Rectosigmoid Area Research Articles

Early Outcomes of Hirschsprung's Disease after Definitive Surgery: A Ten-Year Experience.

This study aimed to examine the characteristics of Hirschsprung's Disease (HD) in patients aged<18 who underwent surgical procedure at Dr. Zainoel Abidin (RSUDZA) General Hospital, Banda Aceh, Indonesia, between January 2010 and December 2020. This retrospective study collected and analyzed data from medical records of 18-yearold or younger children (n = 180) diagnosed with HD at RSUDZA. The surgical procedures included the Duhamel procedure, Soave procedure, the Soave Transanal Endorectal Pull-through (TEPT) procedure, and the Swenson TEPT procedure. Early outcomes of the surgery were then compared between males and females. The comparrative analysis was determined based on Chisquare analysis, where p&#60; 0.05 was considered significant. There were 111 (61.7%) male patients and 69 (38.3%) female patients, with a mean age of 15.2 months. The Soave TEPT is the most frequently performed procedure (91.7%). Emerging clinical manifestations include constipation (176; 97.8%) and soiling (171; 95%). Preoperative barium enema and postoperative pathological examination confirmed that almost all patients (99.4%) had an aganglionic segment confined to the rectosigmoid area. The average length of operation was 69.7 ± 65 minutes and average bleeding time was 5.4 ± 34 mL. The average discharge time was 3.3 ± 73.3 days. No significant difference was found in post-surgery complications between males and females (p&#60;0.5). The immediate complications were not associated with surgical methods (p = 0.83). Our descriptive study has suggested the Soave TEPT technique as appropriate to manage HD.

Case Report of Multiple Rectosigmoid Adenomatous Polyps and Its Management i.e. Transanal Endoscopic Microsurgery

Adenomatous polyps in the colorectal region are prevalent. On account of its rarity and effective excision using Transanal Endoscopic Microsurgery (TEM) with assistance from a Covidien Small Incision Laparoscopic System (SILS) Port, we present this case of an adenomatous polyp wherein the patient complaints of per rectal bleed. Most frequently asymptomatic, adenomatous polyps are the most prevalent. In the present case, five to six polyps were found in the rectosigmoid area during colonoscopy. Rectal bleeding, stomach pain, and changes in bowel function that have a high malignant potential are the most typical symptoms associated with polyps. Large rectal adenomas should only be treated with TEM at this time, and traditional Trans Endoscopic (EMR/ESD) should be stopped. Despite the availability of newer procedures like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), TEM is still the method of choice. TEM is not recorded in our country up till now. This is the first time it is performed in our country. Keywords: Adenomatous Polyp; Transanal Endoscopic Microsurgery; Small Incision Laparoscopic System; Endoscopic Mucosal Resection; Endoscopic Submucosal Dissection

Metastatic Cervical Cancer Presenting as a Sessile Polyp in the Ascending Colon

Patients with metastatic cervical cancer, particularly hematogenous metastasis, have a worse prognosis compared to those with localized cervical cancer. Gastrointestinal involvement of cervical cancer occurs in approximately 8% of cases and most lesions are located in the recto-sigmoid area due to direct extension of the disease. Here, we present a case of cervical adenocarcinoma spreading to the ascending colon as a sessile polyp and mimicking a hyperplastic polyp. Histopathological evaluation followed by immunohistochemistry analysis is needed to confirm the diagnosis.

Characteristics and risk factors for colorectal polyps among children in an urban area of Wenzhou, China: a retrospective case control study

