Prior Colonoscopy Research Articles

Pre-procedure Modle Predicts Bowel Preparation Quality Prior Colonoscopy

Pre-procedure Modle Predicts Bowel Preparation Quality Prior Colonoscopy

Individual and Geospatial Characteristics Associated With Use and Nonuse of the Fecal Immunochemical Test (FIT) for Colorectal Cancer Screening in an Urban Minority Population.

Initiatives by the Centers for Disease Control and Prevention as well as the National Colorectal Cancer Roundtable aim to increase the rate of colorectal cancer (CRC) screening. We assess individual and geographic characteristics associated fecal immunochemical test (FIT) CRC screening over 3 years. This is a retrospective study of 1500 FIT kits which were mailed or opportunistically handed to eligible participants in Brooklyn, New York from January 2014 to December 2016. Eligibility criteria included increased risk for colon cancer, uninsured or underinsured, and a minimum age of 50 years to warrant CRC screening. We looked at the association of individual demographic characteristics and FIT screening by logistic regression using SPPS version 23 software. In addition, using ArcGIS, we coded patients address and layered census tract population information to find associations. In total, 1367 Cancer Services Participants met our study criteria. The study sample was predominantly female (95.2%) and minority (46% African American, 24.7% Hispanic, 17.3% Caucasian, 11.4% Asian) and on average 59 years old (SD, 5.7). A large majority (73%) had household incomes below $20,000/year. Approximately half (49.9%) of all Cancer Services Participants returned their FIT kit. In participants who did not return their FIT kit, the majority were African American (41%), followed by Hispanics (26.5%), Caucasians (20.6%), and Asians (11.8%). Multivariable logistic regression showed that a screening history of prior colonoscopy or FIT, gender, ethnicity, and educational attainment were significantly associated with FIT CRC screening uptake (P<0.05). Geospatial mapping showed clusters of low screening uptake in areas of high poverty. Hot-spot analysis identified areas of significant vulnerability. FIT uptake remains suboptimal. Individual predictors as well as area poverty is associated with low screening uptake. Geospatial mapping is an effective tool for evaluating CRC screening uptake.

317 Increased Interval Between Screening and Surveillance Colonoscopy Is Associated With Decreased Withdrawal Time

INTRODUCTION: Colonoscopy is currently the most effective method for prevention of colon cancer in patients as seen by the declining rates of colon cancer since screening has been implemented. Adenoma detection rate is an important quality measure that is affected by many factors, including withdrawal time. Limited research has evaluated whether prior history or interval time between colonoscopies affects withdrawal time. METHODS: Inclusion criteria: 872 patients at a tertiary academic center who underwent screening and surveillance colonoscopies. Exclusion criteria: patients with missing procedure timestamps, incomplete or aborted procedures, history of gastrointestinal malignancy, prior colon resection, genetic syndromes, or inflammatory bowel disease. For withdrawal time, log-transformation was applied to normalize the data. For the association of withdrawal time with history of prior colonoscopy analysis of variance was used. RESULTS: Overall, no significant difference was found in the withdrawal time in patients with or without a prior colonoscopy (12.42 vs. 11.66 minutes, P = 0.114). Subgroup analysis in the screening group did not show any difference (10.83 vs. 11.66 minutes, P = 0.668). In patients undergoing screening with prior colonoscopies, the withdrawal time was significantly decreased with increased colonoscopy interval, which was defined as the time from the prior colonoscopy to the current colonoscopy (range 1-357 months, P = 0.033). This was also seen with patients undergoing surveillance (range 1-194 months, P = 0.005). For patients undergoing surveillance, the withdrawal time for patients with interval of ≤ 3 years was significantly longer than that for the patients with interval &gt;3 years (14.05 vs. 11.86 minutes, P = 0.036). Similar results were seen even after adjusting for polyp removal (12.05 vs. 10.99 minutes, P = 0.021). CONCLUSION: Increased interval between a patient’s prior colonoscopy is associated with a shorter withdrawal time. However, bias does not appear to exist on a patient’s initial screening colonoscopy. Reassurance from prior results may affect the endoscopist’s decision to withdraw more quickly. Large-scale or prospective studies should be done to validate these findings.

1627 Segmental Colitis Associated With Diverticulosis: An Emerging Entity Among the Non-Specific Colitis

INTRODUCTION: An 86 y/o male with diverticulosis and hypertension, arrived at the ER due to intermittent episodes of bright rectal bleeding associated with lower quadrant abdominal pain since 3 weeks ago. Laboratories without anemia, leukocytosis, eosinophilia or any other abnormality. CT abd/pelvic revealed a segmental area of concentric mural thickening and narrowing of the lumen of the sigmoid colon, concerning for a mass. No prior colonoscopies or GI alarming features. GI service consulted for diagnostic endoscopic procedure. CASE DESCRIPTION/METHODS: Sigmoidoscopy was remarkable for severe diverticular disease of the rectal mucosa with associated significant erythema, exudative material and loss of vascular pattern consistent with an inflammatory process. At 20 cm from the anal verge, a luminal narrowing covering &gt; 90% of the lumen extended up to 27 cm. Pathology report from the area of obstruction showed acute over chronic inflammation without granulomas, microorganisms or dysplasia. He was started on rectal mesalamine and a 14-day course of oral antibiotics (metronidazole and ciprofloxacin). Surgery service consulted which agreed with medical management. Within two weeks after completion of antibiotics, colonoscopy was performed revealing marked improvement of the luminal narrowing evidenced in the previous colonoscopy at 20cm, including less degree of inflammation and fewer loss of vascular pattern among the segmental area within multiple diverticuli. Biopsies taken from the same narrowing were remarkable for chronic inflammation without dysplasia. All findings were consistent with segmental colitis associated with diverticulosis (SCAD). DISCUSSION: SCAD is an inflammatory process that affects colonic luminal mucosa in areas that are affected by diverticulosis. The prevalence is 1.5 – 11.4% among those with diverticular disease. The pathogenesis of SCAD is unclear. The clinical presentation is not specific and thus similar to other pathologies, including inflammatory bowel disease, for which makes this condition difficult to diagnose. There are currently no guidelines for its management. It is frequently based on the administration of salicylates, antibiotics and surgical intervention for refractory cases. Currently it is unclear if SCAD is in fact a spectrum of IBD or if it is itself a separate entity. The rarity of SCAD supports the claim that further research is needed to better understand the disease and thus improve its management and clinical outcomes.

