Sigmoidoscopy Research Articles

S1853 Gastrointestinal AL Amyloidosis: A Rare Cause of Symptomatic Colitis

Introduction: Gastrointestinal (GI) symptoms of systemic diseases are often poorly characterized. Evaluation of intractable symptoms may include advanced studies, such as computed tomography (CT) and magnetic resonance imaging scans, esophagogastroduodenoscopy (EGD) and colonoscopy. Amyloidosis, characterized by the extracellular deposition of insoluble misfolded proteins, can result in the deposition of abnormal proteins into the GI tract. GI amyloidosis (GIA) is difficult to diagnose and treat due to its variable etiologies and clinical manifestations. Current literature on GIA is vastly limited to case reports. We describe a case of GIA diagnosed by colonic biopsy. Case description/methods: 77-year-old female with past medical history of hypertension and chronic kidney disease presented with nausea, vomiting, diarrhea, left lower quadrant pain (LLQ) , anorexia, and a 20-pound weight loss. She was evaluated five months prior and treated for dyspepsia without relief. A recent CT scan of her abdomen revealed transverse, descending, and sigmoidal colonic wall thickening consistent with colitis. Antibiotics failed to improve her symptoms and unfortunately resulted in Clostridium difficile colitis. On physical exam, she was hypotensive, tachycardic, tender to palpation in the LLQ, and had 1+ pitting pedal edema. Labs revealed a leukocytosis, and anemia with hemoglobin 9.4 g/dL. GI pathogen panel was negative. Repeat CT scan revealed a thickened gastric wall in addition to previously noted colonic wall thickening. EGD and flexible sigmoidoscopy noted gastritis, duodenitis, and diffusely friable exudative colonic mucosa with underlying fibrosis (Figure 1). Pathology revealed extensive amyloid deposition. Bone marrow biopsy with flow cytometry showed plasma cell myeloma, confirming the diagnosis of GIA. Discussion: GIA is differentiated by systemic versus localized forms; the incidence of AL amyloidosis is approximately 1/100,000 in Western countries. Studies have shown that biopsy proven GIA is a rare phenomenon, consisting of as little as 3.3% of all cases. The most common symptoms of GIA are GI bleeding, malabsorption, nausea, vomiting, and protein-loss gastroenteropathies. Clinicians should be aware of these symptoms in elderly patients so that GIA can be diagnosed and treated early to minimize morbidity and mortality.Figure 1.: Endoscopic images demonstrating diffusely friable, exudative mucosa at the splenic flexure (A), descending colon (B,C) and sigmoid colon (D,E,F).

S1889 Colon Cleansing for Weight Loss: A Case of Severe Pancolitis

Introduction: Colon cleanses in the form of oral laxatives marketed as weight-loss tools are becoming increasingly popular. Here, we outline a case of a previously healthy 30-year-old female who presented with diarrhea and was found to have severe pancolitis after a 14-day colon cleanse in the form of an oral herbal supplement called ZuPoo. Case description/methods: The patient initially presented to the emergency department with diarrhea and abdominal pain that persisted 10 days after stopping a colon cleanse. On arrival, she was tachycardic to 140bpm, tachypneic to 40bpm, and febrile to 38.2°C. Labs were notable for a leukocytosis of 20,900 μl and a normal lactate of 1.4 mmol/L. Blood cultures and infectious stool panels including c dif were negative. CT scan of the abdomen showed diffuse severe pan colitis and moderate small bowel dilatation. She was started on IVF and empiric IV antibiotics and admitted. She underwent a sigmoidoscopy on day 2 with concern for inflammatory bowel disease showing mild to moderate inflammation with biopsies negative for active inflammation (Figure 1). Her diarrhea progressed, and she was persistently tachycardic despite heavy IV fluid resuscitation with a leukocytosis of 56,000 μl and a lactate of 9.6 mmol/L. On day 4 she became pulseless in asystole after an episode of large volume emesis. She was intubated and ROSC was achieved after 20 minutes. An x-ray of her abdomen showed pneumatosis intestinalis and she underwent emergent bowel resection. She had progressive multi-organ failure and 4-pressor shock. Over the following 3 days, she underwent multiple bedside laparotomies with bowel resections. She was treated with broad spectrum antibiotics and high dose steroids before the ultimate decision to withdraw care was made. Discussion: This case demonstrates a temporal relationship between a colon cleanse and severe prolonged diarrhea with pancolitis on imaging without a clear etiology otherwise. There is available data on the risks colonic irrigation for weight loss including dehydration, electrolyte imbalances, infection, and perforation. Information on the risks of herbal supplements used for colon cleansing, however, is not widely available and poorly studied. A 2016 study showed that 10.5% of women aged 23-35 used over the counter laxatives for weight loss. While studies in the past have outlined the dangers of laxative abuse, further research is needed to carefully elucidate the risks of commercially available herbal supplements marketed as colon cleanses for weight-loss.Figure 1.: Previously healthy 30-year-old patient presented with prolonged diarrhea after using an herbal colon cleanse for weight loss with a flexible sigmoidoscopy showing mild erythema, granularity, and decreased vascular pattern in the rectum and sigmoid colon.

