Introduction

Acute hemorrhagic rectal ulcer (AHRU) is one of the most common diseases in elderly patients with underlying medical conditions and often results in serious outcomes. Although AHRU is a potentially life-threatening disease, its characteristics and clinical course are not fully elucidated.

Aims & Methods

We aimed to clarify the clinical characteristics of patients with acute hemorrhagic rectal ulcer. We enrolled consecutive 68 AHRU patients admitting to Nippon Medical School Hospital from September 2015 to December 2022, and their clinical characteristics and outcomes were determined according to medical records retrospectively.

Results

Clinical characteristics of AHRU patients were as follows: mean age 79; including 33 males and 35 females.
31 patients (46%) had a performance status (PS) of 3 or more. Comorbidities were cardiovascular disease in 24 patients, chronic renal failure (eGFR<30 for more than 3 months) in 12 patients, cerebrovascular disease in 14 patients, chronic hepatitis and cirrhosis in 2 patients, hypertension in 33 patients, diabetes in 22 patients, and dyslipidemia in 21 patients. Medications were antiplatelet agents in 27 patients, anticoagulants in 18 patients, NSAIDs in 7 patients, and steroids in 6 patients. 24 of 68 patients (38%) underwent endoscopic hemostasis (clip in 15 cases, hemostatic forceps in 9 cases, and combined clip and HSE injection in 1 case), interventional radiology in 1 case, and transanal suture in 4 cases. Rebleeding was observed in 16 of 68 patients (24%). Rebleeding after endoscopic hemostasis was observed in 7 of 24 patients (29%), of which 3 patients performed emergency colonoscopy after rebleeding. Of the 68 patients who required blood transfusion during hospitalization, 50 patients (74%) had a mean transfusion volume of 10.6 units (2-50). 13 (19%) of the 68 patients died during hospitalization due to exacerbation of their comorbidities.

Conclusion

AHRU was more common in elderly patients with comorbidities and lowered PS. Patients with AHRU who was required for endoscopic hemostasis was associated with frequent rebleeding, and some patients were led to severe outcome due to their complications or exacerbation of comorbidities. Therefore, management of patients with AHRU should focus on not only controlling the local bleeding but also managing their comorbidities and complications.

Introduction

The global incidence of early-onset colorectal cancer is rising at an alarming rate, underscoring the urgent need for effective preventive and therapeutic strategies. While age-associated molecular and pathological alterations have been reported, the immunological landscape—particularly the roles of distinct T cell subtypes in anti-tumor immunity—remains poorly characterized in early-onset colorectal tumor, especially in endoscopically resected colorectal tumors.
In this study, we investigated the association between T cell subtype densities—specifically CD3+, CD4+, CD8+, and FOXP3+ T cells—and clinicopathological features, with a particular focus on tumors arising in younger individuals. Early-onset colorectal tumors were defined as those diagnosed before the age of 50, whereas later-onset tumors were defined as those diagnosed at age 50 or older.

Aims & Methods

This study aimed to evaluate the relationship between T cell subtypes and the clinicopathological features of early-onset colorectal tumors. We utilized a molecular pathology database comprising 169 cases of colorectal cancer and adenoma, analyzing a total of 306 colorectal lesions. Among these, 214 lesions were classified as early-onset tumors and had been resected via endoscopic techniques—including cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection—at Nippon Medical School Hospital in Japan between February 2017 and January 2020.
Formalin-fixed paraffin-embedded (FFPE) tissue blocks were collected, and immunohistochemical staining for CD3, CD4, CD8, and FOXP3 was conducted. The densities of CD3+, CD4+, CD8+, and FOXP3+ cells were quantified within tumor, stromal, and normal tissue regions. Depending on lesion size, one to five fields of view (median: five) were selected and imaged at 200x magnification using a BZX800 fluorescence microscope (KEYENCE). Automated image analysis was employed to determine the average number of each T cell subtype. Quantification within stromal and normal regions was restricted to specimens with sufficiently large resected tissue to include these areas in addition to tumor tissue. Clinicopathological variables were assessed retrospectively. Statistical analyses included the chi-square test for categorical variables, Spearman’s rank correlation for assessing associations, the Mann–Whitney U test for comparison of continuous variables, and the Kruskal–Wallis test for comparisons across three or more groups.

Results

Tumor locations were distributed as follows: 126 cases (41%) in the proximal colon, 142 cases (47%) in the distal colon, and 37 cases (12%) in the rectum. Compared with later-onset colorectal tumors, early-onset tumors had significantly lower numbers of CD3+, CD4+, and CD8+ T cells (all P <0.001). In contrast, no significant difference was observed in the number of FOXP3+ T cells between the two groups.
Additionally, the densities of CD3+, CD4+, and CD8+ T cells decreased with increasing tumor diameter (all P <0.001). The distributions of CD3+, CD8+, and FOXP3+ T cells also differed significantly by tumor location (P = 0.040, 0.006, and 0.013, respectively).

Conclusion

Analysis of endoscopically resected specimens suggests that anti-tumor immune responses mediated by T cells may vary depending on age of onset, tumor size, and tumor location. These findings highlight the need for further research to identify subsets of early-onset colorectal tumors that may require more intensive surveillance following endoscopic resection, based on their immunological profiles.

Introduction

Although transcatheter arterial embolization (TAE) has been reported to be effective for colonic diverticular bleeding, the patient outcomes of TAE have not been fully elucidated. The present study was conducted to investigate the patient characteristics and outcomes of TAE for colonic diverticular bleeding.