1454 Recurrent Isolated Colon Ischemia Secondary to Kayexlate. Kayexelate Helps History to Repeat Itself

INTRODUCTION: Kayexalate, sodium polystyrene sulfonate, is often used for treatment of hyperkalemia. This resin based medication has been associated with colon ischemia. CASE DESCRIPTION/METHODS: 69 y/o male with extensive past medical history of end stage renal disease (ESRD) on hemodialysis (HD), atrial fibrillation not on anticoagulation, stroke with right hemiparesis s/p trach and PEG dependent, and left colostomy for diversion. He was transferred from the HD clinic to the ED for acute anemia, hypotension and hematochezia from ostomy. He was admitted for hemorrhagic shock, received intravenous fluid resuscitation, blood transfusions and was started on inotropic support. Infectious workup was negative. Computed tomography angiography was negative for acute bleed. EGD was unremarkable. Colonoscopy revealed extensive circumferential ulceration and pseudomembrane in the cecum and proximal ascending colon. Biopsies were consistent with colon ischemia. He improved clinically with supportive care and discharged. Three months later he was admitted for parotitis and hyperkalemia. He was started on Kayexalate and then developed hematochezia from ostomy with hemodynamic stability a few days later. He underwent repeat colonoscopy revealing persistent ulcerations with erythematous friability in the same area previously seen in prior colonoscopy. Biopsies this time revealed acute reactive epithelial atypia with embedded polystyrene sulfonate crystals. DISCUSSION: It is well known patients with renal failure on dialysis have a higher risk of developing colon ischemia. Kayexalate has been seen to cause colitis, which can progress to necrosis in 1% and perforation. This is hypothesized to be due to the release of prostaglandins and mesenteric vasoconstriction, thus causing mucosal damage. This may explain why this patient with recent history of right colon ischemia had Kayexalate induced injury in the same area. Symptoms of this damage can be seen within days to weeks after administration of medication, as in this case. In conclusion, patients with ESRD presenting with hematochezia, careful review of medications should be done as Kayexalate may induce colon ischemia. ESRD patients with previous colon ischemia, urgent HD rather than Kayexalate may be preferred, as the latter may recur as colon ischemia in the setting of previously injured tissue.

1610 Don't Let Your Past Determine Your Destiny

INTRODUCTION: Synovial sarcoma (SS) is a rare mesenchymal soft tissue sarcoma usually involving extremities close to large joints. SS of the GIT is uncommon; SS of the colon is extremely rare. Recognition and management of SS of the GIT can be very challenging. Here we report a rare case of asymptomatic SS of the rectosigmoid diagnosed as a surprising finding of surveillance colonoscopy. CASE DESCRIPTION/METHODS: A 59-year-old asymptomatic lady with past medical history of diabetes mellitus, morbid obesity, colon polyps was referred for surveillance colonoscopy. Prior colonoscopy six years ago revealed two sigmoid colonic tubular adenomas. Examination was unremarkable except for a BMI of 44. Thorough examination of the musculoskeletal system did not reveal any abnormalities. Colonoscopy revealed a large, 5 cm pedunculated and superficially ulcerated round mass in the rectosigmoid colon, filling most of the lumen with the distal end of the lesion being ∼15 cm above the anal verge. Biopsy demonstrated spindle cells with marked nuclear pleomorphism, high mitotic index rate, positive SS18 (SYT) gene rearrangement testing on FISH. Immunohistochemistry (IHC) was positive for TLE1, OSCAR, MCK, AE1/AE3, CK7 with Ki-67 of 70% and negative for desmin, CD117, DOG1, p63, CK5, CK6, S100, SMA. Findings were consistent with SS. Staging CT and PET-CT did not demonstrate distant spread. Robotic laparoscopic anterior resection with wide surgical resection margins and lymphadenectomy revealed T1N1 LN 2/20 stage 3 monophasic synovial sarcoma, with negative margins, 20% tumor necrosis and high mitotic rate. The patient was started on adjuvant chemotherapy with 5 cycles of Adriamycin 75 mg/m2 and Olaratumab on day 1 and day 8 of a 21-day cycle. A repeat PET-CT and a flexible sigmoidoscopy, six months later, did not reveal any tumor recurrence. DISCUSSION: Increasing number of cases of GIT SS are being reported. The majority of GI SS cases involved esophagus and stomach with pain, obstruction and bleeding being the common presenting symptoms; SS of the large intestine is extremely rare. Diagnosis is established by molecular genetics and IHC. Standardized treatment-guidelines are currently lacking. It is of paramount importance to i) consider SS on the list of differentials of colonic neoplasms, ii) report these unusual cases to better understand the pathophysiology, treatment options and success rates. This would facilitate more targeted and effective treatments for SS of the colon.