S1736 A Case of Primary Signet Ring Cell Carcinoma in a Colon Polyp on Routine Colonoscopy

Introduction: Colon polyp size contributes significantly to the assigned surveillance interval for prevention of colorectal carcinoma (CRC). Polyps ≤5-mm generally have a negligible risk of malignancy and colonic invasion (< 1%) and are often amenable to standard endoscopic resection. We present a patient undergoing her index average risk screening colonoscopy found to have rare colorectal primary signet ring cell carcinoma (SRCC) in a 5-mm polyp, necessitating surgery. Case Description/Methods: A 52-year-old Hispanic female with hypertension presented for her first routine screening colonoscopy. She denied a family history of gastrointestinal malignancy and was otherwise asymptomatic. A 5-mm, Paris Is sessile polyp was noted in the sigmoid colon (Image 1a) and was resected en-bloc with a cold snare. Histology showed poorly differentiated, invasive adenocarcinoma with signet ring cells (Image 1d). A staging abdominopelvic CT scan did not reveal pathologic lymphadenopathy or distant metastatic disease. Based on the histological findings and imaging, the patient returned for a flexible sigmoidoscopy to tattoo the lesion, and then underwent robotic-assisted laparoscopic sigmoid colectomy. There was no evidence of malignancy in the surgical pathology specimen. Discussion: SRCC is an epithelial malignancy with prominent intracytoplasmic mucin typically found in gastric glandular cells. Colorectal primary SRCC is a rare clinical entity accounting for 1% of all CRCs. It is often detected at an advanced stage, and therefore its overall prognosis is worse than other types of CRC. Risk factors for lymph node metastasis in pT1 polyps invading the submucosa include deep submucosal invasion for sessile lesions, poor differentiation, lymphovascular invasion, rectal location, tumor budding/mucinous tumors and the presence of either positive or indeterminate resection margins. The decision regarding surgical intervention after endoscopic resection of pT1 colorectal polyps is a complex one and depends upon the risk of residual cancer in the bowel wall and metastatic spread to adjacent or remote lymph nodes. Studies suggest that endoscopic resection before surgical resection of a high-risk pT1 CRC has no adverse effects on morbidity and mortality. In SRCC, factors such as advanced age, higher tumor grading and size, primary tumor location and nodal involvement are significantly correlated with a poor prognosis, thus, as seen in our patient, immediate colectomy provides the highest chance of survival.Figure 1.: A computed tomography scan of the abdomen exhibited diffuse fluid-filled dilatation of the colon with wall thickening and peri-colonic haziness, most prominent in the sigmoid colon and rectum. Chronic bilateral hydronephrosis and chronic cystitis were present as well.

S1801 Lost Sleep over Melatonin Induced Colitis

Introduction: Lymphocytic colitis (LC), a subtype of microscopic colitis, is an uncommon cause of chronic diarrhea. It has a rising incidence of 12.6 per 100,000 person-years due to increased understanding and awareness of the disease. Aside from watery diarrhea, other signs and symptoms are nonspecific and may include abdominal pain, fatigue, and weight loss. LC has been associated with a number of medications including non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPIs), and selective serotonin re-uptake inhibitors (SSRIs). We present a rare case of LC induced by melatonin usage. Case Description/Methods: A 77-year-old male with new onset primary insomnia presented with complaint of diarrhea. Symptoms had been ongoing for 6 weeks characterized by 5 watery, non-bloody bowel movements per day. He denied recent dietary changes, travel history, infectious symptoms, or sick contacts. Notably, at symptom onset he had started taking melatonin for his insomnia, but otherwise, denied any other new medications. He was prescribed loperamide, which did not significantly improve his symptoms prompting further workup and a referral to a gastroenterologist. Comprehensive stool panel, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and immunoglobulin A (IgA) were all unremarkable. Patient eventually underwent flexible sigmoidoscopy, which showed grossly normal appearing colonic mucosa. Random biopsies were obtained with pathology showing 20 plus intraepithelial lymphocytes per 100 epithelial cells, which is consistent with LC. Given the temporal association between the initiation of melatonin and onset of symptoms it was suspected that melatonin was the causative agent. Patient declined budesonide treatment and fortunately with cessation of melatonin had resolution of symptoms 12 weeks later. Discussion: The etiology of lymphocytic colitis and related disorders is likely multifactorial involving environmental triggers in genetically susceptible individuals. Throughout our literary review this appears to be the first documented case report of LC secondary to melatonin use. Diagnosis of LC and related disorders is difficult given overlap with other chronic diarrheal diseases. However, management LC is considerably different than other diarrheal diseases highlighting the importance of accurate diagnosis. Treatment of LC includes cessation of any precipitating medications and dietary restrictions as well as initiation of budesonide, the standard drug of choice.

