Rectal Stricture Research Articles

S3403 Sevelamer-Induced Colitis in a Patient With End-Stage-Renal-Disease Presenting as a Rectal Stricture

INTRODUCTION: Sevelamer, an intestinal phosphate binder used commonly in CKD (chronic kidney disease) patients for management of hyperphosphatemia, is not absorbed systematically and is excreted in feces. There have been several reported cases of sevelamer-induced colonic ulcers presenting mostly as hematochezia. CASE DESCRIPTION/METHODS: We present a 52-year-old male with history of end stage renal disease (ESRD) on sevelamer with a history of left lower abdominal pain and chronic severe constipation, without hematochezia, found to have an ulcerating rectal stricture with signs of inflammation and “fish scale” two-toned sevelamer crystals noted on rectal biopsy. He had a longstanding history of constipation from opioid abuse requiring fecal disimpaction under monitored anesthesia care (MAC). DISCUSSION: This case highlights the importance of cautious use of sevelamer in patients with a history of chronic constipation. Sevelamer crystal colitis thus may be considered as a potential cause of a benign rectal stricture.Figure 1.: Rectal mucosa (CM) with fish scales two-toned Sevelamer Crystals (SC) with signs of inflammation.Figure 2.: Colonoscopy showing rectal stricture.Figure 3.: CT abdomen showing rectal wall thickening and stool in rectum.

S1676 A Case of Rectal Primary Krukenberg Tumor

INTRODUCTION: Krukenberg Tumors (KTs) are secondary ovarian tumors defined as mucinous signet-ring cell carcinomas. Nearly 30% of ovarian tumors are metastatic in origin, with KTs accounting for 1–2% of all ovarian tumors. Worldwide, stomach is the primary site in most KT cases (70%), followed by colorectal and breast. However, in Europe and the USA, colorectal and breast cancers are the most common primary tumors metastasizing to the ovaries. KTs occur in 3–14% of women with colorectal cancer (CRC), with 20% arising from the rectum. The prognosis for KTs is poor, although CRC primary KTs appear to benefit from more aggressive treatment with cytoreductive surgery and post-adjuvant chemotherapy. We present a case of rectal primary KT to improve awareness of CRC KTs in the western population, as well the implications of histological type on management. CASE DESCRIPTION/METHODS: Our patient is a 48 year old African American female who underwent surgical resection of a 6.6cm complex right ovarian mass seen on MRI after having reported one year of abdominal pain, nausea, and progressive constipation. Ascites was noted prior to surgery. Final surgical pathology specimens demonstrated mucinous carcinoma with signet ring features. Immunohistochemical (IHC) evaluation was CK20+/CDX2+ and CK7-, suggestive of colorectal primary. Laboratory values were notable for CEA 1.0ng/mL, CA-125 44 U/mL, and the absence of iron deficiency anemia. An upper endoscopy was performed, ruling out gastric malignancy. A colonoscopy revealed a non-traversable malignant appearing stricture 15 cm from the anal verge with biopsies demonstrating poorly differentiated adenocarcinoma with signet cell features. Our patient was lost to follow up for several months as she explored alternative natural therapies before ultimately transitioning to hospice care with palliative FOLFOXIRI. DISCUSSION: CRCs are a relatively common primary source for KTs in the western population. While the median survival of patients with KTs is 14 months, there is a small but promising body of evidence that select patients with CRC primary KTs may have a survival benefit with optimal cytoreductive surgery and post-adjuvant chemotherapy. IHC markers may help identify the primary tumor, as the pattern of CK20+/CDX2+ and CK7- is classic for a colorectal primary. Our case serves to improve awareness of CRC primary KTs, and the unique treatment survival benefits for these patients.Figure 1.: MRI image of a 6.6cm complex right ovarian mass.Figure 2.: Invasive signet ring cells forming cords and nests within ovarian stroma (x40 hematoxylin and eosin stain).Figure 3.: Non-traversable rectal stricture 15cm from the anal verge.

