Intermittent Rectal Bleeding Research Articles

A rare case of giant peritoneal loose body: A case report

Peritoneal loose bodies (PLBs) are uncommon abdominal lesions, typically asymptomatic and discovered incidentally during surgery. Giant PLBs, exceeding 5 cm in size, are even rarer and can present with clinical symptoms mimicking other abdominal pathologies. We present a 57-year-old male with a giant PLB presenting as intermittent abdominal pain, distention, and rectal bleeding. Imaging studies suggested colo-colic intussusception due to a colonic lipoma. The patient underwent an exploratory laparotomy revealing a segment of the descending colon containing multiple lipomas, one causing intussusception. In addition, a separate giant PLB 6 × 5.5 cm with central calcification was identified. A segmental colectomy with primary anastomosis and resection of the PLB was performed. The patient recovered well and reported complete resolution of symptoms at follow-up. Pathology confirmed a benign lipoma and a giant PLB. This case highlights the potential for giant PLBs to cause clinical symptoms and emphasizes the importance of including them in the differential diagnosis of abdominal complaints, even in the absence of a classic presentation. Exploratory laparotomy remains a definitive approach for diagnosis and management in such cases.

Chronic radiation proctitis refractory to steroid enema was successfully treated by metformin and sodium butyrate: a case report

BackgroundRadiation proctitis (RP) is a significant complication of pelvic radiation. Effective treatments for chronic RP are currently lacking. We report a case where chronic RP was successfully managed by metformin and butyrate (M-B) enema and suppository therapy.Case presentationA 70-year-old Asian male was diagnosed with prostate cancer of bilateral lobes, underwent definitive radiotherapy to the prostate of 76 Gy in 38 fractions and six months of androgen deprivation therapy. Despite a stable PSA nadir of 0.2 ng/mL for 10 months post-radiotherapy, he developed intermittent rectal bleeding, and was diagnosed as chronic RP. Symptoms persisted despite two months of oral mesalamine, mesalamine enema and hydrocortisone enema treatment. Transition to daily 2% metformin and butyrate (M-B) enema for one week led to significant improvement, followed by maintenance therapy with daily 2.0% M-B suppository for three weeks, resulting in continued reduction of rectal bleeding. Endoscopic examination and biopsy demonstrated a good therapeutic effect.ConclusionsM-B enema and suppository may be an effective treatment for chronic RP.

HIV Associated Kaposi’s Sarcoma with Visceral Involvement and Rectal Bleeding

Abstract Introduction/Objective Kaposi’s sarcoma (KS) is one of the complications of advanced HIV disease and human herpes virus 8 (HHV-8) is the etiological agent. Most cases of KS are cutaneous and resolved with HIV treatment, few cases of KS present with visceral involvement and have a poor prognosis. Any part of the gastrointestinal tract (GIT) may be affected by KS, however visceral involvement without cutaneous lesions is extremely rare. KS has metastatic potential and can be fatal if treatment is not initiated immediately. Methods/Case Report A 29 years old homosexual man with a history of multiple sexually transmitted diseases and HIV infection (CD4: 331 cell/μL, CD4/CD8: 0.2, HIV RNA: 10542 copies/mL) presented to the emergency department in a hypovolemic state with hemoglobin of 6 g/dl. He received HAART 3 years ago but discontinued it due to the COVID pandemic. He had a history of recurrent and intermittent rectal bleeding which was exacerbated during the past 3 months. On physical examination, a bleeding rectal mass and bilateral inguinal adenopathy were noted. An imaging study was performed and showed a 14 cm anorectal mass extruding through the anal canal, with bilateral axillary, inguinal, pelvic side walls, iliac chains, and periaortic lymphadenopathy. Flow cytometry of the fresh biopsy tissue revealed a T cell-predominant lymphoid population with reversed CD4/CD8 ratio, compatible with the patient's known history of HIV, with no immunophenotypic evidence of lymphoma. Histopathologic examination of an excisional biopsy of the rectal mass showed mild to moderate atypical spindle cells arranged in vague fascicles and separated by slit-like vessels and extravasated red blood cells. Immunohistochemical (IHC) stain revealed the atypical spindle cells were positive for HHV-8, CD31, CD34, D2-40, BCL2, Vimentin, and Ki-67 (35%-highly proliferative) whereas these cells were negative for AE1/AE3, CK5/6, P40, CD45, Desmin, and S100. A diagnosis of KS was made. Results (if a Case Study enter NA) NA Conclusion We present a case of visceral KS without cutaneous involvement, which may pose a difficulty in diagnosis. The GIT, lungs, and lymph nodes are the relatively common sites that are affected by visceral KS. KS manifests various histopathological and clinical pictures, and a delay in diagnosis can cause a worse prognosis. The treatment options for KS are depending on the clinical presentation and the extension of the lesions. A combination of HAART, chemotherapy, and radiotherapy could be an effective treatment in the early stage of the disease.