BackgroundScarce evidence exists on pediatric colorectal polyp risk factors. This study explored the clinical manifestations, morphological and pathological characteristics of, and risk factors for pediatric colorectal polyps.MethodsThis retrospective case-control study included children who received colonoscopy, divided into a colorectal polyp group and a normal control group based on colonoscopy results. The risk factors for colorectal polyps in children were analyzed through logistic regression analysis.ResultsThe mean age of children with polyps was 6.77 ± 3.44 years. Polyps were detected predominantly in males (72.9%); hematochezia was the primary clinical manifestation (80.25%). Most polyps were juvenile (88.9%) and solitary (87.7%); 50.6% were located in the rectosigmoid area. Univariate analysis showed that gender (P = 0.037), age (P < 0.001), family aggregation (P < 0.001), specific immunoglobulin E (sIgE) (P < 0.001), platelet count (P = 0.001), aspartate aminotransferase (AST) (P = 0.016), meat intake (P = 0.010), and vegetable intake (P < 0.001) were significantly associated with colorectal polyps. Age ≤ 6 years (3–6 years: OR: 26.601, 95% CI: 3.761–160.910; < 3 years: OR: 22.678, 95% CI: 1.873–274.535), positive family aggregation (OR: 3.540, 95% CI: 1.177–10.643), positive sIgE (OR:2.263, 95% CI: 1.076–4.761), and higher meat intake (OR:1.046, 95% CI: 1.029–1.063) were risk factors for pediatric colorectal polyps in logistic regression analysis. Higher vegetable intake (OR: 0.993, 95% CI: 0.986–1.000) was a protective factor against pediatric colorectal polyps. The area under the curve (AUC) of meat intake in the receiver operating characteristic (ROC) curve analysis for predicting colorectal polyps was 0.607; the best cut-off value was 92.14 g/d (P = 0.010, 95% CI: 0.527–0.687). The meat and vegetable intake combination AUC in predicting pediatric colorectal polyps was 0.781 (P < 0.001, 95% CI: 0.718–0.845).ConclusionsJuvenile, solitary, and located in the rectosigmoid region polyps are most common in children. Hematochezia is the main clinical manifestation. Most polyps were, but multiple and proximally located polyps were also detected. Age ≤ 6 years, especially 3–6 years, positive family aggregation, positive sIgE, and higher meat intake are risk factors for pediatric colorectal polyps. A higher vegetable intake is a protective factor.

PTEN hamartoma tumour syndrome: case report based on data from the Iranian hereditary colorectal cancer registry and literature review

BackgroundPTEN hamartoma tumour syndrome (PHTS) is a rare hereditary disorder caused by germline pathogenic mutations in the PTEN gene. This study presents a case of PHTS referred for genetic evaluation due to multiple polyps in the rectosigmoid area, and provides a literature review of PHTS case reports published between March 2010 and March 2022.Case presentationA 39-year-old Iranian female with a family history of gastric cancer in a first-degree relative presented with minimal bright red blood per rectum and resistant dyspepsia. Colonoscopy revealed the presence of over 20 polyps in the rectosigmoid area, while the rest of the colon appeared normal. Further upper endoscopy showed multiple small polyps in the stomach and duodenum, leading to a referral for genetic evaluation of hereditary colorectal polyposis. Whole-exome sequencing led to a PHTS diagnosis, even though the patient displayed no clinical or skin symptoms of the condition. Further screenings identified early-stage breast cancer and benign thyroid nodules through mammography and thyroid ultrasound.Method and results of literature reviewA search of PubMed using the search terms “Hamartoma syndrome, Multiple” [Mesh] AND “case report” OR “case series” yielded 43 case reports, predominantly in women with a median age of 39 years. The literature suggests that patients with PHTS often have a family history of breast, thyroid and endometrial neoplasms along with pathogenic variants in the PTEN/MMAC1 gene. Gastrointestinal polyps are one of the most common signs reported in the literature, and the presence of acral keratosis, trichilemmomas and mucocutaneous papillomas are pathognomonic characteristics of PHTS.ConclusionWhen a patient presents with more than 20 rectosigmoid polyps, PHTS should be considered. In such cases, it is recommended to conduct further investigations to identify other potential manifestations and the phenotype of PHTS. Women with PHTS should undergo annual mammography and magnetic resonance testing for breast cancer screening from the age of 30, in addition to annual transvaginal ultrasounds and blind suction endometrial biopsies.