S2266 Crohn’s Disease or Not

INTRODUCTION: Lymphogranuloma venereum (LGV) is a sexually transmitted disease due to Chlamydia trachomatis infection. It can present with symptoms and endoscopic features similar to Inflammatory Bowel Disease (IBD). We report a case of LGV proctitis initially diagnosed as Crohn’s disease. CASE DESCRIPTION/METHODS: A 52-year-old man developed rectal bleeding, 8-10 loose stools a day, abdominal pain and a 20 pound weight loss over 6 months. Perianal exam found large verrucous lesions typical for Crohn's disease and rectal exam demonstrated an anorectal stricture. CTE showed rectal wall thickening, with numerous enlarged lymph nodes. Diffuse severe inflammation edema, friability, erosions in distal sigmoid progressing to confluent ulcerations and luminal narrowing in the rectum was found on colonoscopy. Biopsy showed severe active colitis with ulceration, granulation tissue and focal changes of chronicity but without granuloma, dysplasia or viral inclusions. HIV was negative in 1999 and 2005. Prior to starting therapy for Crohn’s disease, the patient confided to having unprotected receptive anal intercourse in the past. HIV testing was positive with a CD4 count of 148 cells/mm. He was started on HIV medications. Serologic panel was positive for Chlamydia trachomatis (LGV) infection. He was treated with doxycycline for 21 days and his symptoms markedly improved. He is well without GI symptoms 6 months after LGV treatment and on maintenance HIV medications. DISCUSSION: LGV is a genital ulcerating disease caused by Chlamydia trachomatis. It is rare in Europe and North America found mostly in HIV-positive men who have sex with men. LGV commonly presents with manifestations similar to inflammatory bowel disease including rectal bleeding, frequent bowel movements, tenesmus and ano-rectal pain. If untreated, patients may develop rectal strictures and fistulae. On endoscopy, erythema, friability and ulceration have been described. On rectal biopsy, inflammation, crypt abscesses, granuloma formation and transmural inflammation are found making it difficult to differentiate from IBD. The diagnosis of LGV depends on clinical presentation and identification of risk factors. Nucleotide amplification test can help make a diagnosis; PCR can help with differentiating specific chlamydia serotypes. A 21 day course of doxycycline 100 mg PO twice daily is the preferred treatment. LGV infection should be considered in the differential diagnosis of inflammatory bowel disease involving the rectum.Figure 1.: CTE showing rectal wall thickening, with numerous enlarged lymph nodes.Figure 2.: Colonoscopy demonstrating diffuse severe rectosigmoid inflammation.Figure 3.: Biopsy showed severe active colitis with ulceration and granulation tissue.

Postoperative "complications" following laparoscopic-assisted anorectoplasty: A systematic review.

This study reviewed the literature on the postoperative complications following laparoscopic-assisted anorectoplasty (LAARP). A Medline and Embase search was performed for the terms "anorectal malformation" (ARM) "laparoscopic" and "complication". Articles without English full text, review articles, systematic reviews, case reports, case series < 5 cases and duplicate articles were excluded. Two reviewers independently performed the eligibility assessment and data extraction. Data were collected for type of malformation, surgical technique, postoperative complications and functional outcomes RESULTS: The search retrieved 108 articles, of which 38 met the inclusion criteria and offered 1058 patients for analysis. Rectoprostatic and rectobladder neck fistula were the most common types of ARM in males, whereas it was the common cloaca in females. Analysis of complications demonstrated rectal prolapse (n = 149; 14.08%) being the most prominent, followed by urethral diverticulum (n = 32; 3.02%), anal stenosis (n = 37; 3.49%), recurrent fistula (n = 7; 0.66%) and rectal stricture (n = 4; 0.37%). Krickenbeck classification was used for functional assessment in 638 patients, with fecal soiling grade 2 or > 2 in 79. Data on functional outcome specific to the type of malformation was available for 246 patients: fecal soiling grade 2 or > 2 in 15/94 (15.95%) with rectoprostatic fistula, 26/73 (35.61%) with rectobladder neck fistula, 6/47 (12.76%) with common cloaca, and 1/22 (4.54%) with no fistula. Rectal prolapse, posterior urethral diverticulum and anal stenosis are the most common complications after LAARP. Inconsistent and non-uniform functional assessment and non-availability of information about the sacrum and spine make it difficult to analyze the functional outcome following LAARP.

