Pedunculated Polyps Research Articles

S1786 Pancreatic Metastasis Secondary to the Masters of Costumes, Renal Cell Carcinoma

Introduction: Renal cell carcinoma (RCC) has been one of the most studied cancers, and its metastatic capabilities are well documented in literature. RCC accounts for 80%-85% of primary renal neoplasm. Approximately 25% of individuals have distant metastases at the time of diagnosis. Its metastatic capabilities continue to be one of the most challenging aspects of the disease. Metastasis to the pancreas has been described in about 2%-5% of all malignant pancreatic tumors. Case Description/Methods: Case of an 80-year-old man with medical history of Stage IV RCC, treated with immunotherapy. Treatment was discontinued due to adverse effects. Patient presents to the ER with a complaint of intractable pruritus. On laboratory values, found with elevated liver enzymes and total bilirubin, with a mixed hepatocellular and cholestatic pattern, reason why gastroenterology service was consulted. Physical examination showed generalized jaundice. Abdominal CT scan showed multiple intrabdominal lesions, including in the pancreas, causing intra and extrahepatic ductal dilation. MRCP showed multiple intrabdominal masses encasing the common bile duct, causing intra and extrahepatic biliary tree and distal pancreatic duct dilation. Concern of a primary pancreaticobiliary malignancy arose. On EGD, multiple gastric and duodenal clean base ulcers and 2 large pedunculated polyps in the second portion of the duodenum removed using hot snare polypectomy technique, and random biopsies on gastric and duodenal ulcers taken. On EUS, a large hyperechoic vascular lesion was observed in the pancreatic head, infiltrating the intrapancreatic bile duct. Another large 3.3 cm x 3.0 cm vascular mass at the gastro-hepatic ligament was observed. Biopsies from duodenal ulcer, duodenal polyp, and pancreatic mass were consistent with metastatic clear cell neoplasm as seen in RCC. ERCP was made to place a fully covered metallic stent at CBD stricture caused by extrinsic compression. Discussion: RCC is the most common renal tumor. Up to 25% of cases present with advanced disease at diagnosis. Our patient presents with multiple intrabdominal masses causing biliary tree and pancreatic duct obstruction. Advanced endoscopic techniques and cross-sectional images play an essential role in the diagnosis and management of pancreaticobiliary pathologies. Other etiologies such as metastatic RCC may mimic primary pancreaticobiliary malignancies. In this case, advanced endoscopic modalities were used for tissue diagnosis and management of metastatic disease.

S3521 A Rare Case of Duodenal Leiomyoma

Introduction: Only 1–5% of gastrointestinal neoplasms are found in the small intestine. Adenocarcinomas, lymphomas, and neuroendocrine tumors are the most common malignant tumors seen in the small intestine, while gastrointestinal stromal tumors, leiomyosarcomas, and leiomyomas are uncommon. The jejunum, ileum, and duodenum are the three most common locations for leiomyomas. We are presenting a rare case of a female with duodenal leiomyoma. Case Description/Methods: A 70-year-old female presented to the hospital with complaints of fatigue and weakness. Laboratory evaluation showed iron deficiency anemia with hemoglobin 7.5g/dl and hematocrit 25.4%. The patient reported an episode of black tarry stool about a week before the presentation. The patient received one packed red blood cell transfusion, and upper gastrointestinal endoscopy (EGD) was performed to evaluate anemia. EGD revealed non-erosive gastritis and gastric erosions without any current or recent bleeding stigmata. A single large pedunculated polyp was found in the duodenum's first portion, extending into the second portion of the duodenum(a). Biopsy from the polyp revealed submucosal leiomyoma without any evidence of dysplasia or malignancy(b). The next day, a colonoscopy showed significant diverticulosis and non-bleeding internal hemorrhoids. The patient remained hemodynamically stable and was discharged home the next day. The patient presented about a month later with iron deficiency anemia again. Repeat EGD and colonoscopy performed this time showed no obvious source of bleeding. We also conducted a pill cam study, which also came back negative. (Figure) Discussion: It is unusual for leiomyomas, which are benign smooth muscle tumors, to develop in the gastrointestinal tract. Males are more likely than females to be diagnosed with duodenal leiomyomas in the 6th and 7th decades of life. The origin and pathology of these tumors in the gastrointestinal tract remain a mystery. Leiomyomas of the duodenum seldom cause symptoms. When a duodenal tumor is larger, it might cause more severe symptoms, such as bleeding, nausea, vomiting, and weakness. In our patient described above, we believe the leiomyoma caused bleeding, as no other definitive source of bleeding was found even after a complete evaluation. The case describes a rare duodenal tumor with an unusual presentation.Figure 1.: a. EGD showing a large pedunculated polyp extending from the first portion to the second portion of the duodenum. b. H&E stain showing submucosal benign spindle cell proliferation. No atypia, pleomorphism or mitotic activity.