S1712 Peutz-Jeghers Polyp Presenting With Colo-Colonic Intussusception – Managed Endoscopically

Introduction: Adult intussusception is defined as the invagination of proximal bowel into distal bowel. This phenomenon occurring in adults is rare, generally arising in the small intestines with a small percentage occurring in the colon [1]. We present a rare case of a twenty-five-year-old man with intussusception complicated by colonic obstruction that was found to have an eight-centimeter polyp acting as a lead point. Case Description/Methods: A twenty-five-year-old male with no past medical history presented with abdominal pain and hematochezia. He reported nausea but denied other symptoms. He denied tobacco or illicit drug use but did admit to intermittent alcohol use. He was afebrile and hemodynamically stable. A CBC, BMP, and LFT's were within normal limits. A CT scan of the abdomen and pelvis demonstrated a 3-cm focal enhancing lesion at the junction of the descending and sigmoid colon with associated intussusception (Figure 2). Flexible sigmoidoscopy showed an eight-centimeter polyp at the descending colon with colonic obstruction (Figure 1). Air insufflation resulted in resolution of the intussusception and obstruction. The polyp was resected and sent for pathology which showed a Peutz-Jeghers polyp (Figure 1). The patient was discharged home and unfortunately was lost to follow up. Discussion: Intussusception is classified according to location, cause and presence or absence of a lead point. The ultimate goal in management is the reduction of prolapsed bowel to prevent ischemia and necrosis via surgical or endoscopic intervention. An uncommon cause of adult intussusception is Peutz-Jeghers Syndrome (PJS) - an autosomal dominant disorder characterized by hyperpigmented mucocutaneous macules, hamartomatous polyps within the gastrointestinal tract, and an increased risk of developing cancer [3]. The risk for developing cancer in PJS is 85%, representing a four-fold increased risk in comparison to the general population [2]. Therefore, early diagnosis and establishment of routine cancer screening is paramount in the long term management of patients with PJS.Figure 1.: A). Endoscopic image of eight-centimeter polyp in situ B). Endoscopic image showing encapsulation of polyp via snare C). Endoscopic image demonstrating scar after polypectomy D). Resected eight-centimeter polyp Figure 2. E) and F). Transverse and coronal sections of the CT scan of the abdomen/pelvis demonstrating a 3-cm focal enhancing lesion at the junction of the descending and sigmoid colon with associated intussusception.

S129 Flexible Sigmoidoscopy Is Sufficient for Evaluation of Diarrhea in Patients With Suspected Immunotherapy-Mediated Colitis

S129 Flexible Sigmoidoscopy Is Sufficient for Evaluation of Diarrhea in Patients With Suspected Immunotherapy-Mediated Colitis

S2941 Fecal Microbiota Transplant in Recurrent Clostridium difficile Enteritis Following Colectomy

