Semipedunculated Polyp Research Articles

S3575 Case of Iron Deficiency Anemia Secondary to a Pyogenic Granuloma

Introduction: Pyogenic granulomas (PG) are lesions in the skin or mucosa composed of vasodilative granulation tissue. Although commonly found in the oral cavity, they are rare throughout the rest of the gastrointestinal (GI) tract. Gastrointestinal PGs typically present as insidious microcytic anemia, which can be severe. We present a case of a patient with iron deficiency anemia secondary to pyogenic granulomas. Case Description/Methods: A 75-year-old Caucasian female referred to the hospital for evaluation for coronary artery bypass graft. Medical history was significant for coronary artery disease, microcytic anemia, tobacco use. On workup, she was found to have iron deficiency anemia with labs showing a hemoglobin of 8.5 g/dL and mean corpuscular volume of 78.3 fL. Her baseline hemoglobin was 12 g/dL last known 5 years before. Iron studies showed low iron at 24 ug/dL and low transferrin saturation of 7%. She denied any hematemesis, melena, or hematochezia. Digital rectal exam demonstrated soft, brown stool. Diet at that time was unchanged from baseline. No other sources of non-GI bleed were identified. Further endoscopic work-up was obtained. Colonoscopy and video pill capsule were unmarkable. Esophagogastroduodenoscopy revealed three large, gastric polypoid lesions that were consistent with visual findings of pyogenic granulomas (Figure). Biopsy revealed an entirely fibrin composition and inflammatory cells with granulation tissue and a strip of reactive foveolar epithelium. Patient was treated conservatively with iron supplementation. Discussion: Pyogenic granulomas are a benign polypoid form of capillary hemangiomas. Initially, it was thought that PGs were caused by infection, but they are most likely multifactorial, including mucosal irritation resulting in reactive processes. Endoscopically, these lesions are commonly erythematous, pedunculated polyps. They are typically described as having a smooth, but visibly ulcerated, surface that can be friable or oozing blood. Further, visual aspects of PG include the underlying vasculature causing dark red to fresh sanguine appearance. Histologically, PGs are lobular-patterned hemangiomas with capillary vessels. Similar to this case, granulation tissue and a single layer of endothelial cells may also be present. Conservative management includes supporting blood loss with iron supplementation. If unresponsive, endoscopic management includes resection with a snare polypectomy, endoscopic mucosal resection, band ligation, or heat application.Figure 1.: Semi-pedunculated polyps (arrows) with hyper vascular appearance. No obvious stigmata of bleeding.

S2055 Intra-Diverticular Polyp Associated With Acute Diverticulitis

Introduction: The incidence of both colon polyps and diverticulosis increases with age. Intra-diverticular polyps are a very rare findings despite the relatively high prevalence of both colon polyps and diverticulosis. Acute diverticulitis happens in approximately 5-10% of patients with diverticulosis. Risk factors for acute diverticulitis have been well described including age, NSAIDs, and dietary factors. There is limited evidence on the incidence of diverticulitis associated with colon polyps. Case Description/Methods: A 44-year-old woman with no significant medical history was referred for evaluation after a recent episode of acute uncomplicated diverticulitis confirmed on CT. She was treated with a short course of antibiotics in the outpatient setting. The patient had a normal BMI and was not using any NSAIDs previously. The patient subsequently underwent a diagnostic colonoscopy and was found to have sigmoid diverticulosis. A single 5 mm semi-pedunculated polyp was found arising from the base of a diverticulum (Figure). The polyp was resected using forceps to evert the diverticulum and fully visualize the polyp. Histologic examination revealed an inflammatory polyp. Discussion: Here we present a case of a patient who was found to have an intra-diverticular polyp after an episode of acute diverticulitis. The patient had no other risk factors for acute diverticulitis which suggests the polyp may have been the underlying cause of the diverticulitis. Intra-diverticular polyps are rare. To the best of our knowledge, diverticulitis caused by such polyps is exceedingly rare. Polyp location or growth in the diverticulum may led to obstruction, inflammation or erosion of the thin diverticular wall. Because the polyp was inflammatory, we cannot rule out the possibility that it may have developed after the episode. Whether the polyp was the trigger or the result of diverticulitis, this rare association highlights the importance of a colonoscopy after an episode of acute diverticulitis to rule out other pathology.Figure 1.: Left: Intra-diverticular polyp. Right: Forceps were used to fully visualize and resect the polyp.

Incidental Colonic Ganglioneuroma on Surveillance Colonoscopy.