S152 Gastrointestinal Tract Injuries Associated With Sevelamer: A Systematic Review

Introduction: Sevelamer is a phosphate binder that is used to treat hyperphosphatemia in patients with chronic kidney disease. Sevelamer is known to cause multiple gastrointestinal side effects including nausea, vomiting, constipation, and abdominal pain. However, sevelamer crystals were observed in rare cases in the gastrointestinal tract (GIT) with associated serious injuries including inflammation, ulceration, ischemia, and perforation. In this study, we conducted a systematic review to investigate the association of sevelamer with GIT injuries. Methods: We conducted a systematic search in MEDLINE, EMBASE, Scopus, and Cochrane Central Register of Controlled Trials to identify eligible reports of sevelamer-associated gastrointestinal tract injuries. The bibliographies of identified articles, Goggle scholars, and websites of relevant professional associations were also searched for relevant studies. Two independent reviewers identified eligible studies and data were extracted in Excel. Only studies that had sevelamer crystals seen in the histopathological exams were included. (Table) Results: We included 58 studies describing a total of 77 patients with a mean age of 58.8 years. Diabetes was present in 27% of cases and at least one risk factor to have slow GIT motility was identified in 63.3% of patients. Both sevelamer carbonate and sevelamer hydrochloride were reported to be associated with GIT injury. Gastrointestinal bleeding (44.2 %) and abdominal pain (37.7 %) were the most common presenting symptoms. The large intestines were the most common area of involvement (74 %), especially in the rectosigmoid area (36.4 %). Ulceration (52 %) and inflammation (48.1 %) were the most common histopathological findings. Stopping sevelamer was the most common pharmacological intervention. 20.8% of patients required surgical intervention, while 6.5% had an endoscopic intervention. Full recovery was reported in 45.5% while 6.5% of patients died. Conclusion: While sevelamer crystals can be found incidentally in the mucosa of the GIT, there is growing evidence that sevelamer use can be associated with GIT injury. Slow GIT motility can be an important risk factor to develop sevelamer-associated GIT injury. If a GIT injury was found during endoscopy and sevelamer crystals were identified on histopathological exam, discontinuing sevelamer and using an alternative phosphate binder should be considered. Further studies are needed to identify risk factors and the best approaches for primary and secondary prevention. Table 1. - Characteristics of included studies GIT: gastrointestinal tract, GIB: Gastrointestinal bleeding Demographics Age (years)Malesfemales 58.88 ± 10.934 (44.2 %)35 (44.5 %) Comorbidities DiabetesConstipationPrevious abdominal surgeryBlood thinnersPossible Slow GIT motility 27 (35.5 %)4 (5.2 %)15 (19.5 %)16 (20.8 %)49 (63.3%) Sevelamer treatment Sevelamer carbonateSevelamer hydrochlorideBothAverage doseMedian doseDuration 16 (20.8 %)12 (15.6 %)1 (1.3%)4,176.29 mg3,200.00 mg5 days – 7 years Symptoms GIBAbdominal painDiarrheaNausea/vomitingEsophageal dysphagia 34 (44.2 %)29 (37.7 %)12 (15.6 %)10 (13%)1 (1.3%) Location of GIT injury EsophagusStomachSmall IntestinesIleocecal valveLarge intestinesCecum and/or ascending colonTransverse ColonDescending colonRectosigmoidDiffuse colonic or unspecifiedAppendix 8 (10.4 %)8 (10.4 %)3 (3.9 %)3 (3.9 %)57 (74 %)8 (10.4 %)7 (9.1 %)1 (1.3%)28 (36.4 %)15 (19.5 %)2 (2.6 %) Histopathological abnormalities* UlcerationInflammationPerforationNecrosisIschemiaStrictureInflammatory polyp 40 (52 %)37 (48.1 %)14 (18.2 %)11 (14.3 %)6 (7.8 %)3 (3.9 %)3 (3.9 %) Pharmacological interventions Stopped SevelamerDecreased sevelamer doseContinued Sevelamer 35 (45.5 %)1 (1.3 %)1 (1.3 %) Procedural interventions Surgical interventionEndoscopic treatmentEndovascular intervention 16 (20.8)5 (6.5 %)1 (1.3 %) Outcomes RecoveredDeathNot reported 35 (45.5 %)5 (6.5 %)37 (48.1 %) *Includes both microscopic and macroscopic findings.

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.