Anal adenosquamous carcinoma on perineal fistula: A case report

Introduction: Adenosquamous Carcinoma (ASC) of the anus presenting both glandular and squamous histopathologic features is a rare colorectal neoplasm. Case presentation: A 63-year-old man presented with a one-year history of intermittent rectal pain and bleeding on a perineal fistula. Pathological analysis of the surgical specimen revealed adenosquamous carcinoma of the anus, The patient received neoadjuvant treatment with chemotherapy and radiotherapy over a period of five weeks. then he underwent abdominoperineal resection and a permanent colostomy. Histology revealed invasive adenosquamous carcinoma on the resection specimen and the patient was started on adjuvant therapy with FOLFIRINOX. Discussion: Primary ASC of the colon and rectum are extremely rare clinical entities with poor prognosis. Most of the data come from individual case reports and a few small series, making it a challenge to understand the histogenesis of the disease. And the treatment modalities are not yet well codified, which has an impact on overall survival. Conclusion: Early diagnosis and radical surgery with other available therapeutic modalities can improve clinical outcomes.

S2681 A Pain in the Rectum: Syphilis Manifesting as Proctitis

Introduction: Anorectal syphilis is often challenging to diagnose due to the atypical clinical presentation and asymptomatic disease course. Patients who engage in high-risk sexual behavior are at increased risk for sexually transmitted infections. We present a unique case of rectal bleeding and diarrhea secondary to anorectal syphilis. Case Description/Methods: A 31-year-old uninsured man presented to the ER with a 1 month history of rectal bleeding, abdominal pain and diarrhea. His past medical history is remarkable for untreated HIV and Factor V Leiden deficiency. He reported being sexually active with multiple male partners and engaging in unprotected anal receptive intercourse. He denied alcohol, tobacco or ilicit drug use. Vital signs were unremarkable on admission. Physical exam was significant for a soft abdomen with palpable tenderness in the lower quadrants without guarding or rebound tenderness. Digital rectal exam was negative for blood, stool, visible lesions or ulcerations. Labratory analysis revealed a hemoglobin of 15.2 g/dL and HIV CD4 count was 877 per mcL. Chemistry panel including liver tests were within normal limits. Computed tomography (CT) of the abdomen revealed mucosal thickening of the rectum with mild fat stranding consistent with inflammation. In the setting of reported hematochezia and abnormal imaging findings the patient underwent colonoscopy which revealed multiple, shallow ulcerations confined to the rectum. Ulcer biopsies were obtained and revealed active proctitis with spirochetes on immunostaining. Treated was initiated with Penicillin G. He had improvement in abdominal pain and resolution of hematochezia. (Figure) Discussion: Syphilitic proctitis is most often associated with pain on defecation, intermittent rectal bleeding and diarrhea. In high risk patient groups, such as MSM and sex workers, clinical suspicion should be high for sexually transmitted infections that affect the anorectal region. Diagnosis of syphilis is based on clinical findings, serological testing and in some cases, tissue biopsy. Primary disease usually occurs at the exterior anal verge, at points of sexual contact. Our case describes syphylitic ulcerations scattered within the rectum without exterior involvement, making it a highly unusual presentation. Although various diagnostic information can be helpful, it is vitally important that physicians rely on their own expertise and knowledge to recognize subtle findings that may help establish a diagnosis, especially in those who are immunocompromised.Figure 1.: Multiple scattered ulcerations in the rectum (white arrows).

