Mid-transverse Colon Research Articles

A Rare Case of Metastatic Hepatocellular Carcinoma to the Colon with Associated Paraneoplastic Syndrome

Purpose: Hepatocellular carcinoma (HCC) is an aggressive malignancy with poor prognosis that is associated with a 4-6 month mean survival. Early detection with surgical resection offers the best chance for long-term survival. There are rare cases of patients with extrahepatic HCC recurrences. We report an unusual case of extrahepatic HCC occurring 18 and 36 months following initial presentation. Results: A 79-year-old man presented with 1 month of persistent epigastric pain. An abdominal CT revealed a large (16.5 × 13.8 cm), lobulated mass in the left hepatic lobe. Hepatitis B and C serology were negative. An alpha feto-protein (AFP) was 123 ng/mL. A left hepatic lobectomy was performed. Pathology revealed a high grade hepatocellular carcinoma. Surveillance included serial AFPs (which had normalized) and regular CT scans. Sixteen months after hepatic resection, he had a gastric outlet obstruction. An abdominal CT revealed a large (8.4 × 8.1 cm) exophytic gastric mass. An AFP was 23 ng/mL. An EGD with EUS revealed a retrogastric mass with cystic components. FNA obtained necrotic tissue and tumor fragments consistent with metastatic HCC. A distal gastrectomy with roux gastrojejunostomy was performed. Pathology revealed a poorly differentiated carcinoma consistent with the primary HCC. He remained clinically stable for 18 months when an abdominal CT revealed a mid-transverse colon mass. A colonoscopy performed prior to the hepatic resection removed 5 diminutive tubular adenomas. A repeat colonoscopy revealed a partially obstructing, malignant appearing mass. Biopsies revealed a poorly differentiated carcinoma consistent with metastatic HCC. Additionally, biopsies of the nodular mucosa in the cecum revealed lamina propria, intraepithelial and muscularis mucosal eosinophils. The peripheral eosinophil count was 24%. A transverse colectomy with primary anastomosis was performed. The specimen was described as an eccentric fungating lesion involving the full thickness of the bowel with gross invasion of the pericolic fat. There were no other intra-abdominal masses or liver metastases. Conclusion: This is a rare case of extrahepatic HCC metastases occurring at 18 and 36 months following hepatic resection. Gastrointestinal involvement of HCC is highly unusual, occurring in 0.5-2% of cases. The most common site of GI involvement is the duodenum, followed by stomach and least often colon. The presumed mode of transmission is direct invasion of the GI tract. However, hematogenous spread to the colon has been speculated and is thought to have occurred in this patient. Awareness of the unusual occurrence of extrahepatic metastatic HCC is important to ensure adequate surveillance following primary resection.

Large Bowel Obstruction Secondary to a Colonic Bezoar: A Case Report

Purpose: Bezoars are a rare result of ingestion of poorly digestible or indigestible materials. Predisposing factors include inadequate chewing, poor dental health, excessive consumption of certain foods or previous gastric surgery. While most bezoars are found in the stomach and small intestine, colonic bezoars are unusual and infrequently described in the literature. We present a case of large bowel obstruction due to a bezoar, which required definitive surgery. A 44 year old male with history of diabetes mellitus and pancreatic neuroendocrine tumor with metastasis requiring pancreaticoduodenectomy with en bloc segmental transverse colectomy 8 months prior presented with fever and 2 day history of abdominal pain, nausea, and vomiting. Lab studies revealed mildly elevated liver enzymes (alkaline phosphatase 260 IU/L, AST 43 IU/L, ALT 75 IU/L), a white blood cell count of 13.6 × 109/L, and hypoalbuminemia (2.4 g/dL). Recent serum chromogranin A was normal. CT scan showed a well-defined mass of mixed density and stool within the hepatic flexure. There was marked dilation extending to the transverse colon, but the distal colon was normal. Abdominal ultrasound was negative. Empiric antibiotics were initiated. Colonoscopy was performed to the mid-transverse colon which revealed a bezoar characterized by seeds, fibers, and fibrous material obstructing the lumen (Figure 1). This was partially broken up with forceps and a Roth net. Patchy necrosis of the bowel wall without evidence of stricture or narrowing was seen. The patient developed hypotension, thus the scope was withdrawn. An abdominal film disclosed no free air. Subsequent exploratory laparotomy with right hemicolectomy was performed. Pathology demonstrated ulcerated and partly necrotic colon extending from the ileocecal valve to the prior anastomosis with near perforation. The patient had an uncomplicated postoperative course. We demonstrate a unique case of a colonic bezoar causing large bowel obstruction and pressure necrosis that was successfully treated with surgery. The cause is likely multifactorial, given our patient's history of diabetes and previous colon operation. Conservative management includes enemas and manual disimpaction, however, in cases with life threatening complications prompt surgery is required.Figure 1