Introduction: Fecal microbiota transplant (FMT) is well-known as treatment for recurrent Clostridium difficile infection (CDI). It is curative in 80% of severe or fulminant CDI cases. In this case, we explore the utility of FMT in a patient with recurrent C. diff enteritis (CDE) after colectomy with ileorectal anastomosis. Case Description/Methods: A 46 yr old woman underwent abdominal colectomy with ileostomy 05/2020 with ileorectal anastomosis 07/2020 for severe colonic inertia and h/o ligament release for Median Arcuate Ligament Syndrome in 2/2021. She initially presented with RUQ abdominal pain, nausea, vomiting and diarrhea during the 1st episode of CDI in 10/2020 which was treated with Vancomycin 125mg PO QID for 10 days. Symptoms recurred a month later, C. diff toxin (CDT)+, and this 2nd episode was treated with 3 weeks of Vancomycin 125mg PO QID. Symptoms resolved but recurred 5 months later with hospital admission, again CDT+. CBC and renal function were normal. CT abdomen/pelvis showed nonspecific prominent fluid-filled loops of proximal and mid small bowel consistent with focal ileus or enteritis. Patient was treated for the 3rd time on a prolonged Vancomycin taper (125mg QID x 10 days, 125mg TID x 7 days, 125mg BID x 7 days, 125mg QD x 7 days, 125mg QOD x 14 days) with plans for FMT. She was readmitted 2 months later for pain, nausea, vomiting and diarrhea, CDT-, and underwent planned FMT. FMT was performed via flexible sigmoidoscopy reaching 70cm proximal to the anus with 250cc of donor fecal material mixed with saline (Open Biome). Since FMT, patient has reported resolution of symptoms. Discussion: FMT for recurrent CDI in patients s/p colectomy is not well-documented. A small series of patients s/p colectomy over 20 years showed recurrent CDE does occur after colectomy, and results in severe disease in half of patients, requiring hospitalization in 81%. Risk factors for CDE were colectomy for IBD, colectomy for fulminant CDI, β-lactam use with enteral feeds, and acid suppression after colectomy. Cases of fulminant CDE with multiorgan failure and death have been reported (diagnosed post-mortem). A young man with UC s/p colectomy with IPAA with recurrent CDE was effectively treated with FMT. While rare, recurrent CDE is potentially fatal and warrants consideration of FMT as a treatment modality. Though our patient did not have IBD, was not immunosuppressed and underwent colectomy for reasons unrelated to IBD, the recurrent CDE was effectively treated with FMT.

S3593 A Unique Case of Life-Threatening Anorectal Bleeding Not Amenable to Endoscopic Therapy

Introduction: Anorectal bleeding accounts for a great number of patients presenting with acute hematochezia, with a majority of cases attributed to anal fissures or hemorrhoids. We describe a case of a life-threatening anorectal bleed from a large rectal ulcer not amenable to endoscopic therapy. The ulcer exposed a pulsatile vessel below the dentate line, ultimately requiring surgical consultation for exam under anesthesia and oversewing. Case Description/Methods: An 87-year-old man was admitted to the hospital for the second time in 3 weeks for acute painless hematochezia and symptomatic anemia. A colonoscopy done weeks prior revealed a large circumferential rectal ulcer without high risk stigmata. Biopsies of the ulcer were performed and revealed reactive changes without dysplasia. At that time, bleeding had ceased spontaneously and he was initiated on treatment for stercoral ulceration. Given his overall poor prognosis in setting of refractory metastatic GIST, patient pursued home hospice until returning for this presentation. On physical exam, he was frailwith limited mobility and his underwear was soiled with frank blood. His hemoglobin had decreased by 2 points from his baseline. While patient wished to remain on home hospice, he expressed clear desire to receive focused care for his acute hematochezia. Unsedated flexible sigmoidoscopy was pursued, noting diffuse and circumferential rectal ulceration with active bleeding emanating from a visible vessel along the dentate line. Retroflexion was not pursued given severity of rectal ulceration and perforation risk. Suctioning up of blood with inadvertent suctioning up of mucosa in this area elicited patient discomfort, confirming a sensate area of the anal verge. Because of the location of his bleeding site, endoscopic management was not pursued. After an interdisciplinary discussion regarding goals of care, surgery successfully ligated the bleeding vessel at bedside with local anesthesia. Patient was monitored post procedure in the hospital, continued on a bowel regimen, and able to return to home hospice. Discussion: This case highlights an unusual instance of a life-threatening anorectal bleed necessitating surgical intervention given location along the dentate line. The patient’s hospice status also highlights the nuanced complexity regarding goals of care in the setting of immediately reversible acute GI bleeding and the need for a multidisciplinary approach to optimize patient care.Figure 1.: Pulsating Vessel.

