The patient with multiple intestinal polyps

A Case Report of a Young Adult With Peutz-Jeghers Syndrome Presenting With Acute Small Bowel Obstruction: A Common Complication of an Uncommon Disease

Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by hamartomatous polyposis of the gastrointestinal tract, melanin pigmentation of the skin and mucous membranes, and an increased risk for cancer. Radiological imaging, contrast studies, and scopy-directed biopsies confirm the diagnosis and help in surveillance. Hamartomatous mucosal polyps, which are characterized by a central core of branching smooth muscle connected to a mucosa unique to the site of origin, are pathognomonic for PJS. We present the case of a young male with a history of pain in the abdomen and vomiting. The patient had mucocutaneous pigmentations on the buccal mucosa. CT scan revealed jejuno-jejunal intussusception with multiple small and large bowel polyps causing acute intestinal obstruction. Intraoperatively, jejunal polyps were found to be the cause of jejuno-jejunal intussusception. Histopathology revealed hamartomatous polyps of PJS. Our interest in this case is due to the uncommon case of intussusception in an adult where radiological imaging played an important role in diagnosis.

Short-term outcomes in children undergoing restorative proctocolectomy with ileal-pouch anal anastomosis

INTRODUCTION

Patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) commonly undergo restorative proctocolectomy with ileal-pouch anal anastomosis (RP-IPAA). We sought to describe patient characteristics and postoperative outcomes in this patient population.

METHODS

Using the National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who were 6-18years old who underwent RP-IPAA for FAP or UC were identified. Postoperative morbidity, including reoperation and readmission were quantified. Associations between preoperative characteristics and postoperative outcomes were analyzed.

RESULTS

A total of 260 children met the inclusion criteria, of which 56.2% had UC. Most cases were performed laparoscopically (58.1%), and the operative time was longer with a laparoscopic versus open approach (326 [257-408] versus 281 [216-391] minutes, p=0.02). The overall morbidity was 11.5%, and there were high reoperation and readmission rates (12.7% and 21.5%, respectively). On bivariate analysis, preoperative steroid use was associated with reoperation (22.5% versus 10.9%, p=0.04). On multivariable regression analysis, obesity was independently associated with reoperation (odds ratio: 3.34 [95% confidence intervals: 1.08-10.38], p=0.04).

CONCLUSIONS

Children who undergo RP-IPAA have high rates of overall morbidity, reoperation, and readmission. Obesity was independently associated with reoperation. This data can be used by practitioners in the preoperative setting to better counsel families and establish expectations for the postoperative setting.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Peutz-Jegher’s Syndrome – A Case Report / Peutz-Jegher’s sindrom - prikaz slučaja

Peutz-Jegher’s syndrome is a hereditary disorder characterized by melanocytic macules on the lips and buccal mucosa and multiple gastrointestinal hamartomatous polyps. It is caused by a mutation localized on chromosome 19p13.3. Skin and mucosal pigmentation may be present at birth and usually occur in early childhood, but occasionally may develop later. It is associated with an increased risk of malignancy for gastrointestinal carcinoma and also for breast, ovarian, testiscular, pancreatic and gallbladder cancer. We report a 12-year-old girl who presented with disseminated petty yellowish macules on the bridge of her nose, numerous brown to bluish black macules on her lips and buccal mucosa. Mucocutaneous pigmentation has been present from the age of five, with a negative family history. In our patient, esophageal endoscopy was normal, while the endoscopy of stomach and duodenum revealed multiple diminutive polyps. After clinical evaluation, there were no indications for therapy. Further follow up was suggested. Continuous surveillance is very important for patients with Peutz-Jegher’s syndrome in order to reduce risks of cancer and prevent other morbidity and mortality.

[Gastrointestinal polyposis syndromes]

Hereditary gastrointestinal polyposis syndromes account for around 1% of all colorectal cancers; most of them are associated with a broad spectrum of extracolonic tumors. The initial diagnosis is based on endoscopic findings and polyp histology. Molecular genetic screening is important for the delineation of conditions with a similar phenotype such as autosomal dominant familial adenomatous polyposis (FAP) and autosomal recessive MUTYH-associated polyposis (MAP). Identification of the germline mutation in an affected person is a prerequisite for the exact evaluation of the recurrence risk in relatives and the predictive testing of asymptomatic persons at risk. Beside cases with attenuated adenomatosis or few colorectal adenomas, diagnostic difficulties are common among the hamartomatous polyposes such as the juvenile polyposis syndrome due to their broad clinical overlap and uncertainties in histological assessment. Several poorly defined nonhereditary polyposis syndromes and those with an as yet unknown etiology exist including hyperplastic polyposis syndrome. Early detection and accurate classification are essential since effective methods for surveillance and treatment are available.