S2173 A Twist of Fate: The Cecal Bascule

Introduction: Cecal volvulus is a rare clinical entity with an incidence of 2.8-7.1 per million per year and accounts for 1-2% of large bowel obstruction. The rarest type of cecal volvulus is cecal bascule, accounting for 5-20% of all cases. It occurs when the cecum folds up over itself in an anteromedial orientation with a competent ileo-cecal valve. This allows for gaseous and fluid distention. The pathogenesis is still unclear but the literature suggests that congenital or acquired adhesion may be responsible as a mobile cecum. Symptoms consist of abdominal pain, distention, nausea and obstipation. Diagnosis may be challenging due to its rarity. Here we present a male with an incidental imaging finding suggestive of cecal bascule. Case Description/Methods: An 82-year-old male patient with history of prostate cancer, atrial fibrillation on Apixaban, diabetes and chronic kidney disease who was consulted to gastroenterology services due to rectal bleeding. He reported an episode of intermittent rectal bleeding in the past year mostly secondary to straining due to constipation. Last colonoscopy on 2010 showed diverticulosis plus internal and external hemorrhoids; no polyps or masses. He denied abdominal pain, weight loss, or early satiety. Hemoglobin was stable and normal rectal exam. In view of risk vs benefits patient opted for CT colonography. Study with evidence of diverticulosis and a large cecal bascule. Upon follow-up, he reported feeling well and denied abdominal pain or recurrence of rectal bleeding. He had a complicated appendectomy 7 years ago. Patient was consulted to general surgery for possible cecopexy. Discussion: Cecal bascule is a rare subtype of cecal volvulus that mostly occur in older patients and usually presents with marked GI symptoms, such as obstruction, needing emergent treatment. Risk factors are mostly due to embryogenic defects or iatrogenic (abdominal surgery). Diagnosis is made via imaging study, such as CT, or laparoscopy showing the cecum folding upward resulting in obstruction. Management is mostly surgical with resection and cecopexy. Here with present a case of cecal bascule with a rare presentation of minimal symptoms. The patient had history of a complicated appendectomy most likely being the inciting factor of the cecal bascule. Most cases in literature present after a more recent surgical procedure. The importance of this case is to bring attention of this rare clinical entity, its diagnosis and how it may present with non-specific chronic symptoms.

S2096 PALB2 and the Risk for Colorectal Cancer

Introduction: Colorectal cancer (CRC) is the most prevalent cancer in the gastrointestinal system and the third leading cause of cancer-related deaths in the United States. Hereditary factors play an important role in the risk of CRC and it has been estimated that up to 30% of CRC cases are affected by genetic factors. However, mutations in CRC-susceptibility genes explain less than 10% of CRC cases. Germline mutations in deoxyribonucleic acid (DNA)-repair genes have recently been reported more frequently in CRC. PALB2 is one such germline mutation that was recently evidenced as a CRC risk gene. We present a case of a female patient diagnosed with invasive sigmoid adenocarcinoma in the setting of no significant risk factors except for positive gene testing for PALB2. Case Description/Methods: A 32-year-old female with no significant past medical history presented with an episode of painless, large-volume bright red blood per rectum. She endorsed a 2-month history of intermittent rectal bleeding noted on wiping. Complete blood count revealed a microcytic anemia with hemoglobin of 8.4. Iron panel was consistent with anemia of chronic disease. Colonoscopy revealed a large, infiltrating and partially obstructing mass in the recto-sigmoid colon measuring 6 cm with evidence of mucosal bleeding. Biopsy confirmed invasive adenocarcinoma. Computed tomography (CT) of the abdomen showed multiple hypodense hepatic lesions suggestive of metastatic disease (Figure 1). Discussion: Mutations in PALB2 have been associated with an increased risk of familial cancers including breast, pancreatic, and gastric cancers. PALB2 encodes a protein that functions in tumor suppression and is primarily involved in the DNA repair process. PALB2 is altered in 2.8% of colorectal cancer cases. One study proved that PALB2 was an independent prognostic factor in CRC. Further studies on mutations involving PALB2 in CRC can help delineate a patient’s risk for malignancy and provide vital information for gastric cancer prevention. It will also allow for more personalized treatment options to have improved survival outcomes.Figure 1.: Malignant, partially obstructing tumor in the recto-sigmoid colon that was about 19 to 25 cm from the anal verge.