S1696 Vedolizumab Treatment of Refractory Immune Checkpoint Inhibitor Colitis

Introduction: Immune checkpoint inhibitors (ICI) are commonly associated with gastrointestinal adverse events including colitis. We present a case of severe immune checkpoint inhibitor colitis managed with vedolizumab after failing standard treatment with steroids and infliximab. Case Description/Methods: A 75-year-old male with metastatic melanoma status post brain tumor resection, radiation therapy and 2 cycles of ipilimumab/nivolumab presented with severe new onset diarrhea 3 weeks after his second cycle of ICI. Given concern for ICI induced colitis, oral prednisone was started with initial improvement of diarrhea. Severe diarrhea recurred with tapering and he was admitted to the hospital. After infectious workup was negative, he received a dose of infliximab for presumed immune-mediated colitis with mild improvement. He was discharged on prednisone 60 mg daily with a rapid 2-week taper before receiving COVID-19 vaccination. He received a second dose of infliximab 2 weeks after the first. However, a week later, he was readmitted to the hospital with grade 3 diarrhea, dehydration, weakness, hypotension, and continued weight loss. Flexible sigmoidoscopy revealed continuous mucosal ulceration with congestion and loss of vascular markings from anus to sigmoid colon (Figure 1). Biopsies showed moderate to severe active colitis with ulceration, increased crypt apoptosis, and crypt dropout-most compatible with immune checkpoint inhibitor colitis. After 1 week of poor response to high dose methylprednisolone, he was given 2 doses of vedolizumab 2 weeks apart which lead to a complete resolution of his GI symptoms. Four months later, he remains asymptomatic with a negative PET scan off vedolizumab and ICI therapy. Discussion: Immune checkpoint inhibitors (ICI) revolutionized therapeutics for malignancy in their enhancement of cytotoxic T cell survival, but the resulting robust immune response engenders adverse gastrointestinal events in 1/3 of patients around 1-2 months after the second or third dose. ICI colitis may result in abscess, perforation, and death, and it is imperative to undergo early endoscopy with biopsy plus initiation of steroids or immunotherapy, especially in severe cases. Our patient presented with grade 3 diarrhea and severe immune-mediated colitis refractory to steroids and infliximab, though vedolizumab was effective in resolution.

S1788 Metastatic Urothelial Carcinoma Presenting as Rectal Mass

Introduction: Colorectal cancer is the third most common malignancy worldwide. Metastases to the colon comprise 1% of colorectal neoplasms. We present a case of a new rectal mass discovered on imaging, which was subsequently found to be metastatic urothelial carcinoma. Case Description/Methods: An 81-year-old Hispanic man with history of small bowel resection secondary to mesenteric ischemia, and bladder urothelial carcinoma with metastasis to the lymph nodes, status post transurethral resection of bladder tumor, presented with subacute epigastric pain. Apart from chronic constipation, he denied other gastrointestinal symptoms including abdominal pain, changes in bowel habits, and hematochezia. An abdominopelvic CT was performed for restaging following chemotherapy, and revealed a new heterogeneous enhancing mass in the rectum with extension into the mesorectal fat. The patient underwent flexible sigmoidoscopy with findings of erythematous and congested rectal mucosa without mass or polyps (Figure 1). Biopsy was consistent with carcinoma of urothelial origin, and he was transitioned to third-line chemotherapy due to cancer progression. Discussion: Secondary metastasis to the colorectum is rare, but most prevalent in primary malignancies of the lung, ovary, and breast. Urothelial carcinoma is a malignancy of the transitional cells of the bladder. Typical sites of metastasis include liver, lungs, and bone. Urothelial metastases to the gastrointestinal tract are exceedingly uncommon, with only 33 reported cases in one literature review from 2017. Sixteen of those were metastatic to the rectum. The route of metastasis by urothelial carcinoma is often lymphogenous or hematogenous. When presenting with gastrointestinal involvement, particularly of the rectum, metastasis by direct extension is more common. In our case, there was no evidence of direct extension on imaging, and the likely route of metastasis was lymphogenous. Most patients with metastasis to the gastrointestinal tract present with gastrointestinal symptoms, though up to one-third are asymptomatic and often found on autopsy. Though imaging findings of gastrointestinal masses are concerning for primary malignancy, it is important to consider other causes, such as secondary metastasis.Figure 1.: Endoscopic image of the rectum with erythematous and congested mucosa.