Aims & Methods

We enrolled 50 patients who were performed transcatheter angiography among 294 patients diagnosed as colonic diverticular bleeding by colonoscopy and abdominal CT, and were required for hospitalization from August 2012 to January 2021. Their clinical characteristics and outcomes of TAE were determined according to medical records retrospectively.

Results

The mean age of all 50 patients (44 males and 6 females) was 68 (45-86) years. History of cardiovascular disease in 15 patients, cerebrovascular disease in 7, renal disease in 4, hepatic disease in 5, hypertension in 27, diabetes mellitus in 5, and dyslipidemia in 10. The reasons for transcatheter angiography were rebleeding after colonoscopy in 21 cases (42%), shock vital in 13 cases (26%), extravasation on CT in 4 cases (8%), difficulty in stopping bleeding by endoscopy in 4 cases (8%), and rebleeding after angiography in 7 cases (14%). TAE was performed in 30 of 50 patients (60%). 7 of 50 patients (14%) were performed transcatheter angiography twice, of which 3 patients successfully performed TAE on the second time, 2 patients successfully performed TAE both times. The reasons for unsuccessful TAE were all negative extravasation on transcatheter angiography, and there were no cases in which TAE was technically impossible. In a comparison of 30 successful TAE cases and 20 unsuccessful TAE cases, the mean time from the appearance of hematochezia to transcatheter angiography (9.8 vs. 12.75 h; P=0.413), the rate of extravasation on CT before transcatheter angiography (56% vs. 45%; P=0.419) were not significantly different between the two groups. On the other hand, the rate of early rebleeding within 30 days was significantly lower in patients with successful TAE (13% vs. 60%, P = 0.001).

Conclusion

In cases of colonic diverticular bleeding, transcatheter angiography can be safely performed even when the patient's circulation is unstable. Moreover, the early rebleeding rate was significantly reduced in cases of successful TAE. However, the early rebleeding rate was high in patients who did not receive successful TAE, this should be considered as a future subject.

Introduction

The incidence of early-onset colorectal cancer has been increasing worldwide, and action is urgently needed to address this problem. Although we have previously reported age-related changes with respect to molecular pathology, the vast majority remains unknown regarding the clinicopathologic characteristics of early-onset colorectal cancers and adenomas, especially those resected by endoscopic approaches. In this study, we defined early-onset colorectal tumors as adenoma and carcinoma diagnosed age at 40 or under. The aim of this study was to examine the clinicopathologic characteristics of endoscopically resected early-onset colorectal tumors compared with later-onset colorectal tumors diagnosed at age 40 or older.

Aims & Methods

We examined the clinicopathological characteristics of endoscopically resected colorectal adenomas and carcinomas in 1,005 patients with 2,367 lesions including early-onset colorectal carcinoma/adenoma (159 lesions in 96 consecutive cases from January 2010 to December 2020), late-onset colorectal carcinoma (183 lesions in 90 cases from January 2010 to December 2020), and late-onset adenoma (2,025 lesions in 819 consecutive cases from January 2020 to July 2020) endoscopically resected at the Nippon Medical School Hospital. The chi-square test was used to compare categorical variables, and the Mann-Whitney U test was used to compare continuous variables.

Results

Median age (quartiles) and sex (female/male) of cases were 37 (34-38), 34 (35%) / 62 (65%) in the early-onset tumor group; and 55 (46-72), 277 (30%) / 632 (70%) in the late-onset tumor group, respectively. The distribution rate of tumor location was 49 cases (31%) for proximal colon, 97 (61%) for distal colon, 13 (8.2%) for rectum in the early-onset group; and 1085 (49%), 899 (41%), 83 (10%) in the later-onset group, respectively. Macroscopic types were classified into Ip for 46 cases (29%), Is and Isp for 100 (63%), II for 13 (8.2%) in the early-onset group; and 278 (13%), 1574 (71%), 356 (16%) in the late-onset group, respectively. Histological types were classified into tubular adenocarcinoma or papillary carcinoma for 14 cases (8.8%), high-grade tubular adenoma (TA) for 36 (23%), low-grade TA for 97 (61%), sessile serrated lesion or traditional serrated adenoma for 12 (7.5%) in the early-onset tumor group; and 183 (8.3%), 281 (13%), 1655 (75%), 89(4%), respectively. Compared with the later-onset colorectal tumors, a higher rate of left-sided tumor location and macroscopic type Ip was observed in the early-onset colorectal tumor (p <0.001, respectively). When limited to adenoma lesions, the rate of high-grade was significantly higher in the early-onset colorectal adenomas than those in the later-onset colorectal adenomas.

Conclusion

Regarding tumor location and macroscopic type, unique clinicopathological features were observed in early-onset colorectal tumors compared with later-onset colorectal tumors. Further studies are needed to investigate the association between early-onset colorectal cancer and adenomas stratified by the method by tumor resection.

Introduction

Solitary rectal ulcer syndrome (SRUS) is a chronic benign disorder characterized by the presence of an abnormality of the rectum in persons who have a long history of straining during defecation. It is a misnomer as only 3^rd of the patients have solitary ulcer, many have no ulcer.

Aims & Methods

This was a retrospective observational longitudinal study, conducted in the department of Gastroenterology at Jinnah Post graduate Medical