1175 Ileal Carcinoid Tumors Detected During Screening versus Diagnostic Colonoscopy: Comparison of Tumor Characteristics

INTRODUCTION: Small intestinal carcinoid tumors are the most common type of small bowel malignancy observed. Most are indolent and incidentally found in asymptomatic patients undergoing ileal intubation during routine colonoscopy. Our aim was to survey all patients diagnosed with ileal carcinoid and to compare tumor characteristics for those discovered during screening or diagnostic colonoscopy. METHODS: We reviewed all ileal carcinoid tumor cases from 2005-2018. For each case, we recorded patient age, colonoscopy indication at diagnosis, timing of prior colonoscopy (if ever performed), coexistence of adenomatous polyps in the colon, carcinoid tumor size and stage after resection, and disease-free survival. RESULTS: Twenty-nine (29) cases of ileal carcinoid tumor were identified. Mean patient age at diagnosis was 64. In 5 cases, the tumor was initially identified during urgent surgical evaluation of obstructive symptoms and not during colonoscopy. In the remaining 24 cases, tumors were initially detected during colonoscopy with ileal intubation. Of these, 13 were having initial screening or surveillance. The remaining 11 were having diagnostic evaluation of symptoms, abnormal findings on CT imaging, or both. Table 1 compares carcinoid features for cases detected during screening versus diagnostic colonoscopy. A prior colonoscopy was performed within the preceding 10-year period in 11 cases, and of these, only 3 included terminal ileum intubation. Adenomatous colon polyps were found in 11 of 24 patients, with advanced adenomas identified in 3. Tumor size ranged from 0.5 to 3.7 cm (mean 1.8 cm). Lymph nodes were involved in 21 of 24 patients. In the 3 patients without lymph node involvement, tumors were small (0.5, 0.5, 0.6 cm). At diagnosis, only 1 patient had distant metastases and eventually died from tumor complications 42 months later. Another patient died from an unrelated cause at 99 months after diagnosis. Mean survival-to-date for the remaining 22 patients is 57 months with a range of 2-172 months. CONCLUSION: In our series, most patients with ileal carcinoid tumors were initially diagnosed during colonoscopy rather than during urgent surgery. Nearly all carcinoids discovered during colonoscopy were associated with lymph node involvement at the time of diagnosis. Most, however, did not have or develop distant metastases and have enjoyed prolonged survival. No significant differences in carcinoid tumor size or stage were observed between patients having screening versus diagnostic colonoscopy.

1654 An Unusual Colon Lesion: Colon Metastasis From Primary Lung Adenocarcinoma

INTRODUCTION: Primary lung cancers infrequently metastasize to the gastrointestinal tract. We describe one case of isolated colonic metastasis identified at diagnosis of the primary lung malignancy and the associated immunohistochemical pattern. CASE DESCRIPTION/METHODS: An 80-year-old man presented for evaluation of subacute onset shortness of breath. CT imaging showed a spiculated mass with associated ipsilateral intrathoracic lymphadenopathy. PET-CT was performed for staging and revealed a hypermetabolic focus in the left colon with recommendation for follow up colonoscopy. No other significant lesions or evidence of distant metastatic disease were seen and subsequent biopsy of a subcarinal lymph node demonstrated primary pulmonary adenocarcinoma. The colonoscopy visualized a sessile 12 mm polyp in the recto-sigmoid colon (Figure 1). Prior colonoscopy within 5 years of presentation was normal. Colon polyp morphology showed moderately differentiated adenocarcinoma. Immunohistochemical staining of resected polyp was positive for TTF-1 and negative for CDX2. Oncology recommended tyrosine kinase inhibitor therapy for Stage IV disease and alectinib was initiated with good response at 6 month follow up. DISCUSSION: Non-small cell lung cancer metastatic to the colon is uncommon but can present as a spectrum from asymptomatic mucosal involvement to bulky obstructive disease. Autopsy series and published case reports suggest broad estimates of asymptomatic involvement in between 1-10% of lung primaries, with symptomatic gastrointestinal involvement in &lt;1% of cases.1 Endoscopic presentation of metastatic disease to the gastrointestinal tract is often non-characteristic and differentiating adenocarcinoma tissue of origin is aided by immunohistochemical staining. TTF-1 staining has been shown to be highly specific to pulmonary adenocarcinomas.2 CDX2 expression is an important intestine-specific transcription factor, and CDX2 negativity suggests adenocarcinoma of non-GI origin.3 Used in conjunction, distant metastatic disease to the GI tract can be identified.