CASE REPORT A 73-year-old man with a history of diverticulitis after left hemicolectomy and an end-to-end colo-colonic anastomosis underwent a screening colonoscopy with resection of 4, 2-10-mm tubular adenomas. A 10-mm semipedunculated polyp with a normal mucosal pit pattern under narrow-band imaging was found in the splenic flexure (Figure 1). The polyp was resected using a hot snare and submitted for histopathological diagnosis, which demonstrated colonic mucosa with distorted crypt architecture. The lamina propria was expanded by collection of spindle cells within fibrillary matrix, and irregular nests and groups of ganglion cells indicated a ganglioneuroma (GN) (Figure 2). No clinical symptoms were associated with this finding, and a prior colonoscopy revealed no evidence of GN. Surveillance colonoscopy was recommended in 3 years, given the presence of an adenoma of ≥10 mm in size.Figure 1.: (A) A semipedunculated polyp under white-light imaging in the splenic flexure. (B) A semipedunculated polyp with a normal mucosal pit pattern under narrow-band imaging in the splenic flexure.Figure 2.: (A) An (H&E original magnification 20×) image of the colonic polyp consisting of abnormal appearing ganglion cells (single arrow) and spindled Schwann cells (double arrows). (B) An (H&E original magnification 10×) image of the colonic polyp consisting of abnormal appearing ganglion cells and spindled Schwann cells. H&E, hematoxylin & eosin.Ganglioneuromas of the gastrointestinal tract are rare tumors composed of ganglion cells, nerve fibers, and supporting cells. Gastrointestinal GNs are usually confined to the large intestine and are morphologically classified into 3 categories, namely, polypoid GNs, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis.1 Polypoid GNs are mostly solitary and small (measuring <20 mm), with a sessile or pedunculated appearance. Colonic GNs are characterized by a normal colonic pit pattern under narrow-band imaging. These lesions produce no characteristic symptoms and are usually found incidentally during endoscopy. Rarely, they present with abdominal pain, obstruction, ileus, appendicitis, or weight loss depending on their size and anatomical location.2 Ganglioneuromatous polyposis and diffuse ganglioneuromatosis are associated with genetic syndromes, such as neurofibromatosis 1, multiple endocrine neoplasia 2B syndrome, and juvenile polyposis. Solitary GNs are generally not associated with familial syndromes, although they have been reported in cases of Cowden disease, tuberous sclerosis, polyposis coli, and juvenile polyposis.1 Gastrointestinal GNs are usually treated with endoscopic resection. Currently, no guidelines exist on the management of solitary GNs or recommendations for interval surveillance colonoscopy. Repeat colonoscopy is not necessary because of the benign nature of these lesions, which tend not to recur.3 DISCLOSURES Author contributions: S. Agarwal and Y. Wang designed and drafted the article and acquired data. PG Iyer drafted and revised the article for intellectual content. CL Leggett designed and drafted the article , acquired data, revised the article for important intellectual content, and is the article guarantor. Financial disclosure: None to report. Informed patient consent was obtained for this case report.

S3110 Polypoid Gastric Adenomyoma: A Rare Cause of Bleeding Treated with Polypectomy

Introduction: Gastric adenomyoma (AM) is a rare, benign tumor composed of smooth muscle fibers admixed with ducts and glandular tissue. Usual presentations include nausea, bloating and gastric outlet obstruction. We describe a rare presentation as a bleeding polyp resolving with excisional polypectomy. Case Description/Methods: A 60-year-old woman presented with epigastric abdominal pain and melena for 3 months. Physical examination was unrevealing with a normocytic anemia with a hemoglobin of 11.6 g/dL. Abdominal computed tomography was normal. Endoscopy revealed a 1.5 cm semi-pedunculated polyp oozing blood in the gastric body which was resected with multiple small sessile polyps that were biopsied. On microscopy, the 1.5 cm polyp revealed hyperplastic, dilated foveolar glands with fibromuscular hyperplasia consistent with gastric AM and the other polyps were secondary to reactive gastropathy. Six weeks later, her hemoglobin remained stable. Discussion: Nearly 67 cases of gastric AM have been described in literature until 2017,1,2 typically located in the antrum and pylorus, 85% and 15% respectively.3 Common presentations are gastric outlet obstruction with antral or pyloric wall thickening treated with surgical resection. Uncommonly, gastric AM presents with melena especially in the stomach body.2,4 Wang et al2 reported a series of 15 gastric AMs appearing as mucosal eminences, sized 0.4-3 cm, treated with endoscopy of which 2 were found in the body, and 1 presented with melena. Grossly, they appear similar to other subepithelial polyps eg. GIST, gastritis cystica profunda or carcinoid. Although, the malignant potential is unknown, simultaneous presence of adenocarcinoma and AM has been reported, while recurrence post resection has not.1,2,4 In our patient, mucosal inflammation with oozing suggested the polyp was the source of bleeding that ceased after removal. We believe that this is the first case of a polypoid AM in the stomach body causing bleeding and successfully treated with polypectomy.Figure 1.: Gastric perforation secondary to malignant gastric outlet obstruction.