Ischemic colitis and portal venous gas

A 61-year-old man with severe spinal stenosis who had been on aspirin and clopidogrel for treatment of coronary arterial disease who was admitted to the hospital for preoperative heparinization. On the fifth hospital day, he developed severe abdominal pain and distension. His clinical condition deteriorated rapidly, with hypotension, fever, respiratory failure, and profound metabolic acidosis. A CT scan of the abdomen showed air diffusely throughout the portal venous system; no etiology was apparent (A). His family would not give permission for explorative laparotomy, and, therefore, he was managed by intensive medical therapy, with fluid replacement, mechanical ventilation, and broad-spectrum antibiotics. His condition gradually improved. On the 25th hospital day, a follow-up CT revealed the portal venous gas to have been resolved (B) but the transverse colon was seen to have a thickened wall. On the 27th hospital day, a colonoscopy showed friable, erythematous, and edematous mucosa with scattered longitudinal ulcers from the hepatic flexure to the mid transverse colon (C and D); ischemic colitis was diagnosed. He recovered without further complication and ultimately was discharged.

The role of cytomegalovirus infection in refractory ulcerative colitis: A case report

Cytomegalovirus (CMV) has been identified as a pathogen that contributes to flares of colitis and as a potential cause of steroid-refractory ulcerative colitis. However, clinically relevant patterns of CMV infection in IBD have yet to be identified. We present a case of a 70-year-old male with ulcerative colitis (UC), diagnosed 10 years prior, who presented with acute onset of bloody diarrhea. The patient's disease has been well-controlled for the past 5 years on Imuran and infliximab 5mg/kg every 8weeks. His last colonoscopy was two years prior and showed inactive colitis. Stool studies were obtained and an infectious cause of his diarrhea was negative. He underwent a flexible sigmoidoscopy which showed friable and granular mucosa in the rectum. Biopsies for pathology and viral cultures were taken. The viral culture was positive. However, an extensive histological examination of the tissue did not identify inclusion bodies. Furthermore, the immunohistochemistry (IHC) staining was also negative. After discussion with the infectious disease specialist, it was decided that this most likely did not represent an active infection. The patient had continued symptoms and was started on prednisone with slight improvement in his symptoms. A colonoscopy showed active colitis with diffuse involvement of the rectum and sigmoid. Biopsies were again taken and revealed similar results as above. At this time, we planned a dose intensification of his infliximab to 10mg/kg. However, despite the steroids and dose intensification the patient continued to have severe symptoms and was admitted to the hospital for intravenous steroids and monitoring. A repeat colonoscopy was done at this time, which showed active colitis that had now extended to the mid-transverse colon. Biopsies done during this colonoscopy showed active CMV colitis as evidenced by inclusion bodies and positive IHC stain. The patient was started on a three week course of intravenous ganciclovir. His symptoms resolved after completion of treatment. A follow-up colonoscopy showed improvement in his colitis. Biopsies did not reveal any active inflammation or inclusion bodies. The case presented raises questions regarding the identification, diagnosis and management of CMV colitis in patients with ulcerative colitis. There are conflicting data regarding these issues. In this era of increased use of biologic therapy it is possible that CMV infection may become more prevalent and therefore further studies are needed to identify the prevalence and role of CMV infection in patients with UC. Also, further investigations are needed to identify the most useful techniques for diagnosing active CMV colitis. These have important implications in regards to management and prognosis of refractory disease.