1539 Drug-Induced Colitis as a Side Effect of Calcitonin Gene-Related Peptide (CGRP) Antagonist for Migraines

INTRODUCTION: Drug-induced colitis is a documented though relatively uncommon side effect of several drug classes, and is under-recognized and under-reported. In May 2018, an injectable calcitonin gene-related peptide (CGRP) antagonist, erenumab, was approved by the FDA for migraine prophylaxis. In the following case, this new medication is implicated as a possible cause for severe colitis resembling an inflammatory bowel disease-like picture both clinically and endoscopically. CASE DESCRIPTION/METHODS: A 33-year-old Caucasian female presented with complaints of rectal bleeding, diarrhea, and abdominal pain 2 weeks after starting a CGRP antagonist, erenumab, for chronic refractory migraine headaches. Pertinent laboratory studies showed leukocytosis with bandemia. CT Abdomen/Pelvis showed diffuse colonic wall thickening. Stool studies did not indicate any infectious etiology and an IBD panel was negative. She underwent a colonoscopy that showed severe, deep punched out ulcerations throughout the entire colon. Biopsy showed active colitis. She had a prior colonoscopy in 2009 for work up of IBS, which was endoscopically and microscopically normal. The patient's symptoms and clinical findings resolved after discontinuing the drug. A follow up colonoscopy performed one month after discharge showed evidence of ulcer healing with no new areas of inflammation. DISCUSSION: Blocking CGRP receptors of the central nervous system may reduce headaches, however blocking those of the enteric system can promote breakdown of the colonic mucosal barrier and induce a systemic inflammatory reaction. In animal models, extensive mucosal damage was noted in the subjects receiving CGRP receptor antagonists. This case implies that certain patients may be at risk for developing mucosal barrier disruption from the blockade of the calcitonin gene-related peptide receptor with erenumab or similar drugs. Further research may be needed to elucidate risk factors that may contribute to susceptibility to these deleterious effects. Once those patients that are more at risk are identified, there may be a role for endoscopic surveillance in certain patients taking these medications. While drug-induced colitis is likely to be an uncommon manifestation of blocking CGRP, clinicians should be aware of this potential side effect of targeted therapy and counsel patients receiving this therapy.

2536 Celiac Disease Presenting With Duodenal Ulcerations and Small Bowel Intussusception

INTRODUCTION: Celiac disease is an autoimmune disorder that is triggered by gluten causing villous atrophy in the small intestine. Patients with celiac disease can present with a wide range of symptoms. We present a unique case of celiac disease presenting with duodenal ulcerations and small bowel intussusceptions. CASE DESCRIPTION/METHODS: A 60-year-old male with past history of stage I colon cancer status post partial colectomy 8 years ago presented with diarrhea and weight loss. The patient reported profuse diarrhea accompanied by a 20 lbs. weight loss that started six months ago. He denied other symptoms. His prior colonoscopies 1 year and 4 years after the partial colectomy were unremarkable. Physical examination was unremarkable. Laboratory data including hemoglobin was normal. Stool studies including infectious work up (clostridium difficile, stool cultures, ova and parasites) and fecal calprotectin were normal. A computed tomography (CT) scan of the abdomen and pelvis showed small bowel intussusception, mesenteric lymphadenopathy, and absence of any metastatic disease in the abdomen or pelvis (Figures a and b). A push enteroscopy was performed and revealed multiple scattered superficial ulcerations throughout the duodenum from the bulb to the third portion (Figures c and d). Repeat colonoscopy was unremarkable. Duodenal biopsies showed marked villous blunting, crypt hyperplasia and increased intraepithelial lymphocytes (Figures e and f) consistent with Celiac disease (Marsh 3b criteria). Blood was checked for celiac disease serologies and showed an elevated Anti-Tissue Transglutaminase IgA Antibody and a Deaminated Gliadin Peptide IgA Antibody. The patient was advised to start a gluten free diet. Four months after diagnosis, and being on a gluten-free diet, the patient had complete resolution of diarrhea and regained 20 lbs. of weight. DISCUSSION: Celiac disease can present with a variety of symptoms including diarrhea, nutritional deficiencies, weight loss, and gastric distension. Duodenal ulcerations and small bowel intussusception are exceedingly rare presentations of celiac disease. Even though these presentations have been previously been described separately, but they have not been reported together in an adult patient. Our case highlights that gastroenterologists should bear in mind the differential diagnosis of celiac disease in patients with small bowel intussusception, even in adults.

217 Post Colonoscopy Diverticulitis: How Common Is It?

INTRODUCTION: Acute Diverticulitis (AD) is a common cause of hospitalization. Colonoscopy is a commonly performed outpatient procedure. There is limited data exist regarding post colonoscopy AD. There are few single center studies which discuss about post colonoscopy AD but larger studies are lacking. Our aim is to evaluate incidence, demographic factors, clinical factors and mortality associated with post colonoscopy AD in nationwide patient population. METHODS: We used Nationwide Readmissions Database (NRD) of year 2014 to find patients admitted with AD. From that sample, we found patients who had underwent colonoscopy between one and four days prior to admission. AD patients with and without prior colonoscopy were compared by univariate and multivariate analysis. Chi-square or fisher's exact test was done for categorical variables while t test was used for continuous outcome. Multivariate logistic regression was done to compare in hospital mortality between two groups. RESULTS: There are total 235847 weighted admissions in year 2014 with AD out of which 797 (0.3%) patients had underwent colonoscopy between one and four days prior to admission. Univariate analysis showed that patients who are male and with age above 65 were significantly more associated with post colonoscopy AD. It also showed that patients with post colonoscopy AD had significantly higher mortality and total hospitalization charges (Table 1). In Multivariate analysis, patients with liver disease (Odds Ratio 1.5, P 0.02), kidney disease or electrolytes abnormalities (Odds Ratio 3.9, P &lt; 0.0001), age more than 65 (Odds Ratio 22, P &lt; 0.0001), and those who had recent weight loss (Odds Ratio 3.8, P &lt; 0.001) had higher in hospital mortality while obese patients (Odds Ratio 0.7, P 0.008) had significantly lower in hospital mortality. CONCLUSION: Incidence of AD between 1 to 4 days after colonoscopy is 0.3% (3/1000) which is more commonly seen in elderly patients. Although a rare complication, possibility of AD post procedure should be kept in mind mainly for patients who already had history of AD in the past as second episode of AD can increase their morbidity and mortality significantly. Also risk stratification becomes extremely important in high risk patients such as those who are more than 65 years of age, patients with liver and kidney diseases as they will have higher in hospital mortality and higher total hospitalization charges.