S1711 Ischemic Colitis Combined With Adenomatous Polyp Presenting as Malignant-Like Lesion

Introduction: Ischemic colitis is a common colonic vascular diordedr in the elderly population, so is adenomatous polyps in the colon. We present an unusal case where a patient had an ischemic colitis in the area of an adenomatous polyp, giving an appearance that resembles malignant neoplasm of the colon. Case Description/Methods: An 83-year-old female presented to the emergency department with flash pulmonary edema secondary to hypertensive emergency requiring urgent hemodialysis. She had no history of atrial fibrillation that would suggest thromboembolic phenomenon. She reported no GI bleeding history and never underwent an endoscopy or colonoscopy. Laboratory studies showed up trending troponin (from 0.1 to 2.5) with EKG changes concerning for non-ST elevation myocardial infarction (NSTEMI). Pt was started on treatment with dual anti platelet therapy and heparin infusion. Next morning, the patient reported a sudden urge to defecate and crampy abdominal pain which resolved after large maroon-colored bowel movement. Significant drop in Hb from 9.2 to 7.1 ( >2 grams/dl) was found but the patient remained hemodynamically stable. Colonoscopy was performed which showed a 4-5 cm ulcerated raised lesion with round semi-pedunculated polyp at the edge of the lesion (Kudo Pit pattern 3 L) in the descending colon [Figure]. Biopsies were obtained from the ulcerated lesion as well as the polyp located at the edge of the lesion. Pathologic examination of ulcer lesion biopsy showed necrotic debris and inflammatory exudates with reactive/reparative epithelial changes along with minute fragments showing crypt drop out and hyalinized lamina propria, suggestive of ischemic change. Deeper levels were examined and showed no malignancy. Biopsy of polyp showed fragments of tubular adenoma. Patient recovered from her ischemic colitis and NSTEMI and recovered well and was discharged from the hospital. Discussion: The incidental proximity of the ischemic area to the polyp gave a malignant appearance to the area. However, biopsies confirmed there was only ischemic changes in the ulcerated area and biopsies from the polyp showed tubular adenoma with no malignant cells nor high grade dysplasia. The ischemic colitis is likely the cause of bleeding in this case. She was scheduled for follow-up for discussion of repeat colonoscopy for polyp resection on elective basis.Figure 1.: Ulcerated raised lesion with round semi-pedunculated polyp at the edge of the lesion in the descending colon.

Complete endoscopic removal of a large appendiceal orifice polyp.

A 51-year-old man was referred to our institution for removal of a large semipedunculated polyp (0-Isp) involving the appendiceal orifice ([Fig. 1]). Previous biopsies showed a tubulovillous adenoma (TVA) with high grade dysplasia (HGD). Endoscopic resection under general anesthesia in the operating room was proposed and was agreed to by the patient. A 30-mm 0-Isp lesion extending into the appendix (> 75 % of orifice) was found, with narrowband imaging showing a regular mucosal pattern without areas suggestive of deep invasion. Different endoscopic resection techniques were discussed at this point, such as endoscopic full-thickness resection (EFTR) and endoscopic submucosal dissection (ESD). However, the size, involvement of the appendiceal orifice, and presence of identifiable margins of the lesion favored conventional endoscopic mucosal resection (EMR) ([Video 1]).

S1748 Primary Follicular Lymphoma of the Colon: A Rare Case in a Rare Place

INTRODUCTION: Primary lymphomas of the colon are rare, accounting for < 1% of all GI malignances. Studies describing the disease suggest that it most commonly involves the cecum and presents symptomatically in patients with abdominal pain and weight loss. However, given the rarity of the cancer, literature on the clinical and pathologic features of the disease are still evolving. Here, we present a case of primary follicular lymphoma affecting the sigmoid colon with a description of the corresponding colonoscopy and histologic findings. CASE DESCRIPTION/METHODS: The patient is a 71-year old female referred from her PCP for iron deficiency anemia with a hemoglobin of 11.3 g/dL and positive fecal immunochemical testing (FIT). Her symptoms included intermittent episodes of constipation for several weeks. She denied changes in stool caliber including bloody or tarry appearing stools, B-symptoms such as weight loss or night sweats, or family history of colorectal malignancy. Physical exam was unremarkable. Subsequent colonoscopy revealed an 8mm sessile polyp and 10mm semi-pedunculated polyp with a localized area of nodular mucosa in the sigmoid colon. Polyp and mucosal biopsies demonstrated atypical lymphoid infiltrate with abnormal follicular proliferation positive for CD-20, BCL-2 and BCL-6, consistent with low-grade, stage IE, follicular lymphoma. At 1-month follow-up with oncology, the patient remained asymptomatic after polypectomy and chose conservative management with active surveillance. DISCUSSION: Primary lymphoma of the colon is rare, accounting for less than 0.2% of all GI malignancies. There is limited data on the clinical and pathologic features of the disease however, current studies indicate a female predominance, chief presenting symptoms of abdominal pain and weight-loss, and largely cecum involvement. Here, we present a rare case of follicular lymphoma in the sigmoid colon of a female presenting with constipation and iron deficiency anemia. Colonoscopic features included a sessile and semi-pedunculated polyp with nodular mucosa and histology showing an atypical lymphoid infiltrate positive for CD-20, BCL-2, and BCL-6. This case provides insight both into the varying clinical and pathologic characteristics of a relatively rare disease and the importance of lymphoma as part of the differential in this patient population.Figure 1.: Colonoscopy demonstrating a 10-mm Semi-pedunculated Polyp of the sigmoid.Figure 2.: Nodular Hyperplasia of the sigmoid colon.Figure 3.: Biopsy specimen with the round follicles characteristic of follicular lymphoma seen on histology (arrows).