Utilization of a Colorectal Cancer Screening Test Among Individuals With Average Risk

Colorectal cancer (CRC) screening reduces CRC incidence and mortality. It is important to examine screening patterns over time, including after the introduction of new screening modalities. To compare use of CRC screening tests before and after the availability of the multitarget stool DNA (mt-sDNA) test, given that endorsed options have changed. This longitudinal cohort study used administrative claims data to examine CRC screening use in 2 discrete periods: before (August 1, 2011, to July 31, 2014) and after (August 1, 2016, to July 31, 2019) the mt-sDNA test became available. The MarketScan Commercial and Medicare Supplemental databases were queried for individuals aged 45 to 75 years between August 1, 2011, and July 31, 2019, with average risk of CRC and with continuous enrollment in the databases from August 1, 2001, to July 31, 2019. The proportion of individuals up to date or not due for CRC screening during each measurement year and the type of screening test used among individuals due for screening. Data were reported overall and among individuals aged 45 to 49 or 50 years and older on August 1, 2011. A total of 97 776 individuals with average risk were identified. Individuals had a mean (SD) age of 50.8 (3.5) years, and 54 227 (55.5%) were women. The proportion of individuals with average risk aged 50 to 75 years with commercial or Medicare supplemental insurance who were up to date with CRC screening increased from 50.4% in 2011 (30 605 of 60 770) to 69.7% in 2019 (42 367 of 60 770). Among individuals due for screening and screened, the use of high-sensitivity fecal occult blood test (FOBT) decreased between 2011 (1088 of 6241 eligible individuals [17.7%]) and 2019 (195 of 2943 eligible individuals [6.6%]), and the use of mt-sDNA increased between 2016 (58 of 3014 eligible individuals [1.9%]) and 2019 (418 of 2943 eligible individuals [14.2%]). No consistent trends were observed with fecal immunochemical test (FIT) or screening colonoscopy. Computed tomography colonography, double-contrast barium enema, and flexible sigmoidoscopy were rarely performed. In this cohort study, the proportion of individuals with average risk who were up to date with CRC screening increased between 2011 and 2019 but remained suboptimal. There were no substantial changes in the use of the colonoscopy or FIT; however, there was an increase in the adoption of mt-sDNA and a decrease in the use of FOBT during the study period.

Routine Endoscopy After Acute Sigmoid Diverticulitis: Would a Sigmoidoscopy be Sufficient?

Background: Current guidelines suggest that patients should undergo colonoscopy after CT confirmed acute diverticulitis to outrule colorectal cancer (CRC). The aim of this study was to determine if flexible sigmoidoscopy (FS) could be a viable alternative to full colonoscopy following acute sigmoid diverticulitis.Methods: A retrospective study of 271 patients was performed who were diagnosed with acute sigmoid diverticulitis by CT and subsequently underwent full colonoscopy. Medical records, CT reports, endoscopy reports, and histopathological reports were reviewed.Results: Sigmoid diverticulosis was confirmed on colonoscopy in all patients. No colorectal malignancies were detected. Adenomatous polyps were found in 16 (5.9%) patients, of which three had polyps detected beyond the sigmoid colon. The overall proportion of abnormalities found beyond the sigmoid colon was 1.1% (n=3).Conclusion: The detection of CRC cancer in patients undergoing full colonoscopy following an episode of acute sigmoid diverticulitis is rare. Despite this, current guidelines still advocate for endoscopy due to the potentially serious consequences of a missed malignancy. However, given that the area of concern in these cases is the sigmoid colon, FS may be a feasible means of outruling malignancy in the absence of red flag features that would necessitate a full colonoscopy. Our results support this approach, with no CRC detected and a polyp detection rate equivalent to that of the general population. This offers numerous advantages to a full colonoscopy for the patient and health service by being a quicker, cheaper, safer procedure without the need for full bowel preparation or IV sedation.

Video Abstracts

Purpose/Background: It is well recognised that patients following long course chemoradiotherapy can have a complete clinical response. This offers the possibility for organ preservation. However these patients require intense surveillance which commonly involves frequent MRI scans and flexible sigmoidoscopy. LumenEye is a state of the art endoscopic kit, which allows a convenient, comfortable and efficient way of visualising the ano-rectal area in OPD with high quality images avoiding the need for a formal endoscopic procedure. Methods/Interventions: The device includes (a) LumenEye X1 endoscope (b) Tablet display with full HD screen (c) Intuitive CHiP software and (d) Portable case with workstation. The kit displays full HD images and can capture videos. Results/Outcomes: We have used the LumenEye X1 endoscope to survey patients following a complete clinical response who have opted for organ preservation. It avoids the need for an endoscopy and detailed images and videos can be shared with specialist centres. This has been of particular benefit during the Covid 19 pandemic where there has been a limited endoscopy resource. The technology also has other applications such as the intraoperative assessment of left sided colonic anastomosis. Conclusion/Discussion: LumenEye X1 endoscope offers an alternative to the use of endoscopy in the surveillance of patients with a complete clinical response. It also has the potential to free up valuable endoscopy resources.

