to extranodal disease as well as prompt initiation of therapy are imperative to optimize any potential treatment response in these patients.2594_A Figure 1. Coronal CT of Intussusception.2594_B Figure 2. Coronal PET-CT of Recurrent Abdominal Lymphoma.2594_C Figure 3. Endoscopic View of Ileal Ulceration.

Capecitabine-Associated Ileocolitis Diagnosed on Colonoscopy

Capecitabine is considered a first line agent in adjuvant therapy for colorectal cancer. One of its adverse effects however is that it can commonly be associated with GI side-effects such as diarrhea. When the diarrhea is severe and prolonged, capecitabine associated enterocolitis should be strongly considered in the differential. Herein, we present a rare case of capecitabine enterocolitis, specifically involving the distal ileum and ascending colon, demonstrating the role of colonoscopy in diagnosis. Additionally, this case is meant to demonstrate the disease course and provide our experience in treating this rare condition. We present a 72-year-old female with stage IIIC ascending colon adenocarcinoma who underwent laparoscopic right hemicolectomy started on adjuvant chemotherapy with capecitabine. She was initiated on capecitabine monotherapy for a planned 6 months, however after one month of tolerating the medication, she developed severe, prolonged, and painless diarrhea ultimately lasting 4 weeks. Infectious and ischemic workup was negative. Her initial CT abdomen and pelvis was significant for mildly dilated fluid-filled loops of small bowel with adjacent engorgement of vasa recta and mesenteric edema concerning for enteritis. This was followed up with colonoscopy with ileoscopy finding evidence of granular erythematous mucosa with ulceration both above and below the ileocolonic anastomosis in the distal ileum and ascending colon. Ileal biopsy showed mucosal erosion with acute and chronic inflammation and occasional atypical gland. Our treatment approach with anti-motility agents, cholestyramine, octreotide and oral steroids were largely ineffective in treating the diarrhea. The patient ultimately required TPN to address the patient's severe protein deficiency and malnutrition secondary to the ileocolitis.1570_A Figure 1. A. Axial CT of the abdomen demonstration vasa recta engorgement and mesenteric edema. B. Coronal CT of the abdomen with “comb sign” demonstrating vasa recta engorgement and mesenteric edema1570_B Figure 2. Colonoscopy showing granular erythematous mucosa of the ascending colon (2A and 2B) distal to the ileocolonic anastamosis. Ileoscopy reveals evidence of ulceration in the distal ileum (2C and 2D)To date, there have only been 8 cases published that describe Capecitabine associated enterocolitis, and only 2 of these cases documented colonoscopic evidence revealing ulceration of the ileum. Our case will be the 3rd case which utilized colonoscopic and pathologic evidence of ileal ulceration. In all the published cases, approach to management posed a significant challenge. It appears that a trial of cessation of Capecitabine, fluid and nutritional resuscitation with TPN have shown some benefit. With all cases it appears that capecitabine enterocolitis requires time to ultimately resolve itself.

A Prospective Evaluation of Isolated Terminal Ileal Lesions in Symptomatic Patients: Natural History and Clinical Significance: Presidential Poster Award