Perianal Crohn's Disease in Children and Adolescents.

The incidence of Crohn's disease is increasing worldwide. The clinical course of childhood onset Crohn's disease is particularly aggressive with characteristic disease localization in the ileocecal region and colon, often associated with perianal disease. Severe complications of perianal disease include recurrent perianal sepsis, chronic fistulae, fecal incontinence, and rectal strictures that impair quality of life and may require fecal diversion. Care of patients with perianal Crohn's disease requires a multidisciplinary approach with systematic clinical evaluation, endoscopic assessment, and imaging studies followed by combined medical and surgical management. In this review, we provide an update of the epidemiology, pathophysiology, diagnostics, and management of perianal Crohn's disease in children and adolescents.

An experience of colonic stent placement using a proximal release type stent

We report the japan's first experience of proximal release type colonic stent designed at our department, for malignant stenosis of the lower rectal stricture by peritoneal dissemination of gastric cancer. A 50s female developed malignant rectal obstruction during chemotherapy for peritoneal dissemination following the surgery for gastric cancer, and she was referred to our hospital for colonic stent placement. On admission, her colorectal obstruction scoring system (CROSS) score was 0, and decompression had been performed by transanal urethral balloon catheter placement at the former institution. For the colonic stent placement, via the same catheter, a 0.035 inch Fr RevoWave ultra-hard guidewire was placed, and after endoscopic observation and fluoroscopic imaging, a marking clip was placed, and then a Niti-S colonic stent- proximal stent 22×70 mm was placed. There were no complications observed during stent placement, and the following day, oral intake was started and transferred to her previous clinic for ongoing chemotherapy. For the stent placement for rectal stricture, if the distal edge of the stent locate touch to the dentate line, it willhighly likely cause of pain, and thus it is important to select the appropriate stent length while taking into account the length of stenosis as well as the distance from the anal verge. In addition, it is also important that the stent placement site is neither excessive nor insufficient. The presently developed proximal release type stent enables the distal side of the stent position to accurately match the marking clip, and we believe that it will be useful in stent placement for malignant stenosis of the lower rectum. The ColoRectal Obstruction Scoring System (CROSS) of the Japan Colonic Stent Safe Procedure Research Group is available to the public on their home page (http://colon-stent.com). This group recommends the CROSS, an objective score, to evaluate the patient's condition preoperatively, and to indicate and evaluate decompression methods.

Ultrasonography for bowel endometriosis.

Transvaginal ultrasonography (TVS) should be the first-line investigation in patients with suspicion of deep endometriosis and, in particular, of rectosigmoid endometriosis. TVS cannot assess the presence of intestinal nodules located proximally to the sigmoid (such as ileal or cecal endometriotic nodules), because these lesions are beyond the field of the transvaginal probe. The ultrasonographic findings of rectosigmoid endometriosis are the presence of an irregular hypoechoic nodule in the anterior wall of the rectosigmoid colon. The learning curve for diagnosing rectosigmoid endometriosis by TVS is quite short; approximately, 40 scans are required to a sonographer who trained in general gynecologic ultrasonography to become proficient at diagnosing bowel endometriosis. Several meta-analyses confirmed the high diagnostic performance of TVS in diagnosing rectosigmoid endometriosis. The presence of "soft markers" (negative sliding sign and kissing ovaries) facilitates the diagnosis of rectosigmoid endometriosis. Enhanced TVS (rectal water-contrast transvaginal ultrasonography, sonovaginography, and tenderness-guided transvaginal ultrasonography) does not improve the performance of TVS in diagnosing rectosigmoid endometriosis. These investigations, however, may be useful to ascertain the depth of infiltration of endometriosis in the intestinal wall or the presence of rectal stenosis. Magnetic resonance imaging has the same performance of TVS in diagnosing rectosigmoid endometriosis; however, it should be recommended as a second-line technique in the preoperative workup of patients with previous equivocal TVS findings.