S2024 Elderly Patient, Youthful Pathology: Solitary Colonic Juvenile Polyp Found in a 75-Year-Old Male

Introduction: Colonic juvenile polyps are generally found in the pediatric population. Classically, juvenile polyps (JP) are the most common polyp subtype seen in pediatric gastroenterology, accounting for approximately 80-90% of polyps in children. Generally, JP are diagnosed within the first decade of life and most common presentation is painless rectal bleeding. Other terminology used are juvenile hamartomatous polyp or retention polyps. There is no malignant potential for solitary JP and they tend to not recur. Case Description/Methods: We present a 75-year-old male with past medical history of hypertension, diabetes and hyperlipidemia referred to gastroenterology for surveillance colonoscopy due to a history of tubular adenomas. At the pre-procedure visit, the patient was well without GI complaints such as overt bleeding, change in bowel habits or unintentional weight loss. No family history of colon cancer or polyps was reported. Physical exam and vitals were normal at the time of procedure. Colonoscopy revealed a 40mm pedunculated sigmoid colon polyp which was excised using an endoloop at the stalk base followed by hot snare polypectomy ((Figure A). Three other sub-centimeter sessile polyps in the rectosigmoid area were removed by cold snare polypectomy. Histopathological examination of the large pedunculated polyp was consistent with a JP(Figure B). Other polyps were tubular adenomas. Discussion: Our current patient is the oldest reported case of isolated colonic JP. These polyps tend to have a common phenotypical appearance measuring around 10-30mm and roughly 90% of them are considered pedunculated. JP are ultimately defined by their distinctive histopathological features such as edematous lamina propria with inflammatory cells, cystically dilated glands that are bordered by cuboidal or columnar epithelium with reactive changes, and mucus filled glands. Fortunately for our patient, the presence of only a solitary colonic JP generally carries no known malignant potential. Juvenile polyposis syndrome (JPS) on the other hand is a hereditary condition characterized by the presence of hamartomatous polyps in the digestive tract and is known to have an increased risk of digestive tract malignancies. JPS is suspected when a patient has 5 or more juvenile polyps in the gastrointestinal tract or a juvenile polyp and a family history of juvenile polyps. A DNA test to check SMAD4 or BMPR1A gene is helpful.Figure 1.: (a) A 40mm polyp (Paris 0-Ip) located in the in the sigmoid colon. (b) Hamartomatous polyp has ulcerated surface with benign dilated glands.

JEJUNO-JEJUNAL INTUSSUSCEPTION IN A PATIENT WITH PEUTZ-JEGHERS SYNDROME: A CASE REPORT AND REVIEW

Peutz-Jeghers syndrome is an autosomal dominant genetic disorder associated with pigmented spots on the skin and mucous membrane especially around oral mucosa, lips, nasal alae, palm and soles, as well as hamartomatous polyps in the alimentary canal. Prevalence of Peutz-Jeghers syndrome is between 1 in 8300 and 1 in 280000 people. Here, we present a case of 18 years old lady who presented with complains of peri-umbilical pain and vomiting for 2 months. Physical examination revealed multiple pigmentations over lips, palms and soles. Ultrasonography was normal. On further evaluation using a contrast enhanced computerized tomographic scan of abdomen and pelvis, jejuno-jejunal intussusception was noted. She then underwent exploratory laparotomy along with resection and anastomosis of the involved jejunal segment. Biopsy specimen containing multiple pedunculated polyps was sent for histopathological examination which revealed hamartomatous polyp.