Colonic Tuberculosis

Purpose: Introduction: Gastrointestinal tuberculosis is an unusual disease in the West. However, in recent years there has been a resurgence of colonic tuberculosis in the U.S. secondary to the high influx of immigrants from high-risk areas and the rising AIDS population. We report the cases of 3 patients from endemic countries diagnosed with colonic tuberculosis by colonoscopic biopsy. Case Descriptions: Case 1 – A 29 year old female presented with lower abdominal crampy pain, fever, constipation, weight loss, and iron deficiency anemia. Physical examination was normal except for heme positive stool. Abdominal CT showed marked transmural, circumferential wall thickening of the cecum and proximal ascending colon and local lymphadenopathy. On colonoscopy, a partially obstructing tumor of the hepatic flexure was noted. The pathology report described moderate chronic and moderate active typhlitis with granulomata. The endoscopist was called when cecal biopsy cultures were surprisingly positive for Mycobacterium Tuberculosis. Case 2 – A 33 year old male presented with right lower quadrant abdominal pain, weight loss, nausea, and vomiting. A small bowel follow-through revealed high grade partial small bowel obstruction. On colonoscopy, discontinuous areas of bluish nodular ulcerations were noted in the mid-transverse colon. Initially, these findings were suspicious for Crohn's disease. Biopsies revealed a mixture of histologic alterations including crypt architecture distortion, well-formed, non-necrotizing granulomas in all layers of the bowel, and active inflammation with erosions. No microorganisms were seen on acid-fast stains, but cultures returned positive for M. Tuberculosis. Case 3 – A 65 year old Indian male presented with abdominal cramps and melanotic stools. Physical examination was again normal except for heme positive stool. He was found to have iron deficiency anemia. Colonoscopy revealed a 3 × 1 cm nodular mass in the left transverse colon. The pathology report described granulomatous inflammation. Stains for acid-fast bacilli were negative, but cultures were again positive for M. Tuberculosis. Discussion: Given the vagueness of its signs and symptoms, the diagnosis of colonic tuberculosis can be difficult and requires a high index of suspicion, especially in the immigrant population. Colonoscopy is essential in making the diagnosis. Endoscopic appearance often mimics Crohn's disease or malignancy. Early recognition and biopsies sent appropriately for histology and culture for tuberculous bacilli are key to diagnosis. In light of the changing epidemiology of the disease in recent years, clinicians in the U.S. must be prepared to recognize its features in order to diagnose and treat this entity.

A “Case” of Granuloma

Purpose: Case Presentation: A 22 year old Vietnamese immigrant in Canada for 16 years presented with a 5 month history of abdominal pain, weight loss and diarrhea. History was negative for medical problems, medication and drug use, smoking, alcohol, gastrointestinal bleeding, constitutional symptoms, infectious contacts, recent travel and extraintestinal manifestations of inflammatory bowel disease (IBD). Family history was negative for tuberculosis, IBD and colon cancer. Physical exam showed a pale, cachectic, afebrile, hypotensive (88/54) man with no postural drop. There was mild left lower quadrant tenderness and no lymphadenopathy. Lab investigations revealed hemoglobin 117 g/L, white blood cell count 20.6 × 109/L, neutrophil count 16.9 × 10∧9/L, mean corpuscular volume 79.1 fL and serum albumin 29 g/L. Remaining blood tests including electrolytes, creatinine, liver enzymes, amylase and TSH were within normal limits. Serum endomysial antibody and stool testing were negative. Colonoscopy showed a fistulous opening at the base of the cecum, marked mucosal nodularity with multiple pseudopolyps, deep ulcers and areas of denudation in the cecum, ascending and mid-transverse colon. Corticosteroid therapy was deferred due to possibility of tuberculosis. Intestinal biopsies showed moderate acid-fast bacillus with necrotizing granulomas. Nucleic acid amplification test was positive for Mycobacterium tuberculosis complex. The patient's gastrointestinal symptoms improved with antituberculous treatment and he made a full recovery. Discussion: Our case illustrates three important principles in the diagnosis and treatment of gastrointestinal tuberculosis (GI TB). First, tuberculosis infection should be considered in patients with clinical, endoscopic, radiological and histopathological features of Crohn's disease, especially where there is a predominance of ileal and cecal involvement. Immigration from a country with known endemic tuberculosis is an important risk factor, even if immigration is a remote event. Nonspecific symptoms of GI TB include fever, night sweats, weight loss, abdominal pain and diarrhea. Diagnosis of GI TB is based on detection of acid-fast bacilli in tissue or stool. Second, it is important to exclude the possibility of tuberculosis before the commencement of corticosteroid therapy, often used in the treatment of IBD, since corticosteroid therapy will increase morbidity of the patient with GI TB. Third, treatment of GI TB is primarily medical and although complications such as fistula formation, perforation and hemorrhage may require surgery, it is possible to treat gastrointestinal fistulae due to tuberculosis successfully with medical therapy alone.

A Rare Case of Breast Cancer Metastasis Presenting as Linitis Plastica of Stomach and Colon