Deep endometriosis: The place of laparoscopic shaving.

Deep endometriosis (DE) is considered to be one of the most challenging conditions to manage, especially when it invades surrounding organs like the rectum. Surgical excision of deep rectovaginal endometriosis is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions, or if they evolve. Preoperative radiological examination should be extensive to determine the appropriate surgery: laparoscopic shaving, disc excision, or rectal resection. We demonstrated that in the hands of experienced surgeons, rectal shaving is possible for DE in more than 95% of cases, with low complication rates compared to rectal resection. Shaving and bowel resection are associated with comparable recurrence rates. As shaving is indicated whatever the size of deep lesions, surgeons should first consider rectal shaving to remove DE. Bowel resection should only be performed in case of major rectal stenosis (>80%), multiple and/or posterior rectal lesions and stenotic sigmoid colon lesions.

A newly designed over-the-scope-clip device to prevent fully covered metal stents migration: A pilot study

BackgroundFully covered self-expandable metal stents (FCSEMS) have increasingly been used in the endoscopic management of malignant and benign gastrointestinal diseases.The main limitation of FCSEMS is the risk of migration, occurring in at least one-third of patients.Different methods have been employed for anchorage of esophageal stent, as external fixation with endoscopic snare and internal fixation using both through-the-scope (TTS) and over-the scope (OTS) clips to fix the upper flared end of the FCSEMS to the esophageal mucosa.A new designed over-the-scope device called Stentfix OTSC® System (AG-Tuebingen– Germany), has been developed to avoid migration. It consists in a Nitinol clip preloaded on the applicator cap used to clip the flared end of FCSEMS to the gastrointestinal mucosal layer AimsTo evaluate the clinical outcomes of patients treated with Stentfix device. MethodsFive consecutive patients (median age: 58 years; males, 80%) were enrolled. All patients had experienced FCSEMS migration. The OTSC device was placed to prevent further stent migration. ResultsTechnical and clinical success was achieved in all patients. In one patient with a benign rectal anastomotic stricture long-term luminal patency was achieved after stent placement. One patient died of causes unrelated to endoscopic procedures.The other patients are still being followed. Dysphagia improvement of at least 1 point was seen in these patients. ConclusionsThe StentfixOTSC® System appears to be a useful and safe device in the preventing FCSEMS migration in a variety of clinical scenarios.

Posterior rectal pouch after large full-thickness disc excision of deep endometriosis infiltrating the low/mid rectum and relationship with digestive functional outcome

IntroductionThe aim of our study is to describe MRI appearance of a posterior rectal pouch (PRP) for patients managed for low rectal endometriosis by large full-thickness disc excision and to assess its relationship with postoperative functional digestive symptoms. Material and MethodsSingle center retrospective study including patients managed by low/mid rectal disc excision using a semi-circular stapler (the Rouen technique) from June 2009 to October 2016. Intraoperative findings and data provided by standardized gastrointestinal self-questionnaires (GIQLI, KESS, Wexner and Bristol), before and 1 year after the surgery, were prospectively recorded. Postoperative pelvic MRI were reviewed and PRP was assessed in three planes and its volume was estimated on a 3D T2 weighted sequence. ResultsEighteen patients were included in the study. All patients had postoperative PRP while none of them presented with rectal stenosis. The mean (± SD) volume of the PRP was estimated at 66 ± 32 mL. The mean antero-posterior diameter was 56 mm ± 22 mm, mean height at 44 mm ± 15 mm and mean width at 46 mm ± 11 mm. No positive correlation between the volume of the PRP and the GIQLI questionnaire was found at one year after surgery (r = −0.24, 95%CI -0.51−0.69, p = 0.44). ConclusionLarge disc excision of low and mid rectum leads to a posterior rectal pouch, with no significant impact on postoperative functional digestive outcomes, but it is not followed by bowel stenosis.