S3393 Granular Cell Tumor of the Colon - Surprise Beneath the Mucosa!

INTRODUCTION: Granular Cell Tumors (GCT) are a rare soft tissue neoplasm that arise from Schwann cells. Even though these tumors are generally benign, 1-2% of the cases have been reported to be malignant. Although usually found in the oral cavity or subcutaneous tissue, 8% of cases manifest in the gastrointestinal (GI) tract. In those patients, the esophagus is the most frequently affected organ, followed by the duodenum, anus, stomach. The least common sites are the colon and rectum. To date ∼ 150 cases of Colonic GCT have been reported in the English literature. Most GCT tend to be asymptomatic and less than 2cm in size, hence they are usually discovered incidentally during routine colonoscopy or abdominal imaging. Herein we report a unique case of GCT of the ascending colon measuring 11mm in size in a patient presenting with constipation that was treated successfully with endoscopic resection. CASE DESCRIPTION/METHODS: A 55-year old male with a history of external hemorrhoids presented to the GI clinic with constipation for two weeks. His previous colonoscopy eight months prior revealed a one cm polyp in the ascending colon, but it was not removed due to poor preparation. Repeat Colonoscopy revealed an 11 mm semi pedunculated polyp in the ascending colon. The polyp was removed with hot snare polypectomy followed by the placement of hemostatic clips. (Figure#1). Histopathologic examination of the resected polyp showed an intramucosal and submucosal tumor composed of polygonal cells with abundant amphophilic granular cytoplasm and centrally or eccentrically located small round or irregularly shaped nuclei (Figure#2). Margins of the resected polyp were free of tumor. Immunohistochemical analysis showed tumor cells were positive for S100 (Figure#3), CD68, and inhibin and negative for CD117 and neurofilament. On the basis of the above findings, the tumor was diagnosed as GCT. He followed up with a gastroenterologist as an outpatient one month later and had reported no symptoms. DISCUSSION: Colonic GCT are usually discovered at the time of colonoscopy as small, sessile, yellowish-white nodules or polyps covered by normal-appearing mucosa. Definitive diagnosis can be made by histopathology and immunohistochemical analysis. Endoscopic removal is the safest and most effective treatment. Though typically benign, gastroenterologists should be aware of malignant features such as a size greater than 4cm or rapid growth. It is important to consider GCT when one encounters a subepithelial lesion during colonoscopy.Figure 1.: A-11mm semi-pedunculated polyp in the ascending colon B-Prophylactic application of resolution clip at the polyp removal site.Figure 2.: The morphology of granular cell tumor in intramucosal and focally submucosal location in a colon polyp (H&E: 10x). Infiltrative growth pattern with nested or trabecular cellular clusters or sheets are appreciated. The cells are with abundant amphophilic granular cytoplasm and centrally or eccentrically located small round or irregularly shaped nuclei. No necrosis or mitosis is appreciated.Figure 3.: S100 positive staining highlighted the infiltrating trabecular growth pattern of this granular cell tumor (H&E: 10x).