Purpose: 71-year-old Hispanic female patient underwent screening colonoscopy with complaints of recent onset of constipation and weight loss. At the same time an upper endoscopy was done to evaluate for decreased appetite and early satiety. She had significant past medical history for recurrence of breast cancer with diffuse skeletal metastasis 2 years ago after a decade of cancer free period. Currently, she was receiving palliative chemotherapy. On examination, she appeared cachectic and pale. Laboratory examination disclosed normocytic anemia, with a Hb level of 10.5 g/dL (normal range for Hb in our institution is 11.5–15.5 g/dL). Colonoscopy revealed an irregular configuration of the mucosal surface, luminal narrowing, and poor distensibility in the mid-transverse colon (Fig. A). Multiple biopsies were obtained. Histopathologic examination of the biopsy specimen revealed colonic mucosa with metastatic adenocarcinoma, morphologically consistent with lobular carcinoma of breast (Fig. B). EGD revealed thickened gastric folds; multiple biopsies were obtained. Histopathologic examination of the gastric biopsy specimens also revealed metastatic adenocarcinoma from breast. Extrahepatic gastrointestinal metastasis from breast cancer is uncommon. Metastases to the stomach and small bowel from breast cancer are reported to be more frequent than colonic and rectal involvement. Two reviews dealing with metastatic breast cancer have reported the involvement of colon in about 4% of the patients. Lobular carcinoma is the most common histological type of breast cancer that metastasizes to the colon and rectum. It is important to realize that patients with known breast cancer, especially of the lobular type, with vague, nonspecific abdominal signs and symptoms, particularly of an obstructing nature should be endoscopically screened for gastrointestinal metastases.

Spectroscopic Microvascular Blood Detection From the Endoscopically Normal Colonic Mucosa: Biomarker for Neoplasia Risk

We previously used a novel biomedical optics technology, 4-dimensional elastically scattered light fingerprinting, to show that in experimental colon carcinogenesis the predysplastic epithelial microvascular blood content is increased markedly. To assess the potential clinical translatability of this putative field effect marker, we characterized the early increase in blood supply (EIBS) in human beings in vivo. We developed a novel, endoscopically compatible, polarization-gated, spectroscopic probe that was capable of measuring oxygenated and deoxygenated (Dhb) hemoglobin specifically in the mucosal microcirculation through polarization gating. Microvascular blood content was measured in 222 patients from the endoscopically normal cecum, midtransverse colon, and rectum. If a polyp was present, readings were taken from the polyp tissue along with the normal mucosa 10-cm and 30-cm proximal and distal to the lesion. Tissue phantom studies showed that the probe had outstanding accuracy for hemoglobin determination (r(2) = 0.99). Augmentation of microvasculature blood content was most pronounced within the most superficial ( approximately 100 microm) layer and dissipated in deeper layers (ie, submucosa). EIBS was detectable within 30 cm from the lesion and the magnitude mirrored adenoma proximity. This occurred for both oxygenated hemoglobin and DHb, with the effect size being slightly greater for DHb. EIBS correlated with adenoma size and was not engendered by nonneoplastic (hyperplastic) polyps. We show, herein, that in vivo microvascular blood content can be measured and provides an accurate marker of field carcinogenesis. This technological/biological advance has numerous potential applications in colorectal cancer screening such as improved polyp detection and risk stratification.

A motor-driven single-use colonoscope controlled with a hand-held device: a feasibility study in volunteers

Several new instruments have been developed in the effort to improve the acceptance of colonoscopy for colorectal cancer screening. A new colonoscope, the Invendoscope, is presented here. It consists of an endoscopic sheath with an inverted sleeve, instrument channel, and an electrohydraulic deflecting tip. The instrument is steered by a hand-held device and propelled by a motorized drive unit. Our purpose was to evaluate the feasibility of the new Invendoscope SC40. Prospective single-arm pilot study over 2 time periods using 2 different instrument prototypes (170 and 180/200 cm). Thirty-four healthy volunteers (19 men, mean age 49.7 years). Technical instrument defects led to premature termination in 5 additional volunteers during the 2 study periods (4 in phase 1, 1 in phase 2), who were excluded from further analysis. Total colonoscopy was attempted, with all procedures being performed without sedation. Cecal intubation rate. The cecum was reached in 82% of the 34 cases (95% CI, 66%-92%), with better results in period 2 than in period 1 (90% vs 79%); of the 6 incomplete examinations, 4 reached the mid transverse colon or beyond and 2 were stopped in the sigmoid colon because of pain. The volunteer rating showed a mean score of 1.96 (range 1-6; 1 = no discomfort). No complications were encountered. No data regarding diagnostic accuracy and no data comparing the instrument with conventional colonoscopy are available as yet. This pilot proof-of-principle study of a new motor-driven colonoscope showed promising cecal intubation rates and an absence of pain in 92% of cases. Further clinical and comparative studies are warranted.