Balloon dilation of a congenital rectal stricture in a 16‐week‐old kitten

A 16‐week‐old Persian kitten was referred for investigation of constipation and failure to grow. The owner reported that the kitten had always strained to defecate. Abdominal radiographs confirmed megacolon and CT pneumocolography confirmed the presence of a caudal rectal stricture. During a single procedure and under fluoroscopic guidance, the stricture was effaced by sequentially dilating 10‐mm and 15‐mm balloons. Shortly after discharge, the owner reported complete resolution of clinical signs and oral laxatives were stopped. Repeat radiographs 1 month post dilation showed resolution of the diffuse megacolon and the cat appeared well and had gained weight. This is the first report of a congenital rectal stricture in a kitten and one of the few reports documenting balloon dilation for the treatment of stenotic anorectal lesions (congenital or acquired) in cats.

Balloon dilation with triamcinolone intralesional injection successfully treated rectal stricture in a three-month kitten

This report describes a three-month-old Korean domestic kitten presented with dehydration and poor body condition. Physical examination revealed abdominal distension. Rectal diagnosis was unachievable due to the small rectum diameter. X-ray radiography and endoscopy confirmed presence of abdominal distension and indicated a stricture located 1.5 cm from the anus. A balloon was gently inserted into the rectum and inflated several times followed by triamcinolone injection. Four months later, same procedures were repeated. This report is the first to describe the use of balloon dilation of a rectal stricture followed by intralesional triamcinolone injection in a small cat with poor condition. Keywords: balloon dilation, cat, rectal administration, intralesional injection, triamcinolone

Endoscopic submucosal dissection involving the anal canal presents a risk factor for postoperative stricture.

Although postoperative strictures after endoscopic submucosal dissection (ESD) in the rectum are relatively rare, some rectal lesions require resection involving the anal canal, which is a narrow tract comprising squamous epithelium. To the best of our knowledge, no studies have investigated narrow anal canals when evaluating post-ESD strictures. This study aimed to evaluate the impact of resections involving the anal canal on postoperative stricture development. Between April 2005 and October 2017, 707 rectal lesions were treated with ESD. We retrospectively investigated 102 lesions that required ≥ 75% circumferential resection. Risk factors for post-ESD stricture and, among patients with strictures, obstructive symptoms, and number of dilation therapies required were investigated. Post-ESD stricture occurred in 18 of 102 patients (17.6%). In the multivariate analysis, circumferential resection ≥ 90% and ESD involving the anal canal (ESD-IAC) were risk factors for postoperative strictures (P ≤ 0.0001 and 0.0115, respectively). Among the patients with strictures, obstructive symptoms were significantly related to anal strictures compared to rectal strictures (100% vs. 27.2%, P=0.0041). Furthermore, the number of dilation therapies required was significantly greater among patients with anal strictures compared to those with rectal strictures (6.5 times vs. 2.7 times, P=0.0263). Not only circumferential resection ≥ 90% but also ESD-IAC was a significant risk factor for the stricture after rectal ESD. Furthermore, anal strictures were associated with a significantly higher frequency of obstructive symptoms and larger number of required dilation therapies than were rectal strictures.

The Importance of Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Predicting the Appearance of the Rectal Stenosis or Rectal Obstruction in Patients with Rectal Adenocarcinomas