Efficacy of sigmoidoscopy for evaluating disease activity in patients with ulcerative colitis

BackgroundEndoscopic assessment of disease activity is a key parameter in the management of ulcerative colitis. Whether sigmoidoscopy alone is sufficient to evaluate the disease activity in ulcerative colitis lacks studies.MethodsWe retrospectively analyzed the medical records and endoscopic results of patients with ulcerative colitis followed by colonoscopy in seven tertiary hospitals between January 2012 and December 2018. Endoscopic disease activity was scored using the Mayo endoscopic subscore (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) for each segment from the colonoscopy images. Concordance was evaluated by comparing the highest MES and UCEIS in the rectosigmoid and proximal regions to confirm the usefulness of sigmoidoscopy.ResultsA total of 500 colonoscopic examinations from 333 patients were enrolled. Only in 7.6% [k(kappa): 0.893, r(Spearman): 0.906, p < 0.001] and 8.6% [k(kappa): 0.890, r(Spearman): 0.914; p < 0.001] of cases, MES and UCEIS scored more severely in the proximal colon. Comparison of active disease (MES ≥ 2) in the rectosigmoid area and the entire colon showed a high concordance rate [k(kappa): 0.899, r(Spearman): 0.904, p < 0.001]. Endoscopic healing (MES = 0) also showed a high concordance rate [k(kappa): 0.882, r(Spearman): 0.887, p < 0.001]. In 38 cases (7.6%) of patients with a higher MES in the proximal area, it was significantly higher in patients with previous extensive colitis.ConclusionsSigmoidoscopy and colonoscopy showed a high concordance rate. Therefore, sigmoidoscopy is considered a sufficient substitute for colonoscopy. However, colonoscopy should be considered in patients with previous extensive colitis.

Colonoscopic reduction of atransanal prolapsed ileocolic intussusception.

Transanal protrusion of intussusception (TAPI; also known as prolapsed intussusception) is arare complication. Here, we present asuccessful colonoscopic reduction of ileocolic intussusception presented with transanal prolapse. An 8‑month male child, weighing 8 kg, was referred to our hospital presenting with amass in his anal canal, diarrhea and rectal bleeding for two days. The sonographic evaluation revealed an ileocolic intussusception in the rectosigmoid area. The patient was treated using colonoscopic reduction. To our knowledge, this is the first study reporting colonoscopic reduction for transanal prolapsed intussusceptions. Our study suggests gastroenterologists to consider colonoscopy as atherapeutic method for prolapsed intussusceptions and encourages them to attempt reducing the invagination using this method before laparotomy, especially in cases presenting within 48 h of onset of symptoms and no peritonitis symptoms.

Clinical characteristics and outcome of iatrogenic colonic perforation related to diagnostic vs. therapeutic colonoscopy

AimIatrogenic colonic perforation (ICP) is a rare serious complication of colonoscopy, where standard treatment is controversial. This study aimed to characterize diagnostic ICP (DICP) compared to therapeutic ICP (TICP) and determine the possible indication of endoscopic repair.MethodsWe studied patients with ICP over 7 years starting in 2011. Their demographics and data regarding perforation, treatment, and outcome were investigated by retrospective review of medical records, and the diagnostic and therapeutic groups were compared.ResultsAmong 29,882 patients who underwent colonoscopy, ICP was identified in 28 (0.09%: diagnostic, 15/24,758, 0.06%; therapeutic, 13/5124, 0.25%). A total of 56 patients (33 DICP and 23 TICP) including 28 referred cases were analyzed. Mean age was 62.3 ± 11.4 years, and 24 were men. Perforations occurred mostly in the rectosigmoid region and half were detected during or immediately after colonoscopy. Endoscopic treatment was successful in 22 cases and 34 required surgery. Mortality occurred in 4 (7.1%).Compared to TICP, DICP was more prevalent in females and rectosigmoid region and more frequently detected immediately (all p < 0.05); DICP tended to occur in older patients, be larger and have better chance of endoscopic repair.Regardless of type of ICP, female predominance, smaller perforation, more frequent immediate detection, and shorter hospital stay (all p = 0.01) were found in the endoscopic repair group.ConclusionDICP was more frequent in the rectosigmoid area in older women and could be detected immediately. Immediate detection and small perforation size could be important factors for endoscopic repair. Careful attention and gentle manipulation should be required.