Introduction: Because of the increasing number of ileal intubations, isolated terminal ileal (TI) lesions or abnormal mucosa such as terminal ileal ulcers (TIU), terminal ileal nodularity (TIN), and terminal ileal erosions (TIE) are commonly seen during colonoscopies. In this study, we aim to determine the natural history and clinical significance of isolated terminal ileal lesions in patients having gastrointestinal symptoms. Methods: This was a prospective observational cohort study performed on 117 subjects with TI lesions who underwent ileocolonoscopies from August 2016 to May 2018 for various gastrointestinal symptoms. Clinical, endoscopic, and histological findings of these subjects were noted to determine the etiology. After administration of treatment, subjects were followed up after 4-6 weeks to assess symptom resolution.1175 Figure 1 No Caption available.Results: The mean age of the subjects was 41.6±12.5 years among which 84 (72 %) were males. Out of 117 subjects, the prevalence of TIU, TIN, and TIE was noted to be 67 (57.3%), 37 (31.6%), and 10 (11.1%) respectively. A history of recent NSAIDs use was found in 6 (5.1%) subjects. Among all, the most common manifestation was abdominal pain 98 (83.7%), followed by abdominal discomfort 8 (6.8%), bleeding per rectum 6 (5.1%), melena 2 (1.7%), and chronic diarrhea 3 (2.6%) [Table]. Histopathological examination of the biopsy specimens showed evidence of normal mucosa, chronic ileitis, active ileitis, lymphoid hyperplasia, Crohn's disease, intestinal tuberculosis, eosinophilic enteritis in 16 (13.7%), 58 (50.4%), 17 (14.5%), 16 (13.6%), 7 (5.9%), 2 (1.7%), and 1 (0.85%) patients respectively. 80 (68.4%) patients had a complete symptomatic resolution at 4-6 weeks of follow up visit. Patients with partial symptomatic resolution (25.6%) or with persisted symptoms (5.9%) were planned for repeat colonoscopy to assess endoscopic resolution. Conclusion: Abdominal pain is the most common presenting manifestation of isolated terminal ileal lesions. Among all, more than half of the subjects showed evidence of acute or chronic terminal ileitis with symptomatic resolution within few weeks. Close monitoring and re-evaluation are needed in subjects with persisted symptoms.

Diagnosis of a Bleeding Meckelʼs in an Adult with a Negative Meckelʼs Scan

Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract, occurring in 2% of the general population. Most diagnosis of MD are made in childhood. However, some patients may remain asymptomatic through adulthood or present later in life with complications such as anemia due to ileal ulceration. Strictures occur in MD due to secretion of hydrochloric acid and pepsin by heterotopic gastric tissue. We describe a case of an adult male presenting with abdominal pain and anemia who was diagnosed initially with small bowel ulceration consistent with Crohn's disease. However, he was eventually diagnosed with MD after surgical exploration. This case illustrates the difficulty in diagnosing MD in adults by standard imaging or endoscopy. A 45 year-old South Asian man without significant PMH presented to clinic with a one-year history of progressive anemia associated with fatigue and abdominal pain. Initial evaluation included an upper endoscopy and colonoscopy. A video capsule endoscopy (VCE) study revealed an inflammatory stricture in the distal ileum concerning for IBD. Retrograde DBE defined two ulcerated stenotic strictures located in the mid-ileum immediately adjacent to a diverticulum. Biopsies of the two strictures and diverticulum were suggestive of Crohn's disease. A Meckel's scan was performed and negative. Surgical resection of the diseased segment of bowel was consistent with a MD which was confirmed by histology. Meckel's diverticulum (MD) is primary diagnosed in childhood by 99mTc nuclear imaging or Meckel's scan (MS). The sensitivity and specificity of this scan in children is 85% and 95%, respectively, but falls to 62.5% and 9% in adults. This discrepancy may be related to a decline in heterotopic gastric mucosa with age in symptomatic MD. A case series evaluating an incidental MD in 311 patients found no presence of heterotrophic (ie. gastric and pancreatic) mucosa. One retrospective case-series found that DBE had a significantly higher diagnostic accuracy 85.0% (61.1%-96.0%) for MD than MS 21.4% (5.7%-51.2%) in the adult population with a (P = 0.001). However, DBE is not available in all centers. This same study also reported the diagnostic accuracy of other modalities for MD including small-bowel follow through (63%),VCE (36%),CT (32%), and angiography (0%). In cases in which a MD is suspected but evaluation by imaging and VCE are inconclusive, referral for DBE should be considered.1986_A Figure 1. Mid-ileum Stricture1986_B Figure 2. Stricture adjacent to Large Diverticulum1986_C Figure 3. Histopathology adapted from Fujita, Naoyuki