277 Evaluating Cancer Outcomes of Outpatient Colonoscopies in Elderly Patients Older Than 85 Years of Age

INTRODUCTION: With increasing life expectancy and a growing body of aging patients, the incidence of gastrointestinal diseases including colorectal cancer increases. Currently, there are few studies on cancer outcomes of outpatient colonoscopy in patients older than 85 years of age. METHODS: The endoscopic database at Scripps was queried for all outpatient colonoscopies performed under moderate sedation between April 1, 2012 to March 31, 2017 on patients aged 85 years and older. Endoscopy reports were reviewed for demographics, indication for procedure, and endoscopic findings. Variables including location and stage of tumor, subsequent treatments, and overall mortality were analyzed. RESULTS: 322 outpatient colonoscopies were reviewed. Median age was 86 years. 53% were females. Screening colonoscopies accounted for 2.1% of procedures. 40 (12.4%) colon cancers were detected. 38 (95%) were adenocarcinomas and 2 (5%) were neuroendocrine tumors. Of these, 26 (65%) were right sided colon cancers. Among patients diagnosed with cancer, anemia was the most common indication followed by positive fecal occult blood test (FOBT). 20 (50%) of these patients had a FOBT within the past year. Of those FOBTs, 18 (90%) were positive. Median age of patients with colon cancer was 88 years, with 70% females. 12 (30%) patients had never had a prior colonoscopy. Of those with colon cancer, 19 (47.5%) were diagnosed at an advanced-stage (stage III or IV). Among patients who received treatment, 32 (80%) pursued surgery, 10 (25%) received chemotherapy, and 5 (12.5%) received radiation. 3 (7.5%) patients received supportive care only. 1-year mortality was 22.5% and 3-year mortality was 40% from the time of diagnosis. CONCLUSION: To date, this is the first study in the United States that examines cancer outcomes in an elderly population over age 85 undergoing an outpatient colonoscopy. Overall, colonoscopies in this age group resulted in a high cancer detection rate with anemia being the most common indication for a colonoscopy. Almost half of the detected cancers were advanced-stage and prognosis was overall poor. Interestingly, FOBT may be a useful screening tool to help clinicians assess whether a colonoscopy should be pursued in the elderly population. These findings will hopefully provide clinicians guidance on screening tools and treatment options that can be offered to the growing elderly population.

1613 A Case of Extreme Fatty Expulsion Per Rectum

INTRODUCTION: The purpose of colonoscopies (CLN) is primarily for the prevention &amp; management of disease in the lower gastrointestinal (GI) tract. Colonoscopies can often find fleshy masses found to be benign polyps, colorectal cancer, and even lipomas. These masses are rarely passed through the GI tract. The mechanism of spontaneous expulsion is thought to be primarily from auto-amputation. This auto-amputation occurs when a polyp or mass on a pedunculated stalk twists upon itself. It continues to twist until becoming free from the mucosal layers inside the GI tract. This allows the mass to be free to pass into rectal vault &amp; present as a bowel movement. Though this mechanism is known, spontaneous expulsion of such fleshy masses is thought to be quite rare. CASE DESCRIPTION/METHODS: A 48-year-old male with a past medical history of a partial small bowel obstruction &amp; atrial fibrillation (AF) on rivaroxaban presented to ED with complaints of intermittent abdominal pain &amp; an abnormal bloody bowel movement. Prior CLN in 2014 was negative except for benign polyps. Patient described his stool as an "abnormal mass.” On gross evaluation the stool was noted to be a large yellow/tan fatty mass measuring 4 × 3.4 × 5.3 cm. Histological examination showed benign adipose tissue separated by thin fibro-vascular septae. Evaluation with CLN showed an 18mm pedunculated polypoid lesion on a thick 15mm stalk in the descending colon. The head of the lesion was found to be erythematous with granulation tissue on its surface consistent with recent removal of a large polypoid lesion. Cold forceps were used to biopsy the lesion &amp; revealed benign submucosal lipomatous neoplasm. DISCUSSION: Lipomas are non-malignant neoplasms composed of adipose tissue. They can often be found throughout the body and rarely present in the GI tract. If present in the GI tract they are often found to be submucosal &amp; in the colon. Majority are asymptomatic but can produce symptoms if &gt; 2 cm. This patient’s lipoma was noted to be &gt; 4 cm. This patient presented with intermittent lower abdominal pain, changes in bowel habits, passage of fresh blood per rectum, recurrent AF episodes, along with passing a lipomatous mass. After expulsion of this mass the patient noted decreased episodes of AF. This case &amp; its findings demonstrate that spontaneous expulsion of a lipoma can occur via similar mechanisms of auto-amputation for polyps as previous cases have shown. It also reminds us the relationship between abdominal pathologies &amp; the propensity for AF.