Colonoscopic Ultrasound-Guided Fine-Needle Aspiration Using a Curvilinear Array Transducer: A Single-Center Retrospective Cohort Study.

Curvilinear array ultrasound transducers enable tissue sampling and have therapeutic capabilities. Nevertheless, colonic intubation and maneuvering with these transducers is technically challenging and is therefore typically limited to the rectosigmoid area. This retrospective cohort study aimed to evaluate the safety, feasibility, and diagnostic yield of colonoscopic ultrasound-guided fine-needle aspiration in deep colonic intubation. The impact of this innovation is to enable tissue sampling of colonic and extracolonic lesions guided by endoscopic ultrasound. Curvilinear array ultrasound is used in the evaluation of luminal and extraluminal colonic diseases. Thirteen patients underwent colonoscopic ultrasound with a curvilinear array ultrasound endoscope in a single center for subepithelial lesions, cancer staging, and extracolonic lesions from July 2015 to February 2021. Endosonography was performed using an Olympus EU-ME1 and GF-UCT 180 with a 5-12MHz curvilinear array transducer. The primary outcome was the percentage of patients who were successfully scanned with the endoscopic ultrasound. The secondary outcomes included the success rate of fine-needle aspiration, the diagnostic yield of the tissue samples, and the adverse events related to the procedure. A total of 13 female patients underwent colonoscopic ultrasound. All patients (100%, 13/13) were successfully scanned. Fine-needle aspiration was deemed necessary and successfully performed in 100% (5/5) of the patients. Tissue samples collected by fine-needle aspiration resulted in a diagnostic yield of 60%, and no adverse events resulted from this intervention. This study demonstrates the feasibility of performing colonoscopic ultrasound with a curvilinear array transducer. Fine-needle aspiration for subepithelial, colonic, and extracolonic lesions is feasible and safe in this setting with no adverse events reported in our study. Future research should be directed toward validating colonoscopic ultrasound with a curvilinear array transducer technique in prospective randomized trials. Studies evaluating the feasibility and safety of endoscopic ultrasound-guided interventions in the colon, such as abscess drainage and enteral anastomosis, should be considered.

1354 A Rare Case of Gallstone Ileus Due to Cholecystocolonic Fistula

Abstract Introduction Gallstone Ileus (GI) is an uncommon but potentially lethal complication of cholelithiasis. 50 to 70% of gallstones obstruct in the ileum, the narrowest point of the intestine. More uncommonly the gallstone can travel into the large bowel via an incompetent ileo-caecal valve and impact in the colon at a recto sigmoid junction. GI involving the sigmoid colon is extremely rare cause of large bowel obstruction. The gallstone often enters the large bowel through a fistula formation between the gallbladder and colon, and impacts at a point of narrowing, causing large bowel obstruction. Case Report We describe the case of a 72-year-old man who presented with features of bowel obstruction. CT of abdomen pelvis (CTAP) showed a large 5x5cm intraluminal gallstone obstructing at the rectosigmoid area. It showed presence of pneumobilia and incidental finding of abdominal aortic aneurysm (AAA). An emergency laparotomy revealed a cholecystocolonic fistula. The stone was extracted after milking the stone proximally and loop colostomy formed at colotomy site. The patient made an uneventful recovery. Reversal of stoma was postponed pending endovascular repair of enlarging AAA. Discussion Presenting symptoms of GI are often non-specific, frequently leading to a delay in diagnosis and treatment. Although no fistula was identified in this patient by imaging, the most common cause of GI in most patients is formation of a cholecystoduodenal fistula. Conclusions Compared with biliary enteric fistulae, the occurrence of cholecystocolonic fistulae is remarkably rare. Temporary colostomies can be considered for treating these cases alongside one-stage operations

Robotic-assisted laparoscopy is a feasible method for resection of deep infiltrating endometriosis, especially in the rectosigmoid area.