Ischemic Colitis Masquerading as Crohnʼs Colitis in a Patient with Protein C Deficiency

Introduction: Acute mesenteric ischemia from mesenteric vein thrombosis[MVT] is a rare manifestation of a hypercoagulable state like protein-C /S deficiency. We report a case of protein-C deficiency with ischemic colitis mimicking the radiological and endoscopic features of Crohn's colitis. Case Description: 29 yr/F with protein-C deficiency with no prior complications presented with abdominal pain, tenesmus and bright red blood per rectum. She denied fever or any constitutional symptoms. CBC, liver function tests and coagulation profile were normal. CT scan of the abdomen/pelvis with contrast showed diffuse thickening from mid-transverse colon to the rectum and ruled out MVT. Stool studies including bacterial cultures, clostridium difficile toxin were all negative. Sigmoidoscopy showed skipped areas of bleeding ulcerated mucosa with inflammatory changes in the recto- sigmoid colon suggesting Crohn's colitis and the patient was started on mesalamine [Fig. 1]. Rectosigmoid biopsy showed ulceration, coagulative necrosis and inflammation with fibrin thrombi consistent with ischemic colitis secondary to MVT [Fig. 2]. There was no evidence of chronic changes to suggest inflammatory bowel disease. Discussion: MVT should be suspected when acute abdomen develops in patients with prior thrombotic episodes or a documented thrombophilic state. It was postulated that in our patient protein-C deficiency led to MVT which was not revealed on the CT scan and the bleeding was secondary to mesenteric ischemia. CT scan is considered the diagnostic test of choice and anticoagulation is the standard of care. High index of clinical suspicion, early diagnosis and treatment can prevent progression to gangrenous bowel. Conclusion: Our case underscores the association of mesenteric vein thrombosis with prothrombotic disorders and brings to attention that it can be missed on imaging studies.[figure1][figure2]FigureFigure

A Prospective Pilot Study to Assess Technical Performance of a New Single Use Colonoscope with Inverted Sleeve Technology

Background: Colonoscopy is the method of choice for colorectal screening; compliance however has been hampered by patients' perception of a painful procedure often requiring sedation. We present the first results of a new single use colonoscope with inverted sleeve technology in asymptomatic volunteers. Methods: 28 healthy asymptomatic volunteers (12 male, 16 female, mean age 48 years, range 23 - 69 years) underwent attempted total colonoscopy with a new colonoscope (invendo medical GmbH, Weinheim, Germany); this single use instrument consists of an endoscopic sheath with a electrohydraulic deflecting tip including camera and LED lighting and an inverted sleeve. A 3.2 mm working channel, air insufflation and flushing of optical lens are present. After standard colonic lavage preparation the instrument was introduced and steered by a handheld up to the cecum. I.v. injection of butylscopolmanine (20 mg) was allowed, as were maneuvers of patient rotation and soft abdominal compression. Cecal intubation was documented by unequivocal photographs of appendiceal orifice or visualization of the ileocecal valve, or in exceptional cases, by a plain abdominal film. Results: In 4 cases there were different technical failures of the scope mechanisms preventing further progression in various parts of the colon. Of the 24 remaining examinations the cecum was reached in 19 cases (79%); the 5 incomplete colonoscopies reached the ascending colon, the hepatic flexure and the mid-transverse colon in one case each, and in two volunteers, passage beyond the sigmoid colon was not possible due to pain; one female volunteer had a gynaecological OP. The mean time to reach the cecum was 26 min. (range 10-49 min.). No major pathological findings were detected, and no complications occurred. Volunteers rated the examination on an overall score (1 = no discomfort to 6 = severe pain) at a mean of 1,77 points (range 1-3) except for the two volunteers with failed sigmoid adhesion (pain score 5-6). No sedation was required in any case. Conclusions: This new single use colonoscope holds promise to achieve painless colonoscopy in the majority of cases with a reasonable cecal intubation rate. Further technical refinements will improve its performance up to the status of routine usability.

POLYPOID COLONIC HAMARTOMATOUS INVERTED POLYP

We herein present a unique polyp diagnosed as polypoid colonic hamartomatous inverted polyp. Colonoscopic examination revealed a clover-like submucosal tumor about 30 mm in size with a long stalk at the mid-transverse colon. The polyp consisted of elongated crypts with cystic dilatation located in the submucosal layer. To the best of our knowledge, there have been no previous reports of the same type of pedunculated colonic polyp, similar in appearance to inflammatory myoglandular polyps but covered with a layer of normal mucosa possessing the muscularis mucosae at the uppermost surface of the polyp.