TU2.1 Colonoscopic Polyp Tattooing: To Tattoo or Not to Tattoo?

Abstract Aims Colorectal cancer is often investigated with colonoscopy, where tattooing is performed to identify the location of potentially tumorous polyps to aid surgery and colonic surveillance. BSG guidelines state that polyps ≥20mm in size should be tattooed, except those in the rectum/caecum. Tattoos should be recorded and local policy should be in place. At our trust, St Mark's protocol is used which advises all suspicious lesions be tattooed except those in the rectum/caecum, and 3 tattoos be placed circumferentially. Here, we audit adherence to these guidelines. Methods Retrospective analysis of data collected from Endobase for endoscopies revealing polyps during 2020 at DGH. Results 325 polyps were found in 255 patients (70% male). Sessile and pedunculated polyps were most common, accounting for 77%. Smaller polyps (15–19mm) were most prevalent (52%). Tattooing of smaller polyps (15–19mm) remains low (30%), whereas tattooing of larger polyps has improved (85%). Tattooing of rectal/caecal polyps remains prevalent (19%). Only 30% of tattooed polyps had 3 tattoos. Tattoo information was recorded well in certain sections of Endobase (83% in ‘conclusion’) but poorly in others (61% in ‘therapeutic’). Conclusions There has been an increase in male predominance, and in smaller and pedunculated polyps. These demographic changes are useful to be aware of. Teaching and clearer display of guidelines is required to improve tattooing of smaller polyps, and reduce tattooing of rectal/caecal polyps. However, clearer trust guidelines should accommodate operative variability. Recording tattoo information in Endobase is technically challenging and requires improvement to avoid loss of data.

Double-clip traction endoscopic submucosal dissection: an interesting alternative method for the resection of pedunculated polyps.

Double-clip traction endoscopic submucosal dissection: an interesting alternative method for the resection of pedunculated polyps.

Giant Fibrous Polyp of the Gallbladder Showing a Periphery-Dominant Contrast Enhancement: How to Differentiate It From Early Carcinoma

Although polyp size and stalk diameter are significant for the differential diagnosis of a gallbladder polyp, it is necessary to catch genuine polyp characteristics to differentiate a giant fibrous polyp from gallbladder carcinoma (GBC). This case report analyses the images and their correlation with the pathology. Transabdominal sonography revealed gallstones and a giant pedunculated gallbladder polyp measuring 32 × 18 × 14 mm with a thick stalk. The polyp lacked a hyperechoic surface line and was not delineated by either a deep hypoechoic area or a conically thickened outermost hyperechoic layer. Contrast-enhanced ultrasonography (CEUS) depicted a periphery-dominant enhancement, during the post vascular phase. A noncontrast computed tomogram (CT) did not demonstrate a gallbladder mass; meanwhile, a dynamic study revealed an enhanced polyp showing a periphery-dominant enhancement. Hence, without diagnostic findings suggestive of an obvious advanced GBC or excluding an early GBC, a full-thickness laparoscopic cholecystectomy was performed. The histopathology demonstrated a fibrous polyp with a thick stalk. In conclusion, a giant gallbladder polyp with a thick stalk showing a periphery-dominant contrast enhancement could suggest a fibrous polyp.

Underwater endoloop-assisted endoscopic resection for colorectal pedunculated polyps.

Underwater endoloop-assisted endoscopic resection for colorectal pedunculated polyps.

Discrepancy Between Forceps Biopsy and Resection in Colorectal Polyps: A 1686 Paired Screening-Therapeutic Colonoscopic Finding.