Revisiting imaging features of rectosigmoid vascular malformation with emphasis on multiparametric MRI: a case report

BackgroundGastrointestinal vascular malformations are rare benign vascular neoplasms of the gastrointestinal tract, with the rectosigmoid region being the most frequently involved site. Patients often manifest with recurrent, intermittent rectal bleeding, which might occasionally be life-threatening.Case presentationA 39-year-old man with a history of hemorrhoid operations twice was presented to our gastroenterology department with blood in the stool and abdominal pain. After the colonoscopy, multiparametric MRI, and CT examinations, robotic low anterior resection was performed with the diagnosis of rectosigmoid venous malformation. The histopathological examination confirmed the diagnosis.ConclusionColonoscopy is the preferred method in diagnosing rectosigmoid vascular malformation, but wrong and delayed diagnoses are common. Thus, imaging modalities might add to colonoscopy in equivocal cases.

A unique case of abdominal pain and anemia

A 38-year-old female presented with intermittent abdominal pain and rectal bleeding and found to have severe anemia. The computerized tomography of abdomen and pelvis with contrast showed a solid mass measuring 5.4 × 3.4 × 3.1 cm in the cecum (Figure 1, left). The colonoscopy revealed a large protruding lesion with ulceration in the right colon (Figure 1,right). Multiple biopsies of the ulcerated area were obtained.

S1980 Resolution of High-Grade Anal Squamous Intraepithelial Lesion With Antibiotics Proposes a New Role for Syphilitic Infection in Potentiation of HPV-Associated ASCC

Introduction: Human Papilloma Virus (HPV) is the primary risk factor for the development of Anal Intraepithelial Neoplasia (AIN) and is a leading risk factor for anogenital squamous cell carcinoma (ASCC). Despite common shared risk factors for both HPV and syphilis, co-infection is not well documented, and the role of syphilitic infection in HPV-associated AIN and ASCC potentiation is not defined. Case Description/Methods: A 72-year-old male presented with complaints of mild rectal pain and intermittent rectal bleeding. A flexible sigmoidoscopy was performed, and an anal mass was detected and biopsied. Pathology findings included evidence of a high grade squamous intraepithelial lesion (HGSIL, AIN II/II/AIS) with viral cytopathic effect, consistent with HPV infection. Much of the biopsied lesion demonstrated acanthotic squamous mucosa with intraepithelial neutrophils and abundant submucosal plasma cells, suggesting possible syphilitic involvement. Subsequent immunohistochemical staining for P16 as a surrogate marker for HPV was positive, as was an immunohistochemical stain for spirochetes, supportive of co-infection with Treponema pallidum, the causative agent in syphilis. The patient was referred to an infectious disease specialist and his syphilis was treated with penicillin. Upon follow up with gastroenterology, remarkable near-complete resolution of the suspected HPV actuated dysplastic lesion was observed. Discussion: Resolution of the lesion by antibiotic treatment for syphilitic infection suggested that co-infection by Treponema pallidum may potentiate HPV-associated squamous cell carcinoma based on histological findings. Findings from this case, as well as a review of bacterial involvement and potentiation in various cancers, are reviewed here. Such findings offer new insight regarding the role of STD-associated bacteria and HPV co-infection in the establishment of AIN and may additionally propose new treatment modalities for ASCC.Figure 1.: Co-infection by HPV and syphilis in high grade squamous anal intraepithelial lesion. A. P16 staining demonstrates HPV positivity. B. Hematoxylin and eosin staining of tissue fragment that demonstrated positivity for P16 confirms HPV infection. C. Spirochete stain confirms the presence of Treponema pallidum and syphilitic infection with HPV.