Association of hyperplastic polyposis syndrome, colorectal cancer and meningioma

Recent research has provided compelling evidence that a subset of hyperplastic polyps may be associated with a risk of colorectal cancer. Colorectal cancer with extracolonic manifestation is usually seen in a hereditary syndrome setting, but some association with meningioma has been reported. The association of colorectal cancer with hyperplastic polyposis and meningioma is extremely rare. This report in a 57-year-old female with no family history of colon cancer or polyps, could be the first case of hyperplastic polyposis syndrome, colorectal cancer and meningioma. Hyperplastic polyposis syndrome was diagnosed as per WHO criteria at the time of colon cancer diagnosis. Within 4 months of colon cancer diagnosis she developed seizures. Imaging of the brain revealed meningioma of the left cerebellopontine angle. The patient underwent surgery followed by chemotherapy.

Endopancreatic bile duct cholangiocarcinoma in a patient with peutz-jeghers syndrome

Peutz-Jeghers syndrome is a rare autosomal dominant inherited disease characterized by a special type of hamartomatous gastrointestinal polyps combined with mucocutaneous melanin pigmentations. Patients with the syndrome have a high risk of developing neoplasia, with colon, small bowel, and stomach being the most common gastrointestinal sites. Herein, we present the occurrence of a rare tumor in patients with Peutz-Jeghers syndrome; a cholangiocarcinoma of the endopancreatic bile duct. A minireview is also presented. It can be concluded that cholangiocarcinoma remains a possible diagnosis in PJS patients, as in others that present with biliary obstruction. PJS patients may be at higher risk than others in view of their propensity for malignancy.

Klinik und Genetik des familiären Darmkrebses

Eine familiäre Häufung von Dickdarmkrebs (CRC) und ein früher Erkrankungsbeginn sind Hinweise auf erbliche Tumorsyndrome, die für etwa 3–5% aller CRC verantwortlich sind. Bei diesen monogenen Dispositionen wird der erbliche Dickdarmkrebs ohne Polyposis (HNPCC/Lynch-Syndrom) von der Gruppe der gastrointestinalen Polyposis-Syndrome unterschieden. Bei vielen hereditären Formen besteht ein z. T. charakteristisches Spektrum extrakolonischer Tumoren. Die frühe Erkennung und korrekte Einordnung ist wichtig, da effektive Methoden der Vorsorge und Therapie für Betroffene und Risikopersonen bestehen.

Die Initialdiagnostik umfasst das endoskopische Bild und den histologischen Befund, ergänzt um extraintestinale Manifestationen und die Familienanamnese. Die molekulargenetische Abklärung erfolgt nach weitgehend etablierten und standardisierten Algorithmen. Differenzialdiagnostische Probleme bereiten insbesondere Patienten mit wenigen kolorektalen Adenomen sowie phänotypische Überlappungen bei hamartomatösen Polyposis-Syndromen. Für HNPCC und häufige Polyposis-Syndrome existieren etablierte risikoadaptierte Früherkennungsprogramme.

Der außerhalb der etablierten Tumorsyndrome beobachteten familiären Häufung des – oft spätmanifesten – CRC und dem Auftreten weniger Adenome liegt vermutlich eine multifaktorielle Ätiologie zugrunde. Die Aufklärung der genetischen Faktoren und das Verständnis der beteiligten Signalwege steht hier noch am Anfang, macht aber durch die rasanten methodischen Entwicklungen (z. B. genomweite Assoziationsstudien, CNV-Analysen) rasche Fortschritte.

Adenoma development in a patient with MUTYH-associated polyposis (MAP): new insights into the natural course of polyp development

PURPOSE

Biallelic germ-line mutations in MUTYH have recently been found to predispose for MUTYH-associated polyposis (MAP). Affected patients present with a wide range of clinical phenotypes at the time of diagnosis, but there is little precise information about the natural course of this disease.

RESULTS

Fourteen years of colonoscopic surveillance of an MAP patient (compound heterozygous p.Y165C/p.G382D) showed that adenoma development was slow after initial diagnosis of a single colorectal carcinoma at the age of 44, but then the annual number of new adenomas increased substantially in the patient's early fifties.