1557 Not Your Average Colon Cancer: Diffuse Large B-Cell Lymphoma in a Terminal Ileum Mass and Colon Polyp

INTRODUCTION: Although the GI tract is a common site of extranodal non-Hodgkin lymphoma, primary ileocolonic lymphoma is rare among GI malignancies. Here, we report the case of a man presenting with abdominal pain diagnosed with diffuse large B-cell lymphoma (DLBCL) in his terminal ileum and sigmoid colon on colonoscopy. CASE DESCRIPTION/METHODS: A 72 year-old male with type 2 diabetes mellitus and recurrent UTIs presented with several weeks of abdominal pain and rectal bleeding. A colonoscopy 7 years prior showed diverticulosis. He had a 10 pack-year smoking history (quit 35 years prior). Family history was notable for a father with prostate cancer. Exam showed abdominal tenderness in the right lower quadrant. Laboratory work-up was only notable for ESR 25 and CRP 1.1. CT abdomen/pelvis demonstrated wall thickening in the cecum/ascending colon with surrounding inflammatory change and reactive adenopathy. Colonoscopy showed an ulcerated 2.0 × 1.8 cm mass in the terminal ileum, involving one-third of the lumen circumference (Figure 1). A 1.0 cm semi-pedunculated polyp was found in the sigmoid colon (Figure 2). Pathology of the ileal mass was consistent with DLBCL, non-germinal center B cell origin; pathology of the sigmoid polyp was tubular adenoma with large atypical lymphoid submucosal cells, suggestive of lymphatic involvement. DISCUSSION: The ileocolonic area is the least common site of primary GI lymphoma, accounting for only 0.3-0.5% of malignancies found there. Most patients present with abdominal pain, lower GI bleeding, or weight loss. GI lymphoma is more common in men, age 60-70s. Other risk factors are immunosuppression, chronic viral illness, H. Pylori, IBD, and Celiac disease. CT is the mainstay in diagnostic imaging. However, radiographic and endoscopic appearance cannot differentiate GI lymphoma from other malignancy; biopsy is the only way to confirm diagnosis. DLBCL is the most common subtype, with mantle cell and follicular lymphoma less prevalent. There is no standard treatment, although surgery is generally performed given risk of spontaneous perforation. Chemotherapy is often offered alone or adjuvantly as disease usually extends beyond local fields. Though our case has some typical features of GI lymphoma, ileocolonic involvement is very uncommon, and occurrence in multiple areas is rare, found in less than 10% of primary GI lymphomas. Thus, this case is unique, as the patient had an ileal mass as the primary site of DLBCL with a polyp in the sigmoid, suggesting lymphatic spread.

3125 CMV Infection Presented as Asymptomatic Inflammatory Polyp in Immunocompetent Patient

INTRODUCTION: Colonic manifestations of the CMV infection are significantly more common in immunocompromised patients than immunocompetent individuals. Typical endoscopic findings include inflammatory changes of the colonic wall with ulcerations. Though extremely rare, mass lesions in colon due to CMV infection have been previously reported [1,2]. We report a case of a large inflammatory polyp secondary to CMV in immunocompetent patient during colonoscopy. CASE DESCRIPTION/METHODS: A 71-year old asymptomatic male patient presented for colonoscopy after positive Cologuard test. He denied any gastrointestinal symptoms and had no significant previous medical history. On exam patient had an inguinal hernia. Previous colonoscopy evaluation more than 10 years ago was normal. Colonoscopy revealed a sessile ascending colon 15 mm polyp and 10 mm semi-pedunculated polyp in sigmoid (Figure 1), both of which were removed with hot snare. Histopathology report showed positive immunostaining for CMV in sigmoid polyp. DISCUSSION: CMV related colonic lesion in immunocompetent patient is an unexpected finding. We found only 3 previous reports in the literature [3-5]. Given the potential infectious pathophysiology of this polyp infectious disease referral was made. In addition to the endoscopic removal via polypectomy, antiviral therapy was described as an effective treatment modality in the case of assumed superimposed CMV infection of suture line inflammatory polyps [3].

Retrograde NaviAid Enteroscopy-Assisted Resection of Distal Ileal Hamartomatous Polyps

Introduction: Hamartomatous polyps are rare GI polyps, often associated with Peutz-Jegher syndrome and Cowden's disease. With the advent of capsule endoscopy diagnostic evaluation of the small bowel has improved significantly. Yet, therapeutic interventions remain limited to push enteroscopy or device-assisted enteroscopy with balloon or spiral-overtube which are time consuming and require specialized training and equipment, making surgical intervention necessary far too often. NaviAid is a novel balloon assisted enteroscopy device using through-the-scope balloon on a standard endoscope allowing for deep intubation of the small intestine with rapid procedure times. We present two cases of NaviAid assisted retrograde enteroscopy used for resection of small bowel hamartomas thus preventing the need for surgical resection. Case 1: A 30-year-old female presented with anemia, melena, dizziness and fatigue with prior unrevealing colonoscopy and endoscopy. Her past medical history was noncontributory and family history was negative for cancer. She underwent a capsule endoscopy which showed a 25 mm ulcerated polypoid lesion in the distal ileum approximately 10 cm upstream from the Ileocecal valve. The patient underwent NaviAid assisted retrograde enteroscopy in which the partially obstructing mass was seen in the distal ileum (fig 1), successfully resected en-bloc with endoscopic mucosal resection. Pathology confirmed a hamartomatous polyp with features of Peutz-Jegher Syndrome (fig 2). Case 2: A 46-year-old male with history of Peutz-Jegher syndrome, diagnosed at age 4 years status post bowel resection for repeated bowel obstructions underwent a surveillance capsule endoscopy showing a 20 mm semi-pedunculated polyp in the distal ileum. He underwent a NaviAid assisted retrograde enteroscopy for removal of his distal ileal polyp. En-bloc endoscopic mucosal resection was successfully performed and the polyp was confirmed to be a hamartomatous polyp consistent with his clinical diagnosis of Peutz-Jegher syndrome. Discussion:Hamartomatous polyps can present initially as a small bowel obstruction as seen in patient 2, or insidiously with anemia and bleeding as seen in patient 1. NaviAid assisted enteroscopy successfully allowed for resection of hamartomatous polyps preventing the need for surgical intervention in these patients and should be considered for endoscopic resection of these polyps via antegrade or retrograde enteroscopy.2151_A Figure 1. NaviAid enteroscopy showing large distal ileal hamartomatous polyp2151_B Figure 2. Path showing characteristic arborizing pattern of smooth muscle distribution in the hamartomatous polyp