The purpose of this study was to establish a correlation between markers of inflammation and the risk of rectal stenosis or obstruction, in patients with rectal adenocarcinomas. We performed a retrospective observational study on 188 patients diagnosed with rectal adenocarcinomas. We attempted to establish a correlation between the neutrophils to lymphocyte ratio(NLR), platelet to lymphocyte ratio(PLR) levels and the presence of rectal stenosis or rectal obstruction. From 188 patients included in the study, 65 patients had stenotic tumors (34.57% of cases) and 10 patients had occlusive tumors (5.31% of cases). We obtained a statistically significant correlation between the blood levels of neutrophils, lymphocytes, platelets, and the existence of rectal stenosis. (p[0.05). The cutoff value of NLR that correlates with the presence of rectal stenosis was 2.5 (95% CI: 0.426-0.574, AUC: 0.500). As for PLR, the cutoff value correlated with the presence of rectal stenosis was 106,522 (95%CI: 0.428-0.575, AUC: 0.502). We established a statistically significant correlation between NLR, PLR and rectal obstruction (p[0.05). The cutoff value of the NLR that correlates with the presence of rectal obstruction was 4.633 (95%CI: 0.614-0.751, AUC: 0.685). As for PLR, the cutoff value correlated with the presence of rectal stenosis was 345.05 (95% CI: 0.673-0.803, AUC: 0.742). Our study shows that there is a statistically significant correlation between NLR and PLR and the risk of rectal obstruction in patients with adenocarcinomas. It is still necessary to conduct prospective studies on much larger lots of patients to determine the NLR and PLR values that can predict rectal stenosis as well as rectal obstruction.

THE COMBINATION OF EXTERNAL RADIATION THERAPY WITH HIGH DOSE RATE BRAHYTERAPY BOOST FOR PROSTATE CANCER: A COMPARATIVE CHARACTERISTIC OF TWO FRACTION MODES

The purpose of the study was to analyze treatment outcomes in prostate cancer patients, who received external radiotherapy combined with high dose rate (HDR) 198 Ir brachytherapy boost of 10 Gy in 2 fractions or 15 Gy in 1 fraction. Material and methods. Between July 2012 and June 2017, 98 patients with prostate cancer received radiation therapy at N.N. Petrov National Medical Research Center of Oncology (St-Petersburg, Russia). Intensitymodulated radiation therapy (IMRT) at a total dose of 46–50 Gy was delivered to the prostate, seminal vesicles and regional lymph outflow areas (RTOG, 2009). The patients were then divided into 2 groups. Group I patients (81 patients, 82.7 %) received HDR brachytherpy boost of 10 Gy in 2 fractions, Group II patients (17 patients, 17.3 %) received HDR brachytherpy boost of 15 Gy in 1 fraction. Inclusion criteria were: high or extremely high risk of relapse according to NCCN (2010), no evidence of distant metastases and no evidence of pronounced urinary tract disorders (residual urine volume less than 50 ml, IPSS less than 17 points, maximum urination rate ≥10 ml / sec). Assessment of radiation-induced complications (toxicity) was carried out in accordance with generally accepted RTOG / EORTC (1995) criteria and taking into account the terminological recommendations of CTCAE v 4.0 (2009). Results. The median follow-up time was 39.2 [30.7; 48.7] (20.3–69.8) months in Group I and 37.0 [30.9; 47.9] (23.7–50.7) months in Group II. The 3-year disease-free survival rate in the study groups regardless of the boost was 77.1 % (75.9 % in Group I and 77.8 % in group II, p=0.7). The 3-year disease-free survival rates in patients with high and extremely high risk regardless of the radiotherapy regimen were 88.6 % and 70.8 %, respectively (р=0.04). Genitourinary early radiation toxicity and rectal intestinal early radiation toxicity of grade 3 were observed in 13.5% and 12.3 % of Group I patients and in 17.6 and 5.9 % of Group II patients. The most significant late complications were the formation of urethral stricture (1 patient of group I) and postradiation rectal stenosis (1 patient of group II). Evaluation of the level of erectile function in both groups showed a significant decrease in satisfaction with the quality of sexual life, which, apparently, can be explained not only by radiation damage to the structures responsible for hemodynamics of the penis, but also by castration syndrome due to prolonged hormonal deprivation in the vast majority of patients. Conclusion . The combination of external beam radiation therapy with HDR brachytherapy boost is an effective method of radical treatment of prostate cancer patients with high and extremely high risk of recurrence.

