[Endoscopic removal of large colorectal polyps]

BACKGROUND

Due to the potential risk of malignancy and technical difficulties in achieving complete removal, large colorectal polyps represent a special problem for the endoscopist. The aim of this study was to evaluate the capabilities and risks of endoscopy in complete removal of large colorectal polyps.

METHODS

Endoscopic polypectomy of 189 colorectal polyps (141 sessile, 48 pedunculated) larger than 3 cm in diameter (range 3-13 cm) was carried out. Sessile polyps were removed using the piecemeal technique.

RESULTS

Histology showed an adenoma in 173 cases, and invasive carcinoma was present in the adenoma in 16 patients. Complete endoscopic removal was achieved in one session in 129 sessile polyps and all pedunculated polyps; the other patients required two to ten sessions. Bleeding occurred in 20 patients during polypectomy, and after polypectomy in four. Except for two cases, definitive hemostasis was immediately achieved by endoscopic treatment. Perforation occurred in four patients. 3 were treated conservatively, in one patient who showed an invasive carcinoma of the cecum, resection was performed. There was no mortality due to polypectomy. During a median follow-up period of 77 months (6-107 months), six patients presented with recurrence of a benign adenoma, which was treated endoscopically, and one patient presented with a recurrent invasive carcinoma, which was treated surgically.

CONCLUSIONS

Endoscopic polypectomy is a safe and effective method of treating large colorectal polyps, associated with a low complication rate, reduced hospital stay and lower costs in comparison to surgical procedure.

Consider colonoscopy for young patients with hematochezia

BACKGROUND

Hematochezia is a common complaint in adult patients aged <50 years. Most studies of lower endoscopy for rectal bleeding have concentrated on older patients or have failed to mention the location of lesions.

OBJECTIVE

To determine the findings of complete colonoscopy in adults younger than 50 years with rectal bleeding.

METHODS

Data were retrieved from medical records and included demographics, indications, endoscopic findings, and histology. Lesions were labeled according to location: proximal to the splenic flexure or distal to (and including) the splenic flexure. Excluded were those with a history of colitis, colorectal cancer, polyps, anemia, significant weight loss, severe bleeding, or strong family history of colorectal cancer.

RESULTS

The study included 223 patients with rectal bleeding aged <50 years who had undergone a colonoscopy. Normal findings were recorded for 48 (21.5%). Four (1.8%) were diagnosed with cancer in the distal colon, and 22 (9.9%) were found to have colon adenomas, 6 of whom had proximal adenomas only. Hemorrhoids were present in 135 patients (60.5%). Other findings included colitis, angiodysplasia, diverticulosis, anal fissures, and rectal ulcers.

CONCLUSIONS

Colon neoplasms may be present even in younger adults with nonurgent rectal bleeding. Though most findings were benign and located in the distal colon, colonoscopy should be strongly considered for this patient group.

Inflammatory fibroid polyp of the caecum in a patient with neurofibromatosis

INTRODUCTION

Inflammatory fibroid polyp of the large intestine is uncommon. To our knowledge, this condition has not been reported in a patient with neurofibromatosis.

CLINICAL PICTURE

In this report, a 66-year-old woman with neurofibromatosis was found to have a large polyp in the caecum.

TREATMENT

Right hemicolectomy was performed because of the size of the polyp.

OUTCOME

Pathological examination showed that the polyp was an inflammatory fibroid polyp.

CONCLUSION

Clinicians should be aware that inflammatory fibroid polyps could be one of the many manifestations of neurofibromatosis in the gastrointestinal tract.

[Invagination caused by a malignant jejunal polyp--lessons from a diagnostic error]

Authors reviewed the records of a patient with a 6 year long history of severing abdominal complaints, correct diagnosis came only in the state of acute abdomen for ileus. He underwent numerous radiological exams and gastroscopies in the course of repeated check-ups in other institute. Due to these results his complaints were managed as gastro esophageal reflux. After years of ineffective therapy his parents and physician suggested him to apply for psychiatric treatment. Finally, for the symptoms and radiological results of mechanical upper small bowel obstruction he underwent urgent laparotomy. Approximately a 40 cm long jejunal invagination was found caused by a large jejunal polyp. Segmental small bowel resection was carried out. Histologic examination of the resected specimen proved Grade I. adenocarcinoma. One year after an uneventful postoperative period the patient is free of complaints and symptoms. The differential diagnosis between upper small bowel obstruction and severe vomiting of esophago-gastro-duodenal origin is relatively difficult. For this we recommend utilizing all the recent diagnostic methods in case of hesitancy or ineffective therapy.