2001 Mastocytosis Complicated by Upper and Lower GI Bleeding

INTRODUCTION: Mastocytosis is a rare disease caused by the abnormal proliferation and accumulation of mast cells in 1 or more organs of the body and is divided into cutaneous and systemic disease. Patients have increased susceptibility to urticaria, pruritis and anaphylactic shock. GI manifestations are thought to be related to direct mast cell infiltration and release of mast cell mediators. CASE DESCRIPTION/METHODS: A 39-year-old woman with a history of cutaneous mastocytosis intolerant to cromolyn sodium, Roux-en-Y gastric bypass, gastritis, celiac disease and hemorrhoids presented with melena and hematemesis following a mastocytosis flare and concurrent pneumonia. She had no prior history of GI bleeding, PUD, H. Pylori infection, NSAID or anticoagulation use, liver disease, or family history of GI malignancies. Prior EGDs and colonoscopies were unremarkable. She was on a chronic high-dose of famotidine and prednisolone taken as needed. Physical exam showed mild epigastric and left upper quadrant tenderness, bilateral rhonchi, and hemodynamic stability. Initial laboratory findings were insignificant. She was given IV pantoprazole BID and continued to have melena while remaining stable; with Hb down-trending to 11.6 gm/dL. EGD revealed a large gastric pouch with Roux-en-Y anatomy and 2 non-bleeding cratered ulcers near the congested, erythematous gastrojejunal anastomosis. The larger ulcer (9 mm) had a visible vessel and was clipped. Pathology revealed reactive gastropathy, mild chronic inflammation without H. pylori. Jejunal biopsies showed congestive mucosa and mild acute on chronic inflammation. The patient resumed IV continuous infusion of pantoprazole for 48 hours then transitioned to oral PPI with her usual famotidine. DISCUSSION: Up to 80% of patients with systemic mastocytosis can present with a variety of GI symptoms, with the most common being diarrhea and abdominal pain. Though the etiology of diarrhea is not well understood, abdominal pain is largely attributed to dyspepsia and gastroduodenal ulcers resulting from acid hypersecretion. Symptomatic treatment for GI symptoms largely depends on anti-mediator therapy where H1 and H2 receptors are typically combined. PPIs are added to treat gastric involvement. Cromolyn sodium is a highly effective treatment for GI manifestations (100-200 mg PO up to 4 times/day). Oral corticosteroids may relieve malabsorption and ascites in the rare cases of liver involvement. Lifestyle modifications include avoidance of triggers and stress management if possible.

1955 An Ulcerated Lipoma as the Cause of Obscure Gastrointestinal Bleeding

INTRODUCTION: GI bleeding remains one of the most common reasons for GI consultation, with top causes including peptic ulcer disease, erosive disease, angiodysplastic lesions, varices, Mallory Weiss tears, dieulafoy lesions, and malignancy. Obscure GI bleeding (OGIB), defined as recurrent or persistent bleeding or anemia despite negative endoscopic evaluation, makes up 5% of all GI bleed cases. Approximately 75% of OGIB are found to have small bowel lesions. We outline a case of a rare cause of OGIB. CASE DESCRIPTION/METHODS: A 78-year-old female with history of HTN, HLD, CAD, STEMI s/p DES placement, biliary colic s/p cholecystectomy, is referred to GI clinic for symptomatic anemia. She was found to have a hemoglobin of 8 g/dL from baseline 11–12 g/dL. She had been on dual antiplatelet therapy with ticagrelor until 3 months ago, now on aspirin 81 mg. Anemia workup revealed iron deficiency. CT scan negative. Started on po iron with improvement in symptoms. Denied abdominal pain, weight loss, or overt bleeding. No NSAID use. No prior endoscopy or colonoscopy. No family history of GI malignancy. An upper endoscopy and colonoscopy were done. There was antral erythema, otherwise normal EGD. Duodenal and gastric biopsies were negative. Colonoscopy only notable for extensive diverticulosis and a small tubular adenoma. Capsule endoscopy identified active bleeding in the proximal small bowel and a potential submucosal mass. Push enteroscopy revealed a long polypoid lesion extending from the third to fourth portion of the duodenum, approximately 15 mm in width and at least 100 mm in length with visible ulcerated tip. Mucosa was otherwise normal. Endoloop was applied and tissue removed with a hot snare. Pathology resulted in a submucosal lipoma. She was followed with serial blood counts and continued on iron therapy. She is doing well with continued GI follow up. DISCUSSION: This case of an ulcerated lipoma as the cause of an OGIB is among a handful of other case reports and seem to be similarly found in patients on antiplatelet or anticoagulation therapy. Other cases have undergone surgical resection for symptomatic lipomas, however our case suggests that perhaps in those that are able to stop antiplatelet therapy and have a lesion within reach of an enteroscope, resection of the ulcerated portion may be sufficient treatment and may avoid invasive surgery.