ObjectiveThis study aimed to compare outcomes of mini-invasive surgical treatment of endometriosis, especially conventional laparoscopy with robotic-assisted laparoscopy, and to evaluate the quality of life.MethodsOne hundred three consecutive patients with endometriosis who had surgery from 2014 to 2017 owing to an indication of pain were enrolled in this retrospective study. The majority (n = 77, 75%) of patients underwent conventional laparoscopy and 18 (17%) had robotic-assisted laparoscopy. The quality of life was postoperatively assessed with a questionnaire.ResultsThe rates of parametrectomy (76% vs. 45%,) and rectovaginal resection (28% vs. 4%) were significantly higher in robotic-assisted laparoscopy than in laparoscopy. Additionally, the rate of bowel operations (50% vs. 17%), especially the shaving technique, was higher in robotic-assisted laparoscopy surgery than in laparoscopy (39% vs. 8%). There was no difference in the rate of postoperative complications between laparoscopy and robotic-assisted laparoscopy. Most (91%) of the patients who answered the questionnaire felt that surgical treatment had relieved their pain. In the laparoscopic and robotic-assisted groups, 88% of respondents felt that their quality of life had improved after surgery.ConclusionsThis study suggests that robotic-assisted laparoscopy is a feasible method to resect deep infiltrating endometriosis, especially in the rectosigmoid area.

Ileal fecalomas causing small bowel obstruction: A case report.

IntroductionFecaloma is an accumulation of feces that has formed a mass and has failed to be expelled spontaneously. Because fecal matter is harder and firmer in the left side of colon, and the diameter of the bowel is smaller compared to the right, fecalomas mostly form in recto-sigmoid area. Small bowel fecaloma formation is an extremely rare condition.Case presentationWe report a 49 years old man who presented with small bowel obstruction due to ileal fecalomas for whom enterotomy and removal of fecaloma was done with good outcome.DiscussionFecal matter can accumulate in the intestinal lumen to form a mass separate from other intestinal contents which eventually becomes fecaloma. Formation is usually related to chronic constipation, conditions causing intestinal motility disorder, or in psychiatric patients who could have ingested extraordinary substances. Fecaloma can present as abdominal mass, stercoral colitis, urinary retention or intestinal obstruction. Treatment options include conservative management with bowel rest, laxatives, endoscopic removal, laparotomy and removal via enterotomy.ConclusionFecaloma can be considered in patients who present with small bowel obstruction without any risk factors. Initial noninvasive management should be considered. Failed conservative treatment can be followed by laparotomy and fecaloma removal.

A rare case of endosalpingiosis masquerading as a pedunculated subepithelial colonic nodule: utility of EUS and endoscopic resection

A 54-year-old woman was found to have a nonobstructing pedunculated submucosal lesion 24 cm from the anal verge during a routine screening colonoscopy (A). CT imaging revealed a 1.8-cm irregular plaque-like lesion within the rectosigmoid area, without any lymphadenopathy. EUS showed a 11.6 × 7.7 mm polypoid intramural (subepithelial) lesion in the sigmoid colon, predominantly cystic and anechoic and originating from the submucosa (layer 3), with well-defined borders, and an intact interface between the lesion and the muscularis propria (layer 4) (B).

S3385 Left-Sided Colonic Lymphangioma: A Rare Cause of Tumors Observed on Colonoscopy

INTRODUCTION: Lymphangiomas, benign tumors of lymphatic origin typically affect the head and neck, rarely involving the gastrointestinal tract; reportedly 5 % are found in the abdominal cavity. We present a rare case of a lymphangioma found in the rectosigmoid colon with successful endoscopic removal. CASE DESCRIPTION/METHODS: 62 year old male with a past medical history of a benign mass in the pancreatic tail with resection in 2015 presented with abdominal distension and bloating for three weeks. CT abdomen revealed extensive colonic diverticulosis with areas of muscular hypertrophy along with cecal wall thickening. Colonoscopy was significant for a 15 mm semi-sessile lesion in the rectosigmoid area, confirmed to be a lymphangioma on histopathology. DISCUSSION: While lymphangiomas are uncommonly found in the abdominal cavity, its location is rarest in the sigmoid colon. Symptomatology varies according to size, with larger lesions >2 cm being more prone to acute gastrointestinal complications such as bowel obstruction, bleeding, volvulus and intussusception. Endoscopic removal is a safe and viable option for smaller lesions and should be considered since it leads to less complications, less morbidity, and lower healthcare costs. The incidence of colonic lymphangiomas is increasing with increased surveillance colonoscopies, and physicians should be aware of the symptoms, diagnosis, complications and treatment options.Figure 1.: Lymphangioma in the rectosigmoid colon.Figure 2.: Lesion was clipped with 2 hemostat clips to prevent bleeding after removal by hot snare.Figure 3.: Cystic lymphangioma in the rectosigmoid colon. Hematoxylin and eosin stain showing dilated channels lined by endothelial cells containing lymph nodes. The stroma contains fibrocollagenous tissue and scant cellular infiltrate.