Haemobilia due to hepatic artery pseudoaneurysm

An 83-year-old woman with a history of hepaticoduodenostomy 20 years ago was admitted with upper gastrointestinal bleeding. Emergency upper gastrointestinal endoscopy revealed multiple blood clots over the stomach and first...

癌化した胃ポリープをESDにて切除し得たPeutz-Jeghers症候群の1例

An 18-year-old woman was referred to our department for examination of a large gastric polyp. She had one pigmented spot on her upper lip. She did not have a family history of Peutz-Jeghers syndrome. Esophagogastroduodenoscopy revealed a large semipedunculated polyp measuring 50mm in diameter at the greater curvature of the upper gastric body. Pathological examination of a biopsy specimen showed hyperplasia of glandular epithelium and no evidence of malignancy (Group 1) . Endoscopic submucosal dissection (ESD) was performed. Pathological examination of the resected specimen showed smooth muscle bundles with an arborizing appearance throughout the lamina propria with a tiny focus of well-differentiated adenocarcinoma. We reported a case of adenocarcinoma associated with Peutz-Jeghers syndrome-type gastric polyp that was curatively resected by ESD.

Atypical Eosinophilic Esophagitis

The classic endoscopic findings of eosinophillic esophagitis (EoE) are linear furrowing, concentric esophageal rings, diminished vascular pattern, white surface exudates and linear tears. Occasionally, in severe cases of EoE, a small caliber esophagus and strictures can be seen. These findings are not pathognomonic but collectively suggest the diagnosis of EoE. In this case report, we present a rare endoscopic finding of an esophageal polyp secondary to eosinophillic esophagitis. A 36-year-old Italian woman presented with burning chest discomfort, difficulty swallowing and regurgitation of food for the past year. She reports a history an esophageal tumor diagnosed 19 years earlier, treated with multiple sessions of laser ablation therapy. Due to progressively worsening symptoms she underwent an upper endoscopy and was found to have a single, 3cm semi-pedunculated polyp in the distal esophagus. Multiple biopsies were taken and pathology revealed esophageal mucosa with a focal marked increase in intraepitheal eosinophils. The patient was referred for Endoscopic Ultrasound (EUS) with Endoscopic Mucosal Resection (EMR). Upon further questioning she admitted to having a history of asthma and seasonal allergies, raising suspicion for EoE. She was given a trial of prednisone and proton pump inhibitor. Two weeks later EUS evaluation revealed a single, small 5mm polyp in the distal esophagus. Pathology revealed fragments of a squamous papilloma with acute inflammation. The patient was diagnosed with an atypical endoscopic manifestation of eosinophillic esophagitis. Eosinophilic esophagitis is an allergy-associated disease increasingly recognized in industrialized countries. The prevalence is estimated to reach up to 50 patients per 100,000 people in some regions1. It is unclear whether the increase in prevalence is secondary to a rise in incidence or better understanding of the disease. EoE has been described with classic endoscopic findings such as linear furrowing, concentric esophageal rings, diminished vascular pattern, white surface exudates and linear tears. In this case we recognize a unique endoscopic finding of an esophageal polyp in a young woman secondary to EoE. In review of the literature, this rare finding has primarily been described in the pediatric population. This case should heighten awareness of an association between eosinophilic esophagitis and esophageal polyps.

Familial Adenomatous Polyposis (FAP): A Rare Presentation of Severe Anemia with Pancytopenia