Risk Stratification of Colon Carcinogenesis through Enhanced Backscattering Spectroscopy Analysis of the Uninvolved Colonic Mucosa

Our group has been interested in applying advances in biomedical optics to colorectal cancer risk stratification. Through a recent technological breakthrough, we have been able to harness information from enhanced backscattering spectroscopy, an optics phenomenon that allows quantitative, depth-selective analysis of the epithelial microscale/nanoscale architecture. In the present study, we investigated the ability of enhanced backscattering analysis of the preneoplastic mucosa to predict risk of colon carcinogenesis. Enhanced backscattering analysis was done on intestinal mucosa at preneoplastic time points from two experimental models of colorectal cancer: the azoxymethane-treated rat and the multiple intestinal neoplasia (MIN) mouse. Data were analyzed using two previously validated spectral markers: spectral slope and principle components. We then did a pilot study on mucosal biopsies from 63 subjects undergoing screening colonoscopy. In the azoxymethane-treated rat, when compared with saline-treated controls, significant changes in the enhanced backscattering markers were observed as early as 2 weeks after azoxymethane treatment (before the development of aberrant crypt foci and adenomas). Enhanced backscattering markers continued to progress over time in a manner consonant with future neoplasia. These data were replicated in the preneoplastic MIN mouse mucosa. In humans, spectral slopes in the endoscopically normal cecum, midtransverse colon, and rectum were markedly reduced in patients harboring adenomas when compared with those who were neoplasia free. We show, for the first time, that enhanced backscattering analysis of an aliquot of uninvolved mucosa has the potential for predicting neoplastic risk throughout the colon in both experimental colorectal cancer models and humans.

Intestinal nitric oxide synthase activity changes during experimental colon obstruction

Objective. The experiments in this study were designed to follow the time course of nitric oxide (NO) synthesis in the large bowel during acute mechanical ileus. Material and methods. Occlusion of the mid-transverse colon was maintained for 420 min in anesthetized dogs. Strain-gauge transducers were used to analyze motility changes on the hepatic and lienal flexures, respectively. Constitutive NO synthase (cNOS) and inducible NOS (iNOS) activities were determined in tissue biopsies, and plasma nitrite/nitrate (NOx) level was measured in the portal blood. Following completion of the baseline studies, the animals were treated with either 7-nitroindazole (7-NI, selective neuronal NOS inhibitor), or N-nitro-L-arginine (NNA, non-selective NOS inhibitor). Results. In the sham-operated group the cNOS activities differed significantly in the oral and aboral tissue samples (oral: 102.9; versus aboral: 62.1 fmol/mg protein/min). The obstruction elicited a significant increase in portal NOx and elevated tissue inducible NO synthase (iNOS) activity. NNA treatment decreased the motility index in both intestinal segments for 60 min, but 120 min later the motility index was significantly elevated (2.5-fold increase in the oral part, and 1.8-fold enhancement in the aboral segment, respectively). Treatment with 7-NI decreased the cNOS activity in the oral and aboral parts by approximately 40% and 70%, respectively, and suppressed the motility increase in the aboral colon segment. Conclusions. The motility of the colon was either significantly increased or decreased, depending on the type and selectivity of the NOS inhibitor compounds applied. NO of neuronal origin is a transmitter that stimulates peristaltic activity; but an increased iNOS/nNOS ratio significantly moderates the obstruction-induced motility increase.

Intraoperative measurement of colonic anatomy and attachments with relevance to colonoscopy.

This study examined the variations in colonic length and mesenteric attachments in 118 patients undergoing laparotomy. Measurements were taken according to a set protocol with the bowel pulled medially, or towards the pubic symphysis or the xiphisternum, mimicking the possible displacements that may occur during colonoscopy. A free sigmoid loop was not present in 20 patients (17 percent) because of adhesions. A descending mesocolon of 10 cm or more in length was recorded in ten patients (8 percent) and an ascending mesocolon 10 cm or greater in 11 (9 percent). Some 24 patients (20 percent) had mobile splenic flexures and in 34 (29 percent) the mid-transverse colon reached the symphysis pubis or lower when pulled downwards. Mean (range) total colonic length was 114.1 (68-159) cm. This study helps define anatomical variations that may affect the facility, or otherwise, of colonoscopy.

Primary Amyloidosis Presenting as Recurrent Ischemic Colitis

Ischemic colitis has a myriad of causes. Primary amyloidosis is a rare cause of ischemic colitis with only a few case reports in the literature. We present an unusual case of ischemic colitis due to primary amyloidosis. A 69 year old woman, with history of activated protein C resistance and lower extremity deep vein thrombosis on chronic warfarin treatment, presented with 1-day history of bloody diarrhea and crampy abdominal pain. Three weeks before, she was hospitalized with similar symptoms at another medical facility and diagnosed with ischemic colitis by colonoscopy. After a week of bowel rest, total parental nutrition, and intravenous antibiotics, her symptoms had resolved. She remained asymptomatic until the night prior to her current admission. She was afebrile with a blood pressure of 108/66 mm Hg and a pulse of 109 beats per minute. Physical examination was significant for mild tenderness to palpation in the lower abdomen, without peritoneal signs. Laboratory evaluation revealed normal white blood cell count, hemoglobin of 11.9 g/dL, and an International Normalized Ratio of 5. Abdominal computed tomography showed nonspecific thickening of the colonic mucosa from the splenic flexure to the descending colon. Sigmoidoscopy revealed multiple large ulcers with areas of mucosal necrosis in the proximal sigmoid colon. Biopsies showed focal ulceration with necroinflammatory exudate. Mesenteric angiogram was unremarkable. On hospital day 7, she underwent a total colectomy with end ileostomy after ischemic changes were observed from mid transverse colon to rectosigmoid junction on intraoperative colonoscopy. Histology revealed extensive amyloidosis involving the omentum and entire colon with deposition in the muscularis mucosa, submucosa, and subserosa. Perivascular deposition of amyloid with luminal narrowing was also present. Serum electrophoresis and immunofixation revealed an IgG lambda monoclonal band, while a bone marrow biopsy showed 5–10% lambda restricted plasma cells. Our case illustrates that primary amyloidosis presenting as recurrent ischemic colitis may be missed despite thorough history, laboratory evaluation, radiographic studies and endoscopic biopsies.