327 What to Do When Fecal Immunochemical Test (FIT) Is Positive Following Normal Colonoscopy? Comparison of Adenoma Detection Rate (ADR) of Standard FIT-Colonoscopy and Relook Colonoscopy

INTRODUCTION: For average risk patients, current guidelines generally recommend either yearly FIT or colonoscopy every ten years. A positive FIT test triggers reflex colonoscopy, which can have higher ADR than screening colonoscopy. FIT tests are also frequently performed following a negative colonoscopy in routine practice for concerning symptoms or desire for “early relook.” A positive FIT test often leads to reflex “relook colonoscopy” despite negative colonoscopy within the past 10 years. It is not clear if relook colonoscopy would be necessary or lead to new findings. As such, we aimed to compare colonoscopy findings including ADR in the “relook FIT-colonoscopy” versus the “standard FIT-colonoscopy” population. METHODS: This is a retrospective study of 1,940 patients age ≥ 18 at a community medical center between December 1, 2002 and June 1, 2018: 51 had relook FIT-colonoscopy and 1,889 patients had standard FIT-colonoscopy. The primary outcome was ADR with secondary outcomes including other colonoscopy findings. RESULTS: The group receiving relook colonoscopy was on average younger than the standard FIT-colonoscopy group (61.8 v 64.5, P = 0.049). The relook colonoscopy group had lower percentage of males (37.3 v 45.6%, p&lt; 0.001) but higher percentage of Asians (90.2 v 76.5%, p&lt; 0.001). While the relook colonoscopy group had fewer days between FIT and colonoscopy, this was not statistically significant (61.1 v 68.9, P = 0.800). For patients receiving relook colonoscopy, 82.4% were asymptomatic at time of FIT, while 5.9% had bowel habit changes, 5.9% anemia, 3.9% abdominal pain, and 3.9% rectal bleeding. FIT occurred on average 4.9 +1.8 years following colonoscopy. Standard FIT-colonoscopy demonstrated ADR of 51.2% with cancer identified in 1.6% of patients. The relook colonoscopy strategy had ADR of 39.2% (N = 20); 49.0% of patients had no abnormal findings: 47.1% had hemorrhoids, 23.5% had diverticulosis, and none had cancer (Figure 1). Of the 20 patients with adenoma in the relook colonoscopy group, 3 patients had adenoma &gt;1 cm and 2 had advanced neoplastic polyps (villous and serrated). CONCLUSION: While significant data has demonstrated that colonoscopy following positive FIT is important, data on relook colonoscopy is less clear. Given ADR of 37.7%, patients with positive FIT should receive repeat colonoscopy despite prior normal colonoscopy. Nevertheless, more data is needed to determine validity and criteria for pursuing repeat FIT following a normal colonoscopy.

1601 Cecal Granular Cell Tumour: An Uncommon Site of an Uncommon Tumour

INTRODUCTION: Granular Cell Tumors (GCTs) are tumors arising from Schwann cells of the nerve sheath. They occur at an incidence of about 0.03% and have a predilection for the skin, oral cavity, and breasts. Only 6-8% of all GCTs occur in the GI tract with the esophagus (65%) being the most common site, followed by the colorectum (25%). Less than 20 cases of cecal GCTs have been reported so far. Owing to its rarity, we report a case of an asymptomatic cecal GCT found incidentally during screening colonoscopy. CASE DESCRIPTION/METHODS: A 58-year-old male with no known past medical history presented to the Gastrointestinal (GI) clinic for screening colonoscopy. History was negative for alarm symptoms, including no family history of GI cancers. He had no prior Upper endoscopy or colonoscopy. Physical examination and labs were unremarkable. Colonoscopy revealed an 8mm yellowish, sessile, subepithelial nodule with normal overlying mucosa in the cecum (Figure 1). Biopsy showed clusters of cells with granular cytoplasm that was Periodic acid–Schiff (PAS) positive suggestive of GCT (Figure 2). Immunohistochemical staining was positive for S100, CD 68, calretinin thus confirming the diagnosis of GCT (Figure 3). The patient has since been scheduled for Endoscopic ultrasound (EUS) for further evaluation. DISCUSSION: Colorectal GCTs account for up to 25% of all GI GCTs, with most affecting the right sided colon (cecum and ascending colon). Mostly benign and solitary, but about 2% are known to have malignant potential with poor prognosis. More common in females and in African Americans between ages 40-60 years. Generally asymptomatic and found incidentally during a screening colonoscopy, however in a few cases, patients have presented with hematochezia, abdominal pain, and change in bowel habits. EUS is invaluable in differentiating GCTs from other subepithelial tumors, in determining the size, and depth of invasion. Definitive diagnosis is by histopathology and immunohistochemical staining. There is no general consensus on the management of colorectal GCTs. Conservative management is recommended for tumors &lt; 1cm, asymptomatic, with no deep tissue invasion or malignancy. However, resection is warranted for symptomatic tumors, tumors &gt;1 cm in size, deep tissue invasion or malignancy. Endoscopic removal is preferred over surgery for tumors without deep tissue infiltration or malignancy. Endoscopic and histologic surveillance every 1-2 years is recommended.