Endoscopy in Pregnancy: A Systematic Review

Abstract Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy. Methods A systematic literature search was performed using PubMed. All original research articles with sample size &gt; 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021. Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (&gt;95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (&gt; 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy. Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

A rare complication of acute severe ulcerative colitis.

A 21-year-old female with ulcerative colitis presented with abdominal pain and bloody diarrhea. Laboratory studies revealed markedly elevated C-reactive protein and thrombocytosis. Flexible sigmoidoscopy revealed severe endoscopic activity with ulceration and spontaneous bleeding along rectum and sigmoid colon. Ulcerative colitis had been diagnosed 3 years before, presenting as severe and extensive disease (pancolitis). She had previously failed therapy with infliximab and vedolizumab and had recently started induction therapy with golimumab. She responded well to intravenous corticosteroids but, when switched to oral corticosteroids, there was symptomatic recurrence. Intravenous corticosteroids were re-started and she was evaluated for surgery. At this time, she developed new-onset tachycardia. Electrocardiogram revealed sinus tachycardia with heart rate of approximately 120 bpm. Because tachycardia could result from worsening colitis with potential serious complications, abdominal computerized tomography scan was performed and demonstrated mild lumen dilation and wall thickening consistent with acute colitis without evidence of pneumoperitoneum or toxic megacolon. Surprisingly, thoracic planes revealed the presence of free air dissecting mediastinal space (Figure 1). What is your diagnosis?

An Observational Analysis of a Novel Digital Rectoscope.

This is an analysis of the first 50 in-human uses of a novel digital rigid sigmoidoscope. The technology provides digital image capture, telemedicine capabilities, improved ergonomics, and the ability to biopsy under pneumorectum while maintaining the low cost of conventional rigid sigmoidoscopy. The primary outcome was adverse events, and the secondary outcome was diagnostic view. Fifty patients underwent outpatient (n = 25) and surgical rectal assessment (n = 25), with a mean age of 60 years. This included 31 men and 19 women with 12 different clinical use indications. No adverse events were reported, and no defects were reported with the instrumentation. Satisfactory diagnoses were obtained in 48 (96%) of 50 uses, images were captured in 48 (96%) of 50 uses, and biopsies were successfully taken in 13 uses (26%). No adverse events were recorded. Independent reviewers of recorded videos agreed on the quality and diagnostic value of the images with a κ of 0.225 (95% CI, 0.144-0.305) when assessing whether the target pathology was adequately visualized. The improved views afforded by digital rectoscopy facilitated a satisfactory clinical diagnosis in 96% of uses. The device was successfully deployed in the operating room and outpatients irrespective of bowel preparation method, where it has the potential to replace flexible sigmoidoscopy for specific use cases. The technology provides a high-quality image and video that can be securely recorded for documentation and medicolegal purposes with agreement between blinded users despite a lack of standardized training and heterogenous pathology. We perceive significant impact of this technology for the assessment of colorectal anastomoses, the office management of colitis, "watch and wait," and for diagnostic support in rectal cancer diagnosis. The technology has significant potential to facilitate proctoring and training, and it now requires prospective trials to validate its diagnostic accuracy against more costly flexible sigmoidoscopy systems.

SOLITARY RECTAL ULCER SYNDROME AND ITS RELATION TO SPECIFIC FOOD

Introduction: SRUS was rst identied as clinical identity in 1969. But the etiology is not known. Anal ssure, IBD, proctagia fugax and malignancy, rectal polyps, hemorrhoids, and infections. Rarely ischemia, trauma and cystic profunda colitis and Stercoral ulcers have to be excluded. Hence a careful history is important. Material and methods: Patients presenting with C/O constipation or straining at stools with difculty in passing motion with associated minimal bleeding per rectum on and off period less than a month were included in the study. All patients were investigated for stool for occult blood, Us abdomen, BMFT, CBP and exible sigmoidoscopy. Results:100 patients presenting with constipation and bleeding PR were investigated. Flexible sigmoidoscopy showed multiple pin point supercial ulcers on the anterior rectal wall without involvement of sigmoid colon. The incidence age group wise was seen very high between 20 to 60 years. M: F ratio 47:53. All were positive for stool for occult blood, negative for IBD and malignancy by biopsy. They responded to dietary changes i.e; veg, non spicy, non fried diet with antibiotic, mesalamine (400mg BD) and lactulose 15ml at bed time. 10 days after the test follow up sigmoidoscopy was found normal and patient asymptomatic even after 3 months. Discussion: The incidence of SRUS has become common irrespective of age and sex. The type of food used by all these patients was found to be more or less similar with majority of them using fast food, fried food, and spicy food. Stoppage of the above mentioned food with specic treatment for 10 days resulted in recovery with normal sigmoidoscopy. Conclusion: SRUS incidence is high in general population due to specic food type and evacuation behavior.