S1641 Utility of Colon Capsule Endoscopy in Diagnosis of Colorectal Cancer

INTRODUCTION: Colonoscopy is the gold standard for diagnosis of colorectal cancers. Recent advances in endoscopic technologies has introduced Video capsule endoscopy, which has become widely used to evaluate small bowel and large mucosa for obscure bleeding and even mass lesions. This has led to colon capsule endoscopy (CCE). CCE was introduced in late 2000s and has gained popularity due to non-invasive, and efficacious method in diagnosis of colon lesions. CASE DESCRIPTION/METHODS: We present a case of a 68 yo man with hematochezia for three months. His PMHx includes A fib (takes coumadin). He had intermittent bleeding with bowel moments where he noticed fresh bleed in toilet bowel. He denied any abdominal pain, constipation, diarrhea, or weight loss. His physical exam was benign. His hemoglobin was 14.5 g/dl. No prior endoscopic procedures. He was offered colonoscopy however patient was not amenable to the procedure. Therefore, we offered colon capsule endoscopy (CCE). The CCE was of good quality. Colon was well visualized and showed an ulcerated lesion in the distal rectosigmoid area, occupying more than 70% of the lumen, measuring at least 5 cm in diameter that was concerning for cancer. With this finding, patient was agreeable to proceeded with colonoscopy. Colonoscopy to the ileum (BBPS 3,3,3) showed a rectosigmoid mass seen on capsule colonoscopy at 16 cm from the anal verge. Lesion was non obstructing and occupied 70% of the luminal circumference. Multiple biopsies were taken. Biopsies were consistent with moderately differentiated adenocarcinoma. He was referred to general surgery and oncology. He underwent Lower Anterior Resection. Path showed locally advanced rectal cancer. DISCUSSION: With this case, we intent to highlight the utility of CCE as a screening and diagnostic tool for Colorectal cancer. CCE has emerged as a promising new modality for colonic evaluation. As this procedure is non-invasive, and painless, there is no need for sedation. The patient’s do not need to be off of anticoagulation and take significant time of for colonoscopy that usually requires one to two days of leave. Hence, it a good diagnostic and screening tool for appropriate candidates who do not wish to undergo routine colonoscopy. The limitations include unable to do biopsies, polypectomies and provide therapeutic options for patients with mass lesions, polyps or bleeding. Therefore, CCE can be utilized to decide if colonoscopy is warranted in individuals based on CCE findings.Figure 1.: Colon Capsule Endoscopy imaging of rectosigmoid tumor.Figure 2.: Colon Capsule Endoscopy imaging of rectosigmoid tumor.Figure 3.: Colonoscopy image of circumferential mass lesion in rectosigmoid identified on colon capsule endoscopy.

Molecular characteristics of colorectal hyperplastic polyp subgroups.

The importance of hyperplastic polyps during colorectal carcinogenesis is appreciated related to the understanding of serrated pathway. The morphologic subtypes of hyperplastic polyps in carcinogenesis and the nomenculature of lesions with both hyperplastic and adenomatous areas are controversial. We aimed to reveal the molecular properties of hyperplastic polyp subtypes and the molecular changes in polyps containing both hyperplastic and adenomatous areas. Matherial and Methods: 49 hyperplastic polyps [19 microvesicular (MVHP), 19 goblet-rich (GRHP), 11 mucin-poor (MPHP)] and 10 mixed hyperplastic and adenomatous polyps were analysed for KRAS, BRAF mutations and MSI with real-time PCR. 68,4% of MVHPs and 81% of MPHPs which were localized in right colon had BRAF mutations. While none of the GRHPs showing a KRAS mutation with a rate of 73% was localized in the ascending colon, 63% of them were localized in the rectosigmoid area. In five (50%) of the mixed polyps, KRAS mutation was detected both in the hyperplastic and adenoma components. There was no BRAF mutation in any of the mixed polyps. However, in two cases, the hyperplastic component was MSI-H and the adenoma area was MSS. Hyperplastic polyps, even if smaller than 5 mm, are precancerous lesions bearing different mutations. GRHPs with predominant KRAS mutations and MVHPs and MPHSs with predominant BRAF mutations are precancerous. Although the molecular investigations for HPP/SP are not necessary the morphological subtyping should be included if the case is diagnosed with HPP/SP as it will be useful for attracting the gastroenterologist's attention.