PurposeTo identify pathology discrepancy between forceps biopsies and polypectomy specimens in colorectal polyps, as well as the reliability of biopsy-based treatment strategy.MethodsAll endoscopic polypectomy cases with forceps biopsies performed within 6 months were included in the study. The biopsies were compared with polypectomy specimens in terms of concordance of histological diagnosis. A logistic regression model was used to investigate the independent predictors of upgrade in histological diagnosis compared with concordance in histological diagnosis.ResultsA total of 1686 paired screening-therapeutic colonoscopies and 1739 paired biopsy-polypectomy specimens were enrolled in the study. The grade of dysplasia in 84.5% of biopsy specimens were concordant to polypectomy specimens, but this proportion decreased to 75.4% when the specimens were classified using tubular or villousness structure. 10.1% and 5.4% of biopsy specimens were upgraded and downgraded in assessing grade of dysplasia, respectively, while 14.3% and 10.3% of biopsy specimens were upgraded and downgraded in assessing tubular or villousness structure, respectively. In subgroup analysis stratified by size of polyps, 9.0% and 10.6% of biopsies obtained from polyps smaller than 10 mm were upgraded in assessing dysplasia and tubular or villousness structure, respectively. This proportion increased to 10.7% and 21.3%, respectively, in biopsies obtained from polyps larger than 10 mm. Larger size of polyps and pedunculated polyps were associated with a higher incidence of upgrade in histological diagnosis. Nearly 25% of biopsy specimens with high-grade dysplasia were identified as adenocarcinoma in polypectomy specimens.ConclusionThe concordance between biopsy and polypectomy specimens is not adequate. The biopsy-based treatment strategy is not reliable and should not be considered as an indicator for further treatment, particularly in large or pedunculated polyps.

Clinical features of children with colorectal polyps and the efficacy of endoscopic treatment: an analysis of 1 351 cases

To study the clinical features of children with colorectal polyps and the efficacy of endoscopic treatment. A retrospective analysis was performed on the medical data of 1 351 children with colorectal polyps who were admitted and received colonoscopy and treatment in the past 8 years, including clinical features and the pattern and outcomes of endoscopic treatment. Among the 1 351 children, 893 (66.10%) were boys and 981 (72.61%) had an age of 2-<7 years, and hematochezia (1 307, 96.74%) was the most common clinical manifestation. Of all the children, 89.27% (1 206/1 351) had solitary polyps, and 95.77% (1 290/1 347) had juvenile polyps. The polyps were removed by electric cauterization with hot biopsy forceps (6 cases) or high-frequency electrotomy and electrocoagulation after snare ligation (1 345 cases). A total of 1 758 polyps were resected, among which 1 593 (90.61%) were pedunculated and 1 349 (76.73%) had a diameter of <2 cm. Postoperative complications included bleeding in 51 children (3.77%), vomiting in 87 children (6.44%), abdominal pain in 14 children (1.04%), and fever in 39 children (2.89%), while no perforation was observed. The children aged <3 years had the highest incidence rates of postoperative bleeding and fever (P<0.0125), and the children with a polyp diameter of ≥2 cm had significantly higher incidence rates of postoperative bleeding, vomiting, and fever (P<0.05). Solitary polyps, pedunculated polyps, and juvenile polyps are common types of pediatric colorectal polyps. Electric cauterization with hot biopsy forceps or high-frequency electrotomy and electrocoagulation after snare ligation can effectively remove colorectal polyps in children, with good efficacy and few complications. Younger age and larger polyp diameter are associated with a higher risk of postoperative bleeding.

Endoscopic resection of a descending duodenal polyp with the string-clip traction.

There is few studies about modified endoscopic treatment of duodenal lesions. The string-clip method is an effective option for large pedunculated duodenal polyp. On the one hand, it could increase the tension of the lesion and make endoscopic resection easy. What is more, with the help of clip and dental floss, we do not have to worry about specimen losing. We could deal with the wound first and then retrieve the resected specimen, resulting in an increased safety and efficiency of the endoscopic treatment.

Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (> 20 mm) non pedunculated colorectal polyps: a systematic review and meta-analysis.