Laparoscopic seromuscular colonic biopsies: a surgeon's experience

Background Colonic dysmotility is a recognised cause of chronic constipation in children. Colonic dysmotility is better analysed by examination of the colonic muscle than rectal biopsy, which does not examine the defective area and has a low yield. We explored the role of laparoscopic colonic muscle biopsies to investigate children with intractable constipation. The authors describe the technique, its application, and results from a large series. Methods A retrospective review was conducted of all patients undergoing laparoscopic seromuscular colonic biopsies (hepatic flexure, mid-transverse colon, splenic flexure, and sigmoid colon) by a single surgeon for the investigation of chronic constipation over a 10-year period. Patient records were reviewed to determine the perforation frequency and management, postoperative recovery time and the frequency of an immunohistochemical abnormality. Results One hundred ninety-seven patients (118 boys) were investigated by laparoscopic biopsy during the period. The mean age was 8.0 ± 4.0 years (range, 1.4-22.4). The patients took 28.7 ± 13.6 hours (range, 8-120) to recover, with 37 (19%) having nausea and/or vomiting requiring antiemetics. Most patients (160/197, 81%) were discharged the following day. Six patients (3%) had a mucosal perforation recognised at operation (treated by an Endoloop) with no change in postoperative outcome. Two patients (1%) had an unrecognised mucosal perforation requiring laparoscopic reoperation and Endoloop closure (laparotomy/colostomy not required), with no further sequelae. Eight-six patients (44%) had a specific immunohistochemical neuropeptide anomaly (reduced substance P [84], reduced vasoactive intestinal peptide [2]). Conclusions Laparoscopic biopsy is a valuable tool to investigate chronic constipation in children, allowing a pathological diagnosis to be made in many cases. The complications of the procedure are acceptably low with this technique.

SHAPELOCK™ AS A RAPID FEEDER PORT FOR COLONOSCOPY

The Shape Lock™ Endoscopic Guide is a novel overtube device with a unique “lockable feature” designed to resist loop formation during colonoscopy (Raju et al. Gastrointest Endosc 2004; 59: 416–19). If need be, the Shape Lock can serve as a conduit for quick reinsertion of the colonoscope into the proximal colon. We describe a case where the Shape Lock was used as a Rapid Access Port for colonoscopy to remove multiple, large polyps in the proximal colon. Case Report: A 73-year-old man with a family history of colon cancer underwent colonoscopy for colon cancer screening. Shape Lock as a Rapid Access Port for Colonoscopy: As part of our ongoing evaluation of Shape Lock Endoscopy, we performed colonoscopy with the assistance of the Shape Lock Guide. After endoscopic mucosal resection of each of the 4 large polyps in the proximal colon, the colonoscope and the polyp were withdrawn, and following the delivery of polyp, the scope was rapidly reinserted through the Shape Lock (see figure). Comments: I. Reduction of tortuous sigmoid colon: The Shape Lock assisted in reducing the loops; it took 8 min to reach the splenic flexure and 10 min to reach the cecum. II. Potential concern of maceration of the polyps during the insertion of the Shape Lock proximal to the polyps: No damage was noted to any of the three large polyps in the distal transverse colon as the device moved proximal to them. III. Shape-Lock as a rapid access port to the proximal colon: It took one minute for the total withdrawal of the colonoscope along with a large polyp held in a net, followed by rapid reinsertion of the colonoscope into the mid-transverse colon on each of the four attempts. IV. Effective decompression of the proximal colon: Shape Lock provided an outlet for decompression during colonoscope with-drawl and reinsertion, thereby increasing patient comfort. V. Easy retrieval of large polyps through the Shape Lock: Avoided the risk of large polyps getting stuck at the anus.FigureConclusions: This case demonstrates the potential benefits of Shape Lock Endoscopy to provide a Rapid Access Port for colonoscopic removal of multiple, large polyps in the proximal colon. Further studies are needed, [figure 1]