Ultrasound Guided Hydrostatic Treatment of Meconium Ileus; another Indication for Ultrasound Based Approach to Bowel Obstruction

Dear Editor-in-Chief, The inspissated meconium pellets are a cause or effect of ileocolic obstructions. The present study aimed at explaining our experience of ultrasound-based approach for differentiation and treatment of the inspissated meconium pellets. This study was conducted at Mashhad University of Medical Sciences, Mashhad, Iran, from 2017-2020. Twenty-four neonates (less than 8 days) with inspissated meconium pellets were examined using ultrasound. Moreover, in cases with non-complicated inspissated meconium pellets, ultrasound-guided contrast enema was performed for confirmation of the diagnosis or probable treatment. In ultrasound, the inspissated meconium pellets were observed as uniform hypo- to hyper-echoic tubular or beaded intra-luminal material in ileocolic loops or recto-sigmoid area. These pellets were in five states: simple meconium ileus, localized or generalized meconium, small bowel, meconium plug syndrome, and Hirschsprung's disease. During contrast enema in non-complicated meconium ileus, moving and floating of inspissated meconium pellets was observed during ultrasound scanning, while this issue was not observed in small bowel atresia. The success rates of the hypertonic contrast enema in patients with simple meconium ileus were 80%. The inspissated meconium pellets have an ultrasound appearance. They are mainly observed in patients with simple and complicated meconium obstructions and bowel atresia. Except in complicated meconium obstructions, the ultrasound-guided contrast enema was performed for their differentiation and probable treatment.

Tu1083 CLINICAL CHARACTERISTICS AND OUTCOME OF IATROGENIC COLONIC PERFORATION RELATED TO DIAGNOSITC VS. THERAPEUTIC COLONOSCOPY

Iatrogenic colonic perforation (ICP) is a rare serious complication of colonoscopy, where standard treatment is controversial. This study aimed to characterize diagnostic ICP (DICP) compared to therapeutic ICP (TICP) and determine the possible indication of endoscopic repair. We studied patients with ICP treated during 7 years starting in 2011. Their demographics and data regarding perforation, treatment and outcome were investigated by retrospective review of medical records, and the diagnostic and therapeutic groups were compared. Among 29,882 patients who underwent colonoscopy, ICP was identified in 28 (0.09%: diagnostic, 15/24,758, 0.06%; therapeutic, 13/5124, 0.25%). A total of 56 patients (33 DICP and 23 TICP) including 28 referred cases were analyzed. Mean age was 62.3±11.4 years, and 24 were men. Perforations occurred mostly in the rectosigmoid region (n=36, 64.3%) and half were detected during or immediately after colonoscopy. Endoscopic treatment was successful in 22 cases (39.3%) and 34 (60.7%) required surgery. Mortality occurred in 4 (7.1%). Compared to TICP, DICP was more prevalent in females (p=0.045) and rectosigmoid region (p=0.000) and more frequently detected immediately (p=0.000); DICP tended to occur in older patients (p=0.080), be larger (p=0.080) and have better chance of endoscopic repair (p=0.080). Regardless of type of ICP, female predominance (p=0.009), smaller perforation (p=0.001), more frequent immediate detection (p=0.000), and shorter hospital stay (p=0.007) were found in the endoscopic repair group. DICP was more frequent in the rectosigmoid area in older women and could be detected immediately. Immediate detection and small perforation size could be important factors for endoscopic repair. Careful attention and gentle manipulation should be required, especially at the time of passing through rectosigmoid area of older women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)