Zinner’s Syndrome – The Value of Clinical Imaging and Morphopathological Findings for Diagnosis

Abstract Introduction: Cystic congenital malformations of the seminal vesicle are unusual. More than half of them are associated with ipsilateral renal agenesis. This disease was first described by Zinner in 1914, and since then, more than 200 cases have been reported. Most of the patients with this congenital disease present few symptoms until the middle-age. Case presentation: A 61-year-old male was referred to the Urology Clinic with intermittent pain and sensibility in his lower left abdomen in the last 12 months accompanied by intermittent bowel obstruction. The digital rectal examination could not assess the prostate due to a rectal stenosis. On computed tomography and magnetic resonance imaging (MRI) a cystic tumor with close relations with the bladder wall and prostate, associated with left kidney agenesis was identified. The cystic tumor was surgically removed. The histopathological examination of the tumor revealed a multilocular seminal vesicle cyst, with a muscular wall. Conclusions: Seminal vesicle cysts combined with ipsilateral renal agenesis are rare urological anomalies. Imaging allows a comprehensive investigation of renal and seminal vesicle anomalies. MRI seems to better visualize cysts and differentiate them from ureteroceles, while the histopathological examination contributes to a correct diagnosis. A multidisciplinary team (urologists, radiologists, and morphologists) is necessary for the proper diagnosis of Zinner’s syndrome.

Clinico-etiological spectrum of constipation in children

Background: Childhood constipation is a common problem that has been difficult to define because it may comprise of diverse symptoms, from delay or difficulty in defecation sufficient to cause significant distress, to symptoms of faecal incontinence, displaying of retentive posturing and withholding behaviour to painful defecation and passing of stools so large that they may obstruct the toilet. Knowledge of common etiology of constipation and characteristic presentation may help us in initial management of patient without subjecting them to armour of investigation.Methods: The prospective interventional analytical study conducted in the Department of Surgery and Department of Pediatrics Pt. J.N.M. Medical College and Dr. B.R.A.M Hospital, Raipur (Chhattisgarh), India. Consecutive 81 children with constipation presenting to OPD of pediatrics and pediatric surgery at Dr B.R.A.M Hospital, Raipur (Chhattisgarh), India between January 2010 to January 2011 were included in the study.Results: Mean age at presentation was found overall to be 54.49±10.85 months. Presentation of constipation in boys and girls (44% vs 56% in functional and 54% vs 46% in organic). Of the organic causes Hirschsprung’s disease was the commonest diagnosis made (63%). Other organic causes were Rectal stenosis with anteriorly placed anal canal (1.2%), rectal prolapsed (1.2%), anal fissure (1.2%) and associated with dysgerminoma in pelvic cavity in one case.Conclusions: Assessment and management of pediatric constipation poses many challenges for the practitioner including deciphering whether the problem is organic or non-organic in nature.

2195 Expanding Therapeutic Options for Ileocecal Valve and Rectal Strictures With Lumen-Apposing Fully Covered Metal Stents