Background and study aims Endoscopic mucosal resection (EMR) of laterally spreading tumors (LSTs) > 20 mm in size can be challenging. Piecemeal EMR of these lesions results in high rates of adenoma recurrence at first surveillance colonoscopy (SC1). Snare tip soft coagulation (STSC) of post resection margins is a safe and effective technique to prevent adenoma recurrence. We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of this technique. Patients and methods Multiple databases were searched through April 2021 for studies that reported on outcomes of post EMR STSC for LSTs > 20 mm in size. Meta-analysis was performed to determine pooled odds of adenoma recurrence as well as pooled proportion of adverse events including intraprocedural and delayed bleeding as well as intraprocedural perforation events. Results Six studies including two randomized controlled trials (RCT) and four cohort studies with 2122 patients were included in the final analysis. Overall pooled odds of adenoma recurrence at SC1 with post EMR STSC compared to no STSC was 0.27 (95 % 0.18–0.42; I2 = 0 %), P < 0.001. Pooled rate of adenoma recurrence at SC1 in post EMR STSC cohort was 6 %. Rates of intraprocedural bleeding, delayed bleeding and intraprocedural perforation were 10.3 %, 6.5 % and 2 % respectively. Conclusions Our results show that thermal ablation of resection margins with STSC in LSTs > 20 mm is a safe and effective technique in reducing the incidence of adenoma recurrence.

Complete disappearance of a large pedunculated polyp.

Disappearance of colorectal polyps is rare.1 Here, we report the disappearance of a large pedunculated polyp. A 58-year-old man with suspected colonic diverticular bleeding was referred to our hospital owing to recurrent hematochezia, despite a hemoclip placement on the diverticulum, which was suspected to be the bleeding source. The patient's medical history was unremarkable, and he was not under medication.

A novel polypectomy technique: the "ropeway method" for resection of large pedunculated polyps.

A novel polypectomy technique: the "ropeway method" for resection of large pedunculated polyps.

Effect of artificial intelligence-aided colonoscopy for adenoma and polyp detection: a meta-analysis of randomized clinical trials.

This meta-analysis aimed to determine whether artificial intelligence (AI) improves colonoscopy outcome metrics i.e. adenoma detection rate (ADR) and polyp detection rate (PDR). Two authors independently searched Web of Science, PubMed, Science Direct, and Cochrane Library to find all published research before July 2021 that has compared AI-aided colonoscopy with routine colonoscopy (RC) for detection of adenoma and polyp. This meta-analysis included 10 RCTs with 6629 individuals in AI-aided (n = 3300) and routine (n = 3329) groups. The results showed that both ADR (RR, 1.43; P < 0.001) and PDR (RR, 1.44; P < 0.001) using AI-aided endoscopy were significantly greater when compared with RC. The adenomas detected per colonoscopy (APC) (WMD, 0.25; P = 0.009), polyps detected per colonoscopy (PPC) (WMD, 0.52; P < 0.001), and sessile serrated lesions detected per colonoscopy (SSLPC) (RR, 1.53; P < 0.001) were significantly higher in the AI-aided group compared with the RC group. Subgroup analysis based on size, location, and shape of adenomas and polyps demonstrated that, except for in the cecum and pedunculated adenomas or polyps, the AI-aided groups of the other subgroups are more advantageous. Withdrawal time was longer in the AI-aided group when biopsies were included, while withdrawal time excluding biopsy time showed no significant difference. AI-aided polyp detection system significantly increases lesion detection rate. In addition, lesion detection by AI is hardly affected by factors such as size, location, and shape.