Juvenile colorectal polyps in children: experience in Pakistan

Juvenile colorectal polyps are the most common cause of pediatric hematochezia and contribute to significant morbidity if not treated early. This report describes an experience with juvenile colorectal polyps in children (< or =14 years) from Pakistan. In a 3-year period, 154 polyps were documented in 129 children. The mean age at presentation was 5.2 years, with a male predominance. Most children presented with painless rectal bleeding (+/-13 months) associated with other symptoms, such as protrusion of a mass through the anus, diarrhea, and recurrent abdominal pain. Anemia was observed in 54 children, of whom 14 (26%) required blood transfusion before intervention. Diagnosis was made by digital rectal examination, proctosigmoidoscopy, and barium enema. The average distance of a colorectal polyp was 4 cm from the anal verge. In 108 (84%) children the polyps were solitary, whereas 21 patients had more than one polyp (maximum three) at different locations in the rectosigmoid area. All polyps were successfully removed by proctosigmoidoscopy. Histological examination revealed dysplastic changes in one case, while the rest were inflammatory. Recurrence occurred in seven children within 1 year of initial removal. Juvenile colorectal polyps contribute to a substantial morbidity in children and do carry a minimal risk of developing dysplastic changes, and therefore should be removed early.

A case of inflammatory fibroid polyp causing small-bowel intussusception in which retrograde double-balloon enteroscopy was useful for the preoperative diagnosis

We showed a newly developed method, retrograde double-balloon enteroscopy, to be useful for preoperative diagnosis in a case of inflammatory fibroid polyp accompanied by small-bowel intussusception. A 64-year-old woman was admitted to our hospital with small-bowel intussusception. Results of radiographic and ultrasonographic examination were suggestive of a small-bowel mass. Retrograde double-balloon enteroscopy was performed in an attempt to make a preoperative diagnosis. Endoscopic observation, in combination with histological findings derived from endoscopic biopsy, was suggestive of an inflammatory fibroid polyp. The patient then underwent laparotomy with minimal incision, which revealed a polypoid mass leading to a jejunojejunal intussusception, without bowel necrosis, and a partial small-bowel resection was performed. The pathological diagnosis was an inflammatory fibroid polyp.

Removal of hypertrophied anal papillae and fibrous anal polyps increases patient satisfaction after anal fissure surgery

BACKGROUND

Hypertrophied anal papillae and fibrous anal polyps are frequently found in association with chronic fissure in ano. Usually, no specific attention is given to them and they are considered normal findings. The present prospective study was aimed at determining whether removal of hypertrophied anal papillae and fibrous anal polyps while dealing with chronic fissure in ano confers long-term benefit to patients.

METHODS

Between July 1999 and December 2000, 140 patients undergoing anal sphincterotomy were randomized into two groups to have their fibrous polyps and hypertrophied anal papillae either removed by radiofrequency surgery or left intact. After two years, they underwent a detailed interview by an independent, masked investigator.

RESULTS

Overall 84% of patients who had polyp and papilla removal rated the outcome of their surgery as excellent or good in comparison to 58% of controls. The mean satisfaction grading was 9.2 on a visual analogue scale in the treatment group compared to 8.1 in controls (p=0.004).

CONCLUSION

Removal of hypertrophied anal papillae and fibrous anal polyps should be an essential part of treatment of chronic fissure in ano. Persistence of these structures leaves behind a sense of incomplete treatment, reducing the overall satisfaction on the part of the patient. Radiofrequency procedure is useful in eradication of these concomitant pathologies.

Inflammatory fibroid polyp of the ileum causing intussusception: a case report

Inflammatory fibroid polyp is a rare polypoid lesion of the gastrointestinal tract, histologically characterized by an admixture of numerous small blood vessels, fibroblasts and edematous connective tissue, accompanying a marked inflammatory cell infiltrate which contains eosinophils. Although it generally presents as a polypoid mass in the gastric antrum, it can be seen throughout the gastrointestinal tract. It is believed to represent a reactive, nonneoplastic condition, but its histogenesis remains controversial. A case of inflammatory fibroid polyp of the ileum presenting clinically as intestinal obstruction due to intussusception is presented here.