2019 Lower Gastrointestinal Bleeding Due to Sevelamer-Induced Colitis

INTRODUCTION: Acute lower gastrointestinal (GI) bleeding is uncommonly due to medication induced-colitis, reported in less than 6% of all lower GI bleeds. Identifying medications that may cause GI bleeding is particularly important in chronically ill patients at high risk for morbidity and mortality. A commonly used medication in patients with advanced renal disease is sevelamer, a phosphate binder in renal failure patients. CASE DESCRIPTION/METHODS: A 53-year-old female with end-stage renal disease presented with hematochezia for 2 days. She notes dark black stools for two weeks followed by rectal bleeding. Her past history is notable for a renal transplantation in 2008 with graft failure requiring hemodialysis. She has no history of NSAID use and her prior screening colonoscopy showed no evidence of colitis. Her medication list was extensive and included sevelamer and cinacalcet. The patient was hemodynamically stable. Initial labs showed a hemoglobin of 6.0 g/dl, baseline was 8.0-9.0 g/dl. She was resuscitated with intravenous fluids and received 2 units of blood. Next, the patient’s upper endoscopy showed gastric erythema only with no stigmata of recent bleeding. Her colonoscopy showed a macroscopically normal appearing colon however random biopsies revealed expansion of the lamina propria with significant population of increased eosinophils. Several crystals were embedded within the colonic mucosa and submucosa resembling sevelamer crystals. Based on the pathology, she was diagnosed with sevelamer-induced colitis and this medication was discontinued. Follow-up at 3 months showed the patient remained asymptomatic without further GI bleeding. DISCUSSION: Sevelamer is a common medication used in renal failure patients. It is a resin that binds and prevents absorption of phosphate within the GI tract and has been shown to cause GI issues such as nausea, vomiting and diarrhea. Rarely it can crystalize, become embedded in the GI tract and ulcerate and cause bleeding. A few case reports have described rectosigmoid ulceration and pseudotumor presentation of sevelamer induced colitis.1,2 Understanding and recognizing the potential for sevelamer-induced colitis is important with such a widely used medication.

2888 Hospitalization for Colonoscopy Preparation and Its Effects on Prep Quality

INTRODUCTION: Colonoscopy is the most commonly used method for colon cancer screening. The quality of prep greatly affects the examination. Risk factors for inadequate prep include prior inadequate prep, male gender, prior surgery, diabetes, low health literacy and cognitive delay. Studies have shown improvement in colonoscopy prep using split-dosing however despite this, inadequate prep continues to be a problem. One solution at our institution is to hospitalize selected patients with prior failed outpatient colonoscopy prep in an attempt to improve the prep quality. METHODS: We retrospectively identified all patients who were hospitalized for colonoscopy prep from 2016 to 2018. Patients who did not have documentation of prep quality were excluded. Data including age, gender, indication for procedure and presence of risk factors was gathered. The prior prep quality and prep quality after admission was documented. RESULTS: 122 patients were included in the study. “Screening” was the most common indication for the procedure. Most of the patients had at least one risk factor for inadequate prep. 90 patients had improvement in their prep quality. CONCLUSION: Bowel prep continues to be inadequate in up to 25% of examinations. Several patient related risk factors for inadequate prep have been identified in previous studies. Patients who have risk factors for slow bowel transit such as immobility, CVA and chronic use of narcotics can also be factors in colon prep. We believe the improvement in bowel prep in our study is related to adherence to dietary restrictions, accurate laxative consumption, and improved assessment of stool clearance. Our study also showed a significant number of improved bowel prep quality in patients who had risk factors for poor prep. The cost of hospitalization was not evaluated in our study. We believe that an adequate bowel would result in a longer time-interval for subsequent colonoscopies and reduced overall cost. Our study is limited given its retrospective design and small number of patients. In addition, given that our software does not allow use of the Boston Bowel Prep Scale, the results may be difficult to generalize to other populations. Repeat studies would be needed to assess cost effectiveness. Quality of bowel prep continues to be a barrier to high quality colonoscopy. This study shows that hospitalized bowel prep may help improve prep quality in a select group of patients in the underserved population and with known risk factors.

1479 Luminal Colonic Metastases From Primary Urothelial Carcinoma

INTRODUCTION: Urothelial carcinoma often manifests with painless gross or microscopic hematuria. Significant risk factors are mainly environmental including tobacco use, occupational exposures, and recurrent urinary tract infections. Metastatic disease often progresses via direct soft tissue invasion or lymphatic spread, with a paucity of reported cases of luminal colonic metastases. Here we describe a patient with concerning history for malignancy with multiple risk-factors, found to have luminal colonic metastases from primary urothelial carcinoma. CASE DESCRIPTION/METHODS: A 51 y/o African-American male with medical history significant for HFrEF 15%, HTN, tobacco and alcohol abuse presented for outpatient colonoscopy, referred by his primary care physician for 6-month history of diarrhea and 30 lb weight loss. No prior colonoscopy performed. Family history was significant only for lung cancer in his paternal uncle. Colonoscopy was initially attempted with adult colonoscope, but was exchanged for an adult endoscope following inability to traverse &gt;20 cm, secondary to thickened rectal folds also appreciated on rectal exam (Figure 1). Findings were significant for one 4 mm sessile polyp of the transverse colon and segmental moderately congested, erythematous mucosa throughout the entire colon (Figures 1 and 2). Pathology revealed new urothelial cancer with diffuse luminal colonic metastases. He completed staging work-up, found to have diffuse blastic, osseous bony metastases and was initiated on chemotherapy with further progression of his disease. DISCUSSION: Urothelial cancer often spreads via direct soft tissue invasion or lymphatic spread. Interestingly, our patient presented with advanced disease with atypical luminal colonic metastases, in the absence of direct invasion or soft tissue mass. The pathogenesis of metastasis remains unclear, but is likely related to lymphatic spread. In a thorough review of the literature, no other case of luminal colonic metastases from urothelial primary has been described. Any new change in bowel habit, warrants further evaluation with colonoscopy to rule out carcinoma of colonic or metastatic origin.