S1772 A Giant Hyperplastic Colorectal Polyp With No Malignant Features

Introduction: Hyperplastic polyps (HP) are a benign subgroup of serrated polyps. HP larger than 10 mm is considered a large polyp and larger than 2 cm carry a risk for malignancy. A case of near obstructing giant hyperplastic polyp of the recto-sigmoid colon with no malignant features is presented with a topic review and proposed further follow-up. Case Description/Methods: A 29-year-old African American man presented to the gastroenterology clinic with a 1-year history of early satiety, intermittent rectal bleeding, alteration in bowel habits, and weight loss. Upper and lower endoscopies identified a large pedunculated mass with near-complete obstruction in the recto-sigmoid colon [Figure 1A]. Biopsies show hyperplastic mucosa with no evidence of a malignant process. Imaging revealed distal colonic mass extending over a 6 cm segment [Figure 1B]. CEA and cancer antigen CA 19-9 markers were unremarkable. Laparoscopic sigmoid resection was performed. Histology reported pedunculated polyp 2.5 x 2.5 x 1.8 cm and 2 cm stalk with serrated appearance, hyperplasia, and no evidence of malignancy [Figure 1C]. Postoperative course was uneventful, with improvement in appetite and weight gain. Genetics evaluation deferred further testing. Discussion: HP are the most abundant type and now believed to be a subgroup of serrated polyps (SP). SP are classified into two main subgroups based on malignant potential. The majority of the serrated carcinomas arising from HP follow BRAF and KRAS pathways. Microsatellite instability has also been associated [1]. Serrated polyposis syndrome is associated with the risk of colorectal cancer. Due to the inability of subtracting a single responsible gene, other syndromes should be excluded. Polyps larger than 1 cm are classified as large, and exceeding 3 cm as a giant. Parallel to the size increases the malignant potential. Risk stratification of giant, pedunculated polyps is advised prior to endoscopy due to the risk of perforation and bleeding. Due to the concern for malignant transformation with obstructive signs and symptoms, surgical excision was advised.Further discussions are needed to establish clear guidelines for testing and surveillance of single giant non-malignant polyps. We propose our own management including surgical vs. endoscopic resection, genetic testing, and colonoscopy in 1,3, and 5- year intervals, followed by standard surveillance.Figure 1.: A. Abdominal CT scan. B. Colonoscopic view. C. Lower Endoscopic Ultrasound View. D. Histopathology.

Malignant Melanoma of Anal Canal

Anal melanoma (AM) is a rare and highly aggressive mucosal melanocytic malignancy. We report a case of 70 year old male presented with chief complaints of anal pain and intermittent rectal bleeding with clinical diagnosis of Polyp or Carcinoma. On histopathology examination malignant melanoma was suggested which was further confirmed by immunohistochemistry (S100 and HMB 45 strongly positive). Anal melanoma is rare neoplastic condition with catastrophic outcome.

The Cost of Diagnostic Delay and Error.

For years, diagnostic delays and errors have been tolerated and often ignored, although they have been reported as a leading cause of patient harm.1 Beyond the evident impact on patient outcomes, there are limited data investigating the effect of such delays and errors on health care expenditure. The National Academy of Medicine estimates that $750 billion, or 30% of annual health care spending, is wasted in unnecessary services and other inefficiencies,2 but the contributions of diagnostic error to these excess costs remains uncertain. For this edition of Bending the Value Curve, we present a case that highlights the impact of a diagnostic delay on health care use and expenditures and illustrates factors contributing to the delay. Verbal informed consent for writing this report was obtained from the patient and his guardian. A 17-year-old boy presented to his primary care physician with rectal pain, intermittent rectal bleeding, and loose stools. He denied abdominal pain, fever, weight loss, or sexual activity, and his physical examination revealed anal tenderness to palpation, with no visible tears, bulges, or lesions. He was prescribed escalating treatments for possible hemorrhoids but had minimal improvement over 2 weeks. After a telehealth consult with gastroenterology (because of coronavirus disease 2019 [COVID-19] restrictions at the time), blood and stool samples were obtained for workup of inflammatory bowel disease (IBD), celiac disease, and infectious colitis, and urine samples were sent to evaluate for sexually …