[Diagnostics and surgical therapy of enteric intussusception in adults illustrated by three cases]

The diagnosis of enteric intussusception is rare in adults but not in children. The clinical picture often takes an insidious course. Acute abdomen may also be caused by enteric intussusception. We report on three patients with enteric intussusception and acute abdomen. In two cases, a CT led to the diagnosis of invagination of the small intestine. In one patient, invagination of the terminal ileum was detected during coloscopy. All patients were submitted to limited segment resection and end-to-end anastomosis. In all three cases, the invagination was caused by benign pathological changes. Enteric intussusception in adults always requires surgery. In more than 95% of the cases, pathological findings are obtained intraoperatively, which are benign in the small intestine in 85-95% of the cases.

Prevalence of occult celiac disease in patients with iron-deficiency anemia: a prospective study

BACKGROUND

Occult celiac disease has been reported in 0 to 6% of adults presenting with iron-deficiency anemia. Most prior studies have been retrospective or screened only a selected population of patients with small bowel biopsies. To more accurately define the true prevalence of this disorder in patients presenting with iron-deficiency anemia (with or without stool hemoccult positivity), we initiated this prospective study.

METHODS

Esophagogastroduodenoscopy with small bowel biopsies and colonoscopy were performed in all iron-deficiency anemia patients (including those with hemoccult-positive stools) referred to the gastroenterology service during a 2-year period (1998-2000). Inclusion criteria included iron-deficiency anemia as defined by a serum ferritin < 25 ng/ml and anemia with hemoglobin < 12 g/dl. Patients were excluded for documented prior erosive, ulcerative, or malignant disease of the gastrointestinal tract, previous gastrointestinal surgery, overt gastrointestinal bleeding within the past 3 months, or inability to access the duodenum for biopsy. All patients underwent upper endoscopy with more than two biopsies of the distal duodenum and colonoscopy. A serum immunoglobulin A antiendomysial antibody test was to be performed in those patients with a positive small bowel biopsy to confirm the diagnosis of celiac disease.

RESULTS

One hundred five of 139 consecutive patients with iron-deficiency anemia met the inclusion criteria and were enrolled in the study. Fifty-seven men (mean age, 51.6 yr) and 48 women (mean age, 54.1 yr) constituted the study population. The demographics of this study population included 36 blacks, 38 Hispanics, and 22 whites. Nine patients were of mixed or unknown ethnic background. Forty-three and eight-tenths percent of the men and 37.5% of women had hemoccult-positive stools, accounting for a total of 40.9% of the study patients. Upper endoscopic findings included gastritis in 22.8%, gastric ulcers in 9.5%, duodenitis in 8.5%, esophagitis in 7.6%, Barrett's ulcer in 2.8%, duodenal ulcer in 2.8%, gastric polyp in 2.8%, and celiac disease in 2.8%. Colonoscopic findings included colon polyps in 21.9%, diverticula in 10.4%, and hemorrhoids in 16.1%. Multiple findings were found in 32.3% of patients, and there were no findings in 28.5% of patients.

CONCLUSION

The prevalence of occult celiac disease in this prospective study of patients presenting with iron-deficiency anemia was 2.8%. A significant number of other gastrointestinal lesions amenable to therapy were also found on upper and lower endoscopy in these patients. Given the treatable nature of celiac disease, it should be screened for in patients with unexplained iron-deficiency anemia with or without hemoccult-positive stools.

Hyperplastic polyps and colorectal cancer: is there a link?

Most colorectal cancers (CRCs) are thought to arise in preexisting polyps called adenomas. A second type of colorectal polyp known as a hyperplastic polyp has been regarded as harmless for decades. Patients with hyperplastic polyps are therefore not thought to be at any increased risk of CRC, and best-practice guidelines indicate that these polyps do not require surveillance colonoscopy. Recently, it has become clear that CRC is not a single disease. One type of CRC (30%) shows a chemical alteration in DNA known as methylation, and a proportion of these also show genetic instability at the level of DNA. There is now strong evidence that the hyperplastic polyp is not harmless, but it might serve as the precursor of CRC with DNA methylation and deficient DNA mismatch repair. This novel pathway applies particularly to the subset of hyperplastic polyps that occurs in the proximal colon. If this premise is correct, it would be unsafe to ignore these polyps. There is now a need to define the genetic steps that explain the evolution of CRCs that develop within hyperplastic polyps. At the clinical level, it will be necessary to identify biomarkers for hyperplastic polyps that are especially prone to malignant conversion. Screening can then be targeted more selectively toward patients who are at significantly increased risk of malignant transformation of hyperplastic polyps.