INTRODUCTION: Radiation-induced and Crohn’s-related colonic strictures are debilitating conditions requiring intensive serial endoscopic dilations or surgery. Use of colonic stents in benign strictures are limited by migration risk, lack of removability, and technical difficulties in placement. This is especially true of ileocecal valve (ICV) strictures given the anatomically challenging location and short stents are preferred. We report the cases of an ICV and distal rectal stricture, refractory to endoscopic dilation, that underwent successful lumen apposing fully covered metal stent (LAMS) placement. CASE DESCRIPTION/METHODS: A 32-year-old African American male with a history of Crohn’s disease complicated by ICV stenosis causing recurrent partial small bowel obstruction, was admitted with worsening nausea, vomiting, and abdominal pain. An abdominal CT showed dilated distal ileum to 4 cm with associated fecalization consistent with partial small bowel obstruction. A colonoscopy with balloon occlusion enterography confirmed a short &lt;1 cm severe ICV stricture with non-inflamed colonic mucosa. He opted for an endoscopic dilation to 10 mm with good clinical response but this only lasted for 2 weeks. A stent placement was then performed using a 15 mm × 10 mm LAMS (Figure 1). His abdominal pain markedly improved with radiologic resolution of the small bowel obstruction. A 55-year-old African American female with a history of pelvic radiation for cervical cancer presented with tenesmus and alternating constipation and diarrhea. Barium enema and flexible sigmoidoscopy showed a focal rectal stricture at 10 cm proximal to the anal verge. She underwent serial endoscopic dilations up to 12-mm over a span of 6 months with no significant clinical response and the stricture kept recurring despite 2-3 week intervals between dilations. Ultimately, a 15 mm × 10 mm LAMS was placed (Figure 2). At 8-weeks, her tenesmus and post-constipation diarrhea were completely resolved. DISCUSSION: Our cases demonstrate the feasibility and efficacy of LAMS placement for refractory high-grade strictures even at anatomically challenging locations. LAMS was preferred here due to its removability and short length that could optimally fit in the ICV and distal rectum with an aim to minimize risk of stent migration due to its dumbbell configuration. However, the stricture site has to be reachable by a therapeutic gastroscope. Optimal duration for stent indwelling and risk of restenosis after stent removal remain unclear and warrant further study.

2044 Metastatic Breast Cancer: Another Crohn’s Mimic?

INTRODUCTION: In the US, breast cancer (BC) is the 2nd most common cancer diagnosed in women. Approximately 30% of women diagnosed with BC develop metastatic disease. Usually, it spreads to the liver, brain, bones and lungs; rarely it spreads to the GI tract. We present a case of metastatic breast cancer (MBC) to the GI tract that initially mimicked Crohn’s disease. CASE DESCRIPTION/METHODS: A 66 yo female with a history of right-sided, invasive, lobular BC, s/p lumpectomy, radiation, and adjuvant hormonal therapy presented to her physician with complaints of irregular bowel habits and reflux. An EGD revealed a hiatal hernia and inflammation of the antrum with normal biopsies. A colonoscopy revealed abnormal rectal mucosa with edema, friability and narrowing; biopsies showed prolapse-type changes. Due to progressive and worsening symptoms, a flexible sigmoidoscopy was done. This revealed raw and inflamed tissue in the distal rectum with severe stricturing, requiring dilatation. Repeat biopsies were unremarkable. Crohn’s disease was in the differential as the responsible etiology for the rectal stricture; thus, an MR enterography was done. Multiple skip lesions throughout the GI tract, consistent with Crohn’s disease, were demonstrated and mass-like thickening (without inflammatory changes) in the antropyloric region was also evident (Figure 1). EGD/EUS revealed pyloric stenosis with a thickened and edematous pylorus and duodenal bulb (Figure 2), and hypoechoic tissue in the muscularis propria of the distal antrum/pylorus. FNA and mucosal biopsies were nondiagnostic. Repeat colonoscopy demonstrated a significant distal rectal stricture without mucosal abnormalities. Repeat biopsies, this time, demonstrated poorly differentiated MBC with IHC staining consistent with the patient’s previous lobular mammary carcinoma (Figure 3). The patient subsequently underwent an ex-lap gastrojejunostomy and was found to have a large bulky mass on the serosal surface of her pylorus and duodenum. She is currently on salvage therapy for MBC. DISCUSSION: Our case demonstrates that diagnosing MBC to the GI tract may prove evasive. In a patient with a history of BC and persistent/worsening GI symptoms, it is imperative that one keeps the differential broad and includes MBC to the GI tract as a real possibility. Early endoscopic evaluation with biopsies and appropriate IHC staining of samples should be performed in suspected cases. MBC should be on the list of etiologies that can mimic Crohn’s disease.

Transanal rectal resection for rectal stricture following antibiotic‐induced colitis – a video vignette

Transanal rectal resection for rectal stricture following antibiotic‐induced colitis – a video vignette