Prospective evaluation of the effectiveness of colonoscopic polyp resection

Background: Colon cancer incidence is on the rise and despite having undergone a colonoscopy to screen and remove all visible polyps as a preventive measure, nearly 1 in 110 patients will develop colon cancer within 3 years. The three main possible explanations for this are missing polyps, incompletely removed polyps, or rapidly growing tumors. Objective: To determine the proportion of colonic polyps ≤ 3 cm in size that show evidence of residual polyp tissue following colonoscopy and polypectomy. Methods: Patients who presented for colonoscopy at a community center were invited to participate in this study. Those who had confirmed adenoma were invited to repeat the procedure in 2 to 6 months with biopsies at the resection site to check for the presence of residual polyp tissue. Exclusion criteria included the absence of adenoma in the resected lesion, contraindication to polypectomy or follow-up colonoscopy, refusal to participate in follow-up examination, and other conditions increasing colon cancer risk. If polyps between 5 mm and 30 mm were found, the endoscopist resected them using the hot snare polypectomy technique or endoscopic mucosal resection (EMR). Results: Ninety-one patients completed the study protocol, with 105 lesions being studied. The second procedure was performed between 2 and 24 months. All analyzed lesions were adenoma, and three of them were associated with intramucosal adenocarcinoma. Others included 60 tubular lesions, 37 tubulovillous lesions, and 5 serrated lesions. Thirty-two lesions were flat and were removed by EMR; polypectomy was performed for 73 lesions. There was no residual tissue in the polypectomy group. The EMR group presented three cases of incomplete resection without adenocarcinomas. Conclusion: Our study showed that flat lesions might be an important cause of incomplete resection. In addition, we documented the complete resection of pedunculated lesions in all studied patients. This study provides more evidence to validate the empirical perception in the medical field that assumes the complete resection of pedunculated polyps. Therefore, we suggest that patients who undergo snare removal of pedunculated polyps should follow the regular protocol for colon cancer screening, with colonoscopy every 5 to 10 years. Meanwhile, the surveillance scheme should be reviewed for patients who undergo removal of flat lesions smaller than 30 mm.

Evaluation of cold snare polypectomy for small pedunculated (Ip) polyps with thin stalks: a prospective clinical feasibility study

Background Although the use of cold snare polypectomy (CSP) has spread rapidly, no prospective studies evaluating the safety of CSP for pedunculated (Ip) polyps have been carried out. Aim We performed this study to provide an accurate evaluation of the safety of CSP for Ip polyps. Methods This is a prospective study (UMIN000035687). From January 2019 to February 2021, the safety of CSP for use on Ip polyps <10 mm with thin stalks was evaluated at our hospital. The primary outcome measure was the incidence of bleeding (delayed post-polypectomy bleeding (DPPB) and immediate bleeding). Results During the study period, 89 consecutive patients (including 92 colonoscopies and 114 polyps) were prospectively enrolled. The en-bloc resection rate was 100%. The rate of DPPB after CSP was 0%, however, DPPB after conversion to HSP occurred in 1 case (33.3% (1/3)). The rate of immediate bleeding during CSP was 28.9% (33/114). Polyps with diameters ≥6 mm (OR (95% CI): 2.77 (1.041–7.376); p = .041) were extracted as independent risk factors for immediate bleeding during CSP for Ip polyps. In all, 104 (91.2%) polyps were low-grade adenomas, and the percentage of cases with negative pathological margins was 96.5% (110/114). Conclusions CSP for Ip polyps was safe and had good outcomes. We believe that Ip polyps could be included as an indication for CSP, and that CSP may become the next step in the ‘cold revolution.’ To confirm our results and verify CSP’s inclusion in future guidelines, prospective, randomized studies are necessary.

S1899 A Rare Case of a Primary Colonic Undifferentiated Pleomorphic Sarcoma in a Pediatric Patient