FULMINANT CMV COLITIS DEVELOPING IN A PATIENT AGGRESSIVELY TREATED FOR FLARE OF ULCERATIVE COLITIS

Purpose: A 76 y/o female underwent colonoscopy for 3 weeks history of non bloody diarrhea, abdominal pain, and tenesmus which revealed severe pancolitis characterized by edematous and friable mucosa. Her PMH includes a remote history of ulcerative colitis diagnosed 18 years ago, CAD s/p MI 2 years prior and atrial fibrillation. Aside from a short course of hydrocortisone enemas at the time of initial diagnosis, no other therapy was instituted and her disease remained quiescent. Since the time of diagnosis, the only surveillencce was flexible sigmoidoscopy 6 years ago by her PCP revealing no active disease. Medications include Zocor, Lopressor, Norpace, and ASA. There is no famliy hx of IBD. The severity of colono-scopic findings coupled with clinical dehydration prompted admission. At admission, HR = 90, T = 36.9, BP 115/55 and sats = 97% RA. Her MM were dry and abdominal exam revealed normal active bowel sounds without guarding. Treatment included hydration, Asacol, and Unasyn. Steroids were deferred until pathology ruled out infectious etiology. Abdominal xray indicated nonspecific bowel gas pattern with no evidence of toxic megacolon. Laboratory data revealed WBC = 11.7, HCT = 26.1, Cr = 2.2, K + 3.0, Ca = 6.0, and ALB = 2.3. Stool studies revealed many WBC, but were negative for O&P, and c-diff. Colonoscopic biopsies suggested chronic active colitis with crypt abcesses consistent with IBD. She was started on Hydrocortisone 100mg IV q8h. Shortly after admission, she developed hematochezia requiring blood transfusions. Diarrhea increased in frequency and volume necessitating daily electrolytes replacement. Rowasa enemas were added due to worsening symptomatology. ALB decreased to 1.7 and she developed anasarca despite the addition of parenteral nutrition. Incontinent diarrhea and clinical decompensation prompted relook colonoscopy and colorectal surgical consultation. Colonoscopy to mid transverse colon revealed fulminant colitis characterized by congestion and dusky appearance. The following day (7 of admission), she underwent total abdominal colectomy and construction of end ileostomy. Interestingly, biopsies from the second colonoscopy and resected colon revealed chronic active ulcertive colitis with active CMV infection by immunohistochemistry staining. She was not treated for CMV. Post-op anemia stablized, anasarca subsided, malnutrition resolved. With a restored appetite, patient was discharged after learning ostomy

MICRO-ARCHITECTURAL ALTERATIONS IN ENDOSCOPICALLY-NORMAL MUCOSA PROVIDES ACCURATE RISK STRATIFICATION FOR COLORECTAL NEOPLASIA

Purpose: The “field effect” is frequently exploited for colorectal cancer (CRC) screening; however, the most common markers (i.e. the distal adenoma) lacks both sensitivity and positive predictive value. Micro-alterations in the colonocytes (i.e. the “field”) may reflect the earliest events in colon carcinogenesis although, to date, practical detection of these subtle changes have not been possible. We have pioneered optics for the detection of dysplasia in general (Nature 2000) and in the colon (Nature Med 2001). We have recently developed 4D-ELF, a new generation of light-scattering technology, that allows heretofore unattainable insights into the nano-scale cellular architecture (IEEE 2003). In experimental models, 4D-ELF analysis of uninvolved mucosa had unprecedented sensitivity for CRC risk (Gastroenterology 2004). The aim of this study was to evaluate the ability of 4D-ELF to predict neoplasia in humans. Methods: Forty-five patients undergoing colonoscopy had two mid-transverse colon biopsies from endoscopically normal mucosa. 4D-ELF analysis was performed on fresh tissue using our advanced light-scattering apparatus. Parameters that were evaluated included principal component 1 (PC1) and spectral slope. Patients were divided into high and low risk based on current and past colonoscopy findings (presence of adenoma or carcinoma). Results: PC1 and spectral slope were dramatically and highly statistically significantly altered in colonic neoplasia patients (high risk) when compared to those with normal colonoscopies (low risk) (see figure).Figure 1Conclusions: We demonstrate, for the first time, that micro-architectural changes in the endoscopically normal mucosa could predict the risk of colonic neoplasia. These parameters were markedly superior to any previously described biomarkers. This suggests that that 4D-ELF analysis may have potential applicability in CRC risk-stratification. [figure 1]