Intestinal invagination in adults: preoperative diagnosis and management

BACKGROUND AND AIMS

Intestinal invagination in adults is an uncommon but potentially serious condition that is usually diagnosed during surgery by the presence of a mechanical obstructive syndrome. We report a series of adults with intestinal invagination and discuss preoperative diagnosis and surgical procedures.

PATIENTS AND METHODS

We analyzed the files of all the seven patients aged over 18 years with a postoperative diagnosis of intestinal invagination and treated at our center between 1996 and 2000.

RESULTS

Preoperative causal diagnosis was established in six cases by ultrasonography and computed tomography. All the patients received surgery, three as emergency and four programmed. The lesions causing the invagination were: three benign (Meckel's diverticulum, inflammatory pseudotumor, fibroid polyp) and one malignant (degenerative villous adenoma polyp) located in the terminal ileum, two malignant lesions in the cecum (both adenocarcinomas over a polyp), and in the remaining case a double lymphoma of the jejunum and ileum. The intussusceptions were ileoileal in three cases and ileocolic in four. We performed intestinal resection in six cases and one excision of Meckel's diverticulum.

CONCLUSION

Preoperative diagnosis of intussusception was possible in most cases. Sonography and computed tomography proved the most effective and useful preoperative diagnostic methods. In adults colonic invagination is almost always malignant while small bowel is almost always benign. Invagination in adults must be clarified by surgery, and intestinal resection is the procedure of choice.

[Digestive tract hemorrhage and recurrent ileus. Peutz-Jeghers syndrome-case report]

Authors describe a case of 24 years old woman with recurrent lower GI bleeding and mechanical obstruction. Crohn's disease was diagnosed at the beginning. It was impossible to treat the patient's profound anemia with blood transfusions due to her religion believes. The diagnosis of Peutz-Jeghers syndrome was made postoperatively. During operation mechanical obstruction (invagination of terminal ileum into ascending colon) was released. The invagination was caused by 3 cm large polyp localized in terminal ileum. Subsequently, 8 polyps (varying in size between 0.5 and 3 cm) in the small intestine were localized using intraoperative upper GI endoscopy and enteroscopy and finally surgically removed. Typical hamartomas were found on histopathological examination of removed polyps. Authors present modern attitude to Peutz-Jeghers syndrome--its diagnostics, treatment and follow-up.

Jejunal intussusception caused by an inflammatory fibroid polyp

The case of a 56-year old male with a jejunal intussusception due to the inflammatory fibroid polyp is presented. In the literature, eleven cases with jejunojejunal intussusception due to IFP were reported. This rare entitiy was reviewed with different perspectives in this report.

Adenocarcinoma and multiple adenomas of the large intestine, associated with Cronkhite-Canada syndrome

The Cronkhite-Canada syndrome is a rare non-hereditary disorder with generalised gastrointestinal polyposis, associated with ectodermal changes. We report here a case of adenocarcinoma and multiple adenomas of the large intestine associated with Cronkhite-Canada syndrome in a 61-year-old Japanese man. Histologically, the rectal tumour was composed of well-differentiated tubular adenocarcinoma, admixed with foci of adenomatous components, and associated with hyperplastic mucosa of Cronkhite-Canada syndrome. Multiple polyps, >20 polyps < or = 2.0 cm in diameter, were found near the carcinoma of the resected rectum. Histologically, superficial parts of the polyps were composed of tubular adenomas, and basal parts of the polyps were hyperplastic dilated glands. It was speculated that, in the present case, the rectal adenocarcinoma arose from mucosal hyperplasia (Cronkhite-Canada polyp)-adenoma-carcinoma pathway. This suggested that Cronkhite-Canada syndrome has definite malignant potential, although the frequency of malignant transformation is thought to be low in Cronkhite-Canada syndrome.