Intussusception Secondary to Adenocarcinoma of the Colon

Intussusception in adults is a rare occurrence, accounting for approximately 1%–3% of bowel obstruction cases. Here, we present a case of colocolic intussusception of the sigmoid colon caused by adenocarcinoma. A 67-year-old male presented to the emergency department with abdominal pain and rectal bleeding. A computed tomography (CT) scan revealed intussusception involving the sigmoid colon and a potential mass. In the operating room, the patient underwent flexible sigmoidoscopy, followed by sigmoidectomy and end colostomy. Pathological examination of the resected specimen confirmed moderately differentiated adenocarcinoma of the sigmoid colon with negative margins, and two of the 54 lymph nodes were positive for metastasis. A repeat CT scan of the abdomen showed multiple sub-centimeter low-density hepatic lesions, and biopsy confirmed a metastatic lesion. The patient ultimately elected hospice care. In this report, we describe a rare case of sigmoid intussusception in an adult patient, review the relevant literature, and summarize the diagnostic and management approaches suitable for adult intussusception cases.

Terminal ileum is the most sensitive site for the histologic diagnosis of grade 4 graft-versus-host disease (GvHD) in the lower GI tract and is a harbinger of poor outcome.

The site of the gastrointestinal (GI) tract where biopsies are most likely to be diagnostic of graft-versus-host disease (GvHD) remains controversial. Recent reports have indicated that biopsies from the rectosigmoid have sufficient sensitivity and specificity for diagnosing GI GvHD and can be obtained via a less invasive flexible sigmoidoscopy procedure. While GvHD histologic grades 1-3 have little correlation with patients' symptoms and overall clinical grade, histologic grade 4 GvHD does correlate with severe clinical presentation and a poor prognosis. We examined cases of lower GI biopsies obtained via a complete colonoscopy with ileal intubation for the evaluation of GvHD within a 2-year period from patients who underwent stem cell transplantation. In our study cohort, grade 4 GvHD was significantly more likely to be identified in a terminal ileum biopsy than in a biopsy from another site in the lower GI tract. Significantly, 5 of 6 patients with histologic grade 4 GvHD diagnosed on ileal biopsies died from complication of severe GI GvHD. Given the poor prognosis of histologic grade 4 GvHD in the terminal ileum, the detection of this finding may serve to inform clinicians that escalation or modification of treatment may need to be considered. Furthermore, our findings suggest that terminal ileal biopsies may help to increase sensitivity for identifying patients at high risk for poor outcome of GvHD.

Will a flexi-sig' do? A retrospective review of colonoscopies indicated by diverticulitis alone.

The incidence of colonic diverticulitis is increasing. In Australia the majority of diverticulitis occurs in the left colon and patients typically undergo colonoscopy following an attack. At present debate exists regarding the utility of this costly procedure and a flexible sigmoidoscopy has been proposed as a cheaper, less invasive alternative. This paper seeks to examine whether significant pathology is being detected in the right and transverse colon to warrant colonoscopy, as opposed to a flexible sigmoidoscopy. A retrospective review of colonoscopies performed between August 2016 and August 2018, indicated by diverticulitis alone, performed in a single Australian metropolitan hospital. 189 patient colonoscopies were reviewed in combination with the pathology forms. Only 1 primary colonic malignancy was detected, found in the left colon. 110 traditional adenomas and 35 sessile serrated adenomas were detected. 41.8% of patients had a polyp detected with an average of 1.9 polyps per patient. 38.6% of polyps were resected from the left colon while 61.4% were removed from the right and transverse colon. In total 30 polyps > 10mm or with high-risk histological features were resected, 18 (60%) from the left colon and 12 (40%) from the right and transverse. 20 patients (10.6%) met the criteria for high-risk adenomas and 50% of those had > 40% of their polyps in the right and transverse colon. There was no significant difference in age between patients with polyps and those without. Despite over half the patients having no polyps and only one left sided malignancy. This study demonstrates that the right and transverse colon is responsible for over 50% of the polyps removed and similar proportion of the advanced polyps. Where endoscopic surveillance after acute colonic diverticulitis is performed, this study supports the use of colonoscopy and cautions against flexible sigmoidoscopy alone.