Heterotopic gastric mucosa in the rectum

Abstract Heterotopic gastric mucosa is rare in the pediatric population. We present a case of a 14-year-old girl with a 6-month history of intermittent rectal bleeding and failed sclerotherapy. Excision ultimately demonstrated heterotopic gastric mucosa. This reports highlights that while most of the non-congenital pediatric anorectalpathology will continue to be hemorrhoids and prolapse, heterotopic gastric mucosa should be considered in patients with anorectal symptoms refractory to conventional treatment.

A Clinical Entity Often Missed-Solitary Rectal Ulcer Syndrome in Children.

Background: Solitary Rectal Ulcer Syndrome (SRUS) was a relatively uncommon and easily misdiagnosed clinical entity in children. The diagnosis of this condition was often delayed due to lack of clinical suspicion. Only case series were available and no definitive treatment was postulated. Here, we share our experience of SRUS in our institute and reviewed the literature published so far.Aim: To study the clinical profile and treatment response of Solitary Rectal ulcer Syndrome in Children (SRUS).Materials: The clinical profile and 1 year follow up response of the diagnosed cases of SRUS over a period of 5 years was retrospectively collected from medical record department.Results: The median age of presentation among 24 children was 8 years with majority (75%) above 5 years. All children presented with intermittent rectal bleeding with median duration of 5.5 months. The other presenting symptoms documented were hard stool (79%), mucorrhea (70%), and abdominal pain (58%). One child presented with rectal prolapse. On colonoscopy, 46% had single ulcer while another 46% had multiple ulcers and 8% had polypoidal lesion. All lesions were within distal rectum and had characteristic histological pattern. All children were treated with conventional treatment like dietary fibers and laxatives along with toilet training. About 75% children attained remission and 25% had relapse but responded with corticosteroid enema. None required surgery.Conclusion: Conventional treatments itself induce and maintain remission in most of SRUS patients if treatment is instituted at the earliest. Thus, early suspicion and diagnosis is needed to achieve remission.

Lipoma-Induced Jejunojejunal Intussusception in an Elderly Patient: an Unusual Case

Gastrointestinal system lipomas are most commonly seen in the colon (64%), and less than 2% are located in the jejunum. The cases of intussusception due to small bowel lipomas in the adults have been rarely reported. An 85-year-old female patient had a history of intermittent rectal bleeding for about 1 year. The patient underwent ultrasonography and computed tomography (CT) recommended for a suspected mass lesion with intussusception. CT revealed jejunal lipoma with jejunojejunal intussusception and intramural air densities at the outer wall of bowel. After the partial jejunectomy, the definitive histological examination confirmed the diagnosis of submucosal lipoma in the jejunum.