While anemia is present in nearly one quarter of patients at the time of primary diagnosis of FAP and varies in severity and incidence depending on anatomic site of carcinoma, the full range or degree of anemia and coexistent cytopenias are not well described. A 26-year-old Caucasian-American male without notable medical history presented with dyspnea, fatigue and night sweats for three days associated with a ten-pound weight loss over the past month. The patient was febrile, tachycardic, and pale on examination. Initial evaluation revealed pancytopenia with a significant iron deficient anemia (Hb 3.7 g/dL, MCV 52.4 fL, iron 12 ug/dL, ferritin 7 ng/mL, percent iron saturation 3.8), neutropenia (1100/uL WBC, ANC 675/uL), and thrombocytopenia (96,000/uL PLT). The patient was initially managed for neutropenic fever with suspicion of infection or hematological malignancy. Fecal occult blood returned positive. Infective evaluation was negative. CT demonstrated splenomegaly with non-enlarged scattered lymph nodes. Bone marrow biopsy revealed absent iron stores without evidence of malignancy. After resolution of neutropenia, colonoscopy revealed innumerable pedunculated and semi-pedunculated polyps from rectum to cecum. Pathology returned with multiple fragments of tubular adenomas, negative for high-grade dysplasia or malignancy. Genetic evaluation diagnosed FAP with a heterozygous mutation in the APC gene. Laparoscopic total abdominal colectomy with ileorectal anastamosis confirmed two synchronous invasive moderately differentiated colonic adenocarcinomas arising from separate tubular adenomas, polyposis coli, and metastatic disease involving 1 of 43 mesenteric lymph nodes, defining a stage IIIA pT2M1aM0 colon cancer. The patient now continues with his second cycle of modified FOLFOX chemotherapy. The case above fits the general description of presentation for FAP based on studies to date with fecal occult blood positivity (59% overall) and microscopic bleeding detected in 72% of patients between 20 and 40 years old. Nearly a quarter of patients suffer from anemia overall, ranging by age group (21% age 20-40, 17% age over 40) and location of carcinoma (35% rectal, 44% colonic, 43% small bowel). To the author's knowledge, there are no consistent reports regarding degree of anemia or other cytopenias, which evidently range from mild to severe, even without a history of visible colonic bleeding.

A case of mucosa-associated lymphoid tissue lymphoma of the sigmoid colon presenting as a semipedunculated polyp.

Mucosa-associated lymphoid tissue (MALT) lymphomas are characterized by lymphoepithelial lesions pathologically. Colonic MALT lymphomas are relatively rarer than lymphomas of the stomach or small intestine. Endoscopically, colonic MALT lymphoma frequently appears as a nonpedunculated protruding polypoid mass and/or an ulceration in the cecum and/or rectum. We report a unique case of a colonic MALT lymphoma presenting as a semipedunculated polyp. A 54-year-old man was found to have a 2-cm semipedunculated polyp in the sigmoid colon during screening colonoscopy. The polyp was removed by endoscopic mucosal resection. Histologic examination of the resected polyp revealed diffuse epithelial infiltration by discrete aggregates of lymphoma cells. We diagnosed the tumor as low-grade B-cell MALT lymphoma by immunohistochemical staining.

Inflammatory “Cap” Polyposis

Inflammatory cap polyposis (ICP) is a rare nonneoplastic polyposis of the colon of unknown etiology that can be confused with prolapse-induced polyps and hyperplastic polyposis. We contribute a case of ICP from a 59-year-old woman who was affected by severe constipation and hematochezia. Numerous sessile and semipedunculated polyps were found in the colon, all with cap of whitish fibrin. Histology revealed erosion of the surface, superficial dilated crypts filled with mucoid inflammatory exudate, and minimal crypt serration, all findings typical of ICP. Only the largest polyps had smooth muscle in the mucosa. Ki-67 showed modest expansion and irregular distribution of the crypts proliferative areas. Low-degree positivity for p16, similar to that of hyperplastic polyps, was found. CK20 was expressed as in normal mucosa. Distinguishing between ICP and other polyposis is important because of difference in management.

A Woman With Pruritus Ani

Question: A 79-year-old woman with no medical history presented to our hospital with pruritus ani. A well-defined, circular, erythematous, hypopigmented macule measuring 15 mm in diameter was observed around the anus (Figure A). The patient had no gastrointestinal symptoms, and laboratory findings, including serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels, were normal. Examination of biopsy specimens of the hypopigmented skin lesion showed Paget’s cells. Immunohistochemical staining of the skin lesion was positive for cytokeratin (CK)-20, but negative for gross cystic disease fluid protein (GCDFP)-15. Digital rectal examination revealed a 10-mm, semipedunculated, movable polyp in the lower rectum adjacent to the anal canal. Colonoscopic examination revealed a 10-mm, semipedunculated polyp on the proximal side of the dentate line in the lower rectum (Figure B). Biopsy specimens of the rectal polyp revealed moderately differentiated adenocarcinoma. A wide local excision of the perianal skin including the mucosa of the anal canal and lower rectum was performed. What is the diagnosis? Look on page 1160 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information n submitting your favorite image to Clinical Challenges and Images in GI.