CONCLUSION

This course of the disease, with a strong subsequent acceleration of polyp development, may explain the wide range of polyp numbers counted in newly diagnosed MAP patients as a result of the time of observation. Therefore, MAP should also be considered in younger patients (35-55 years) with only few adenomas or colorectal cancer. The high frequency of medium and severe dysplasia in the patient's preferential small adenomas suggests accelerated progression from adenoma to carcinoma in MAP, but this observation must be confirmed by further studies.

The differential diagnosis and surveillance of hereditary gastrointestinal polyposis syndromes

BACKGROUND

Hereditary gastrointestinal polyposis syndromes account for about 1% of all cases of colorectal cancer and are associated with a broad spectrum of extracolonic tumors. The early detection and accurate classification of these syndromes are essential, since effective methods for surveillance and treatment are available.

METHODS

This review article is based on a selective literature search, the author's own work, and evidence-based guidelines and recommendations.

RESULTS AND CONCLUSIONS

The diagnosis is initially suspected on the basis of the endoscopic findings and polyp histology. Because different syndromes can resemble each other phenotypically, e.g., autosomal dominant familial adenomatous polyposis and autosomal recessive MUTYH-associated polyposis, molecular genetic studies are important for differential diagnosis and for assessing the risk of recurrence. Identification of the familial mutation in an affected patient is a prerequisite for predictive testing in asymptomatic persons at risk and sometimes enables prognostication. In recent years, the rate of detection of mutations has risen by 10% to 30%, and clinically relevant genotype-phenotype correlations have been described for juvenile polyposis syndrome. Except in cases of mild adenomatous polyposis, phenotypic overlap among the hamartomatous polyposes often causes difficulties in differential diagnosis. Thus, in unclear cases, a pathologist with special expertise in gastrointestinal disorders should be consulted for the evaluation of polyp tissue. Aside from the monogenic polyposes, there are many other types of polyposis that are non-hereditary or of unknown cause, including the hyperplastic and mixed polyposis syndromes. Risk-adapted surveillance programs have been established for the more frequently occurring polyposes.

Truncating mutations in Peutz-Jeghers syndrome are associated with more polyps, surgical interventions and cancers

BACKGROUND AND GOALS

Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant polyposis syndrome caused by STK11 germline mutations. PJS is associated with an increased risk of cancer. In our cohort, clinical and phenotypic parameters were correlated with genotypic findings and patients were prospectively followed by surveillance.

STUDY

Thirty-one patients treated between 2000 and 2006, were evaluated. STK11 genotyping was performed and phenotypes of patients with truncating (TM) and nontruncating mutations (NTM) were compared.

RESULTS

Median age at first symptoms was 11 years and complications occurred before the age of ten in 42% of patients. STK11 mutations were detected in 16 of 22 families (12 TM; four NTM). Patients with TM had more surgical gastrointestinal (GI) interventions (p = 0.021), and female patients in the TM group had an increased risk of undergoing gynecological surgery (p = 0.016). Also, there was a trend towards a higher polyp count (p = 0.11) and earlier age at first polypectomy (p = 0.13) in the TM group. Ten carcinomas were detected in six patients resulting in a cancer risk of 65% up to the age of 65 years. Patients with TM tended to develop more cancers (p = 0.10). Importantly, our surveillance strategy used detected 50% of cancers (n = 5) at an early potentially curable stage.

CONCLUSIONS

Our study shows that almost half of PJ patients have complications early in life independent of mutational status. Patients with TM require more surgical GI interventions and tend to develop more polyps and cancers. Furthermore, close surveillance detects early stage cancers in patients. We propose that surveillance should be started as early as 8 years in all patients to avoid complications. Moreover, patients with TM may benefit from surveillance at shorter intervals.

Gastrointestinal illnesses and their effects on the oral cavity

Many disease processes affecting the gastrointestinal (GI) tract may cause observable changes to the oral cavity. In fact, oral cavity changes may represent the first clinical manifestation of an underlying GI condition. Recognition and appropriate referral of a possible GI condition contribute to overall health and wellness in patients. Some of the more important GI conditions that may manifest oral cavity involvement include: reflux disorders, inherited GI polyposis syndromes, and inflammatory bowel disease. This article briefly reviews the aforementioned topics.