1493 Large Fecalith Obstructing the Cecum in a Patient With Rectal Bleeding and Iron Deficiency Anemia

INTRODUCTION: Fecal impaction as a result of fecalith formation can lead to rare but serious complications, such hemorrhage, perforation, intussusception and bowel obstruction. Fecaliths are stones made of feces and are a common finding in clinical practice. A fecaloma is a giant fecalith. Patients typically present with overflow diarrhea, constipation, and abdominal pain. Fecalomas are usually located in the sigmoid colon or rectum, but are rarely seen in the cecum. We present a case of a patient with a fecaloma obstructing the cecum, causing ischemic stricture. CASE DESCRIPTION/METHODS: The patient is a 79-year-old man without a significant past medical history who was referred to gastroenterology clinic for iron deficiency anemia, bloating, intermittent rectal bleeding, and chronic constipation. Home medications include ferrous sulfate. Patient's last colonoscopy was 7 years ago and was significant for internal hemorrhoids. No significant family history. Due to anemia and rectal bleeding he was scheduled for colonoscopy. Colonoscopy revealed the presence of a large, obstructing fecalith in the cecum, with evidence of luminal narrowing. After several attempts, it was removed endoscopically with a large 27 mm hexagonal snare. It was subsequently split into smaller pieces in the transverse colon due to concerns for obstruction. Iron supplementation was stopped. Follow-up colonoscopy revealed a smooth circumferential luminal narrowing of the right side of the colon likely due to ischemic changes from the pressure effect created by the fecalith. The patient was seen in clinic 2 weeks afterwards with significant improvement of his symptoms. DISCUSSION: Although fecaliths are a frequent finding in clinical practice, luminal obstruction and ischemic changes resulting in stricture formation are rare. The need for surgery in our patient was avoided due to successful removal of the fecalith. At this point we believe that iron supplementation caused the fecalith formation, resulting in obstruction and ischemic stricture. Our case illustrates an alternative non-invasive way to manage cecal fecaliths in symptomatic patients thus preventing the need for surgery.

1640 Case Report: Diffuse Large B-Cell Lymphoma Presenting as Multiple Lymphomatous Polyposis

INTRODUCTION: Diffuse Large B Cell Lymphoma (DLBCL) is the most common type of Non-Hodgkin’s Lymphoma (NHL) in the U.S. accounting for one third of all newly diagnosed NHL’s. The gastrointestinal (GI) tract is the most common site of extra nodal involvement with mucosa-associated lymphoid tissue (MALT) lymphoma and DLBCL accounting for 70-95% of all GI lymphomas. Multiple lymphomatous polyposis (MLP) is a rare presentation of GI lymphoma characterized by diffuse proliferation of lymphocytes that present as multiple polypoid tumors involving long segments of the GI tract. MLP classically presents in mantle cell lymphoma, but can also present, although less frequently, in MALT and follicular lymphomas. We present a unique case of a patient that presented initially with lower GI bleed and was subsequently found to have extensive polypoid lesions in the entire colon. Histological evaluation revealed DLBCL, a rare etiology of MLP. CASE DESCRIPTION/METHODS: A 93-year-old woman with chronic thrombocytopenia suspicious for low-grade MDS and history of a large tubulovillous adenoma without high-grade dysplasia or cancer for which she had undergone a right hemicolectomy, presented to the emergency department with intermittent rectal bleeding, severe anemia, fatigue, decreased appetite, and a 17 pound weight loss over the past 2 months. Her hemoglobin level on admission was 6.5 g/dL (baseline Hgb 11 g/dL) and all other cell counts were otherwise normal. Her last colonoscopy ten years ago was normal and she was given the choice to continue or forego colon screening given her age. She had no family history of colon polyps or colorectal cancer. Colonoscopy revealed approximately 50-100 sesile polypoid lesions from the ileocolonic anastomosis to the distal rectum, ranging in size from 2-40 mm. The larger lesions were predominantly located in the proximal colon and were ulcerated and friable. Multiple biopsies were obtained and pathology results revealed diffuse large B-Cell lymphoma. Further studies revealed stage IV DLBCL without bone marrow involvement and she was started on mini R-CHOP chemotherapy. DISCUSSION: Although DLBCL is a rare cause of MLP, it should be included in the differential diagnosis in patients with multiple polypoid lesions throughout the colon that do not fit the typical phenotype for hereditary polyposis syndromes. Lymphomas associated with MLP include MALT and follicular lymphomas; however, DLBCL and other less common lymphomas should be considered when evaluating patients with this entity.