Pyogenic granuloma of the small bowel

A 61-year-old man was referred to our hospital because of melena and progressive anemia requiring transfusion. He was on hemodialysis because of diabetic nephropathy. Although upper gastrointestinal endoscopy, colonoscopy, and a computed tomography (CT) scan were all normal, a subsequent capsule endoscopy revealed a tumor and blood in the middle part of the small intestine (● Video 1). Because both anterograde and retrograde single-balloon enteroscopy failed to reach the tumor and repeated transfusions were necessary, a laparoscopy was performed. The lesion was easily identified during surgery as it had caused a small-bowel intussusception (● Fig.1). The resected specimen showed a mulberry-like semipedunculated polyp 1.5cm in diameter (● Fig.2). Histological study revealed that the tumor was composed of a proliferation of capillaries with a dense inflammatory cell infiltrate in the lamina propria, consistent with a pyogenic granuloma (● Fig.3). The patient’s anemia has improved and his clinical course has been uneventful since the surgery. Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular tumor of the skin and mucous membrane, usually arising on the extremities and oral mucosa. The nomenclature is misleading because pyogenic granuloma is unrelated to bacterial infection, although its real etiology is unknown. Possible triggers include mechanical injury and pregnancy, but drug-induced pyogenic granuloma has also been reported [1,2]. As pyogenic granulomas bleed repeatedly and spontaneous regression is exceptional, surgical removal is a standard approach. Pyogenic granuloma of the gastrointestinal tract is a rare condition: to date, less than 30 cases have been reported in the English literature [3–5]. Although they occur throughout the entire gastrointestinal tract, the small intestine is the commonest site, followed by the esophagus and the colon. Polypectomy is a reasonable option; however, the endoscopic approach is occasionally difficult in cases of small-bowel pyogenic granuloma. In some cases, despite their relatively small size (0.7–3cm in the reported cases), gastrointestinal pyogenic granulomas bleed easily and profusely. Capsule endoscopy and balloon enteroscopy may facilitate the management of small-bowel pyogenic granulomas.

A Second Assisting Endoscope for the Removal of an Accidentally Unreleased Detachable Snare during Colon Polypectomy

The incidence of postpolypectomy hemorrhage ranges from 0.3% to 6.1%, and is the most common complication of polypectomy.1 The risk of bleeding may be especially high after resecting pedunculated polyps because of the presence of a large artery in the stalk. Bleeding can occur in the immediate postpolypectomy period, or may be delayed up to 29 days.2 Several endoscopic techniques have been developed. In 1989, Hachisu3 developed a detachable snare device that completely stops blood flow in the stalk. While loading the detachable snare, it is important to verify that it is properly attached to the hook wire and smoothly pulled into and then pushed back from the coil sheath without getting stuck.4 A second endoscope-assisted endoscopic submucosal dissection for large colorectal tumors has been reported recently.5-7 Here, we report a case in which an accidently unreleased detachable snare used for colon polypectomy was successfully removed by a second assisting endoscope. A 40-year-old man underwent screening colonoscopy. A grossly 1.5 cm-sized pedunculated polyp with a 3 cm-long stalk was observed at the distal descending colon. A detachable snare (MAJ-254; Olympus, Tokyo, Japan) was placed around the lower one-third of the stalk. The detachable snare could not be released from the hook wire of the operating part, as the loop of nylon thread appeared to be tightly stuck between the coil sheath and hook wire. Hence, the snare loop and coil sheath were attached to the colon polyp, and the colonoscope could not be retrieved (Fig. 1). Fig. 1 The unreleased snare observed by the second assisting endoscope. A second assisting gastroscope was inserted. The stalk was cutoff with a conventional snare between the snare loop and the polyp head. Cutting of the unreleased detachable loop with hot biopsy forceps and an insulation-tipped diathermic knife was then attempted, but failed. A conventional snare was placed just above the rubber stopper of the detachable snare (Fig. 2), and the detachable snare, which tightly strangulated the stalk, was successfully released from the stalk by cutting at that position, and all the specimens were retrieved (Fig. 3). No complications such as bleeding or perforation were noted during the 2 weeks of follow-up. Fig. 2 Snare resection of the stalk just above the rubber stopper. Fig. 3 Gross specimen of the removed polyp. Clinical evidence supports the usefulness of the detachable snare in the management of postpolypectomy bleeding, bleeding from esophageal and gastric varices, and angiodysplasias.4 The detachable snare was developed for the prevention of hemorrhage after the removal of large pedunculated polyps.1 Hence, the most probable reason for the detachable snare not being released was that it got stuck between the coil sheath and hook wire in this case. Several complications related to the detachable snare have been reported. It became entangled with the polypectomy snare in one patient, and the proper transection of peduncle failed in another patient.8 A slip-off of an endoloop slip-off in five of 53 patients, and delayed bleeding occurred in three of 53 patients, especially those with semipedunculated polyps.8,9 A second gastroscope may easily be inserted up to the descending colon without increasing the patient's discomfort and may efficiently act as another hand by lifting the dissected lesion during the dissection procedure.5-7 In our case, a second endoscope, however, was required for the successful removal of the unreleased snare and colon polyp, as the first endoscope was unsuccessful.