Introduction: Soft tissue sarcomas are a group of malignant tumors originating from primitive mesenchymal tissue. Rhabdomyosarcomas account for 4% of these tumors while the remaining types account for 3% of these tumors in children. Undifferentiated pleomorphic sarcoma is one of the many types of non-rhabdomyosarcoma malignancies and accounts for 2-6% of all childhood soft tissue sarcomas. They most commonly arise in the extremities. We present a pediatric patient with an undifferentiated pleomorphic sarcoma arising from the cecum. Case description/methods: A 12-year-old girl with a past medical history of obesity presented with intermittent abdominal pain, diarrhea, weight loss, and vomiting over a 4–5 month period. She was taking naproxen daily for the abdominal pain. She was also found to have iron deficiency anemia and anemia with a hemoglobin of 5.3 gm/dl. EGD was unremarkable but colonoscopy revealed a 7 cm fungating non-obstructing large mass in the cecum as well as 2 five mm pedunculated polyps in the rectum. Imaging revealed peri-colonic, mesenteric, and mediastinal lymph nodes as well as a 1.2 cm solid nodule in the left lower lobe. Then she underwent surgery revealing a colo-colonic intussusception and a right hemicolectomy for the malignancy. Later on, the patient had a video assisted thoracoscopic surgery with wedge resection of the pulmonary nodule. Colonic pathology revealed an undifferentiated pleomorphic sarcoma while lung pathology revealed histoplasmosis. Discussion: While rare pediatric malignancies such as this have a scarcity of literature presented, this appears to be the first reported case of an undifferentiated pleomorphic sarcoma arising from the cecum in a pediatric patient. Patients commonly present in the second decade of life with a painless mass but since this patient’s mass is in the intestines, it went undetected until it grew quite large ( > 7 cm). She did have typical symptoms of gastrointestinal malignancy such as vague abdominal pain, weight loss, bowel habit changes, and iron deficiency anemia but a malignancy is oftentimes lower on the differential for the pediatric age group. At the time of diagnosis, it is important perform staging via imaging including CT/MRI and PET. In our patient, when found, it had already metastasized to distant lymph nodes. Surgical resection of local disease can possibly lead to a relapse free life and possibly a cure but oftentimes adjuvant chemotherapy is also needed if there is metastasis.Figure 1.: A and B: Colonoscopy revealed a fungating non-obstructing, non-circumferential large mass in the cecum. The mass measured seven cm in length and 5 mm in diameter.

S2223 Rare Colonic Vascular Ectasia Disguised as a Polyp

Introduction: Vascular ectasia in the gastrointestinal (GI) tract is commonly seen as dilated and congested submucosal blood vessels, which appear as characteristic red flat lesions on endoscopy. In the colon, they can be found incidentally and are estimated to be responsible for 2-30% of lower GI bleeds. Polypoid appearing vascular ectasia lesions are exceedingly rare. We report an asymptomatic case of colonic polypoidal vascular ectasia. Case Description/Methods: A 62-year-old asymptomatic man with a history of diabetes mellitus II and hypertension and no family history of GI malignancy presented for his index screening colonoscopy. A 7cm pedunculated polyp was seen in the sigmoid colon (Figure 1a), with mucosa appearing identical to the surrounding mucosa. It was removed with hot snare polypectomy, and the polypectomy site was clipped with two hemoclips. The rest of the colonoscopy was unremarkable. Pathology demonstrated colonic mucosa with mild hyperplastic changes and submucosal vascular ectasia, as evidenced by markedly dilated and congested submucosal vessel that extended the length of the entire polyp with clusters of smaller congested capillaries spreading into the overlying mucosa, as shown in the 20x (Figure 1b) and corresponding high power 400x (Figure 1c) histopathological images. Pathology was negative for dysplasia. Discussion: Polypoid appearing colonic vascular ectasia lesions are infrequent, and literature review shows only 15 lesions matching the description in our case. In addition, these lesions are typically located in the cecum or ascending colon, accounting for 54-81.9% of colonic vascular ectasia. Classically, angiodysplasia of the colon is associated with aortic stenosis, chronic renal failure, and in patients with Von Willebrand disease. In our patient, the patient was asymptomatic, and the lesion was incidentally identified during a screening colonoscopy. The lesion was a large pedunculated polyp located in the sigmoid colon, unlike most colonic vascular ectasias that appear in the right/proximal colon. Since the lesion is benign and not an adenoma of the colon, the colon cancer surveillance interval was determined to be 10 years. This report is pertinent for endoscopists who may encounter abnormal polypoid masses on colonoscopy. Keeping vascular ectasia on the differential diagnosis will aid in both intra-procedure decision-making and post-procedure follow-up.Figure 1.: A. CT Chest with Pneumomediastinum B. Upper Endoscopy With Erythematous Posterior Oropharynx and an Extrinsic, Longitudinal Bulge in the Proximal Esophagus C. Intraoperative Photograph During Thoracotomy.

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.