1895 “The First Burn Is the Deepest:” A Cautionary Tale in Superficial APC Therapy for Radiation Proctopathy

INTRODUCTION: Globally, prostate cancer is the most commonly diagnosed cancer in men. Radiation therapy remains a mainstay in the armamentarium in the treatment of this disease. Radiation proctopathy is a common side effect of this treatment modality with an incidence in patients treated with brachytherapy alone estimated to range from 8 to 13%, and up to 21% in combination with other modalities [2]. Radiation proctopathy typically presents with diarrhea, mucoid discharge, urgency, tenesmus, and bleeding. Argon plasma coagulation (APC) has become the primary therapeutic modality in the management of radiation injury. It is essential that physicians of all specialties (as well as others who care for these patients) be aware of the multiple complications of this therapy. More severe adverse events, notably rectal ulcers following APC therapy are not uncommon, with an incidence ranging from 3 to 16%. CASE DESCRIPTION/METHODS: A 67-year-old man with a history of prostate cancer treated with radiation therapy one year prior presented with intermittent rectal bleeding for one and a half months. A colonoscopy was performed, which revealed a small area near the dentate line characterized by slightly oozing neovascularized tissue consistent with radiation proctopathy. This area was treated with APC with good effect. Biopsies of this area revealed hyperplastic crypts, lamina propria fibrosis, and vascular ectasias compatible with radiation injury. Three months following treatment, the patient developed recurrent rectal bleeding. A flexible sigmoidoscopy revealed a deep non-bleeding ulcer in the rectum. Subsequent CT enterography and MRI of the pelvis demonstrated a deep rectal ulcer with abutment of a 1.5cm peri-prostatic abscess. The patient was followed closely over the next several months in concert with colorectal surgical colleagues, with serial imaging and subsequent resolution of the peri-prostatic abscess as well as cessation of rectal bleeding. DISCUSSION: As more patients with prostate cancer are treated with radiation therapy the incidence of radiation proctopathy is increasing. Although argon plasma coagulation has been shown to be an effective therapy for this issue, providers must consider and discuss with patients the potential complications of this otherwise effective and generally well-tolerated mode of treatment.

1549 Intermittent Hematochezia Due to Colonic Endometriosis

INTRODUCTION: Endometriosis is a disease defined by the presence of endometrial epithelium implanted outside of the uterus. The prevalence in reproductive age women is 10-15%, with the most common site being the ovaries. However, gastrointestinal involvement of endometriosis has been reported to occur in 3-37% of patients with endometriosis, with the rectosigmoid colon being the most common gastrointestinal site of involvement. The disease is usually diagnosed by imaging and surgical techniques whereas colonoscopy is not typically considered a mode of diagnosis for colonic endometriosis. CASE DESCRIPTION/METHODS: A 46 year old female with past medical history significant for OSA on CPAP, Secondary Polycythemia, HTN, HLD, Depression, and history of hysterectomy with tubal ligation 20 years prior presented as a referral for colonoscopy in the setting of intermittent rectal bleeding. She reported a ten month history of monthly episodic pelvic pain and mild rectal bleeding not associated with bowel movements. The timing of the bleeding was similar to her normal menstrual cycle. However, she denied vaginal bleeding and reports that she had a total abdominal hysterectomy 20 years prior due to a “cyst” on her uterus. In the 2 months prior to colonoscopy, the patient also developed some blood coating her stools intermittently during bowel movements as well. On presentation, patient's vital signs were within normal limits. Cardiac and pulmonary examination were normal. Abdomen was soft, non-tender, and non-distended with normal bowel sounds. On colonoscopy, the patient was found to have small non-bleeding external hemorrhoids, a 5 mm tubular adenoma in the transverse colon, and a 13 mm lesion in the recto-sigmoid colon that appeared to be arising from a depression in the mucosa. Initial attempt to lift lesion with 5 cc of Eleview injected into the submucosa was unsuccessful. Ultimately, the lesion was removed with hot snare. Pathology revealed endometriosis involving the mucosa and submucosa. DISCUSSION: Endometriosis is an uncommon cause of rectal bleeding. In young female patients of reproductive age, this should be on the differential. Moreover, it is important to keep this in mind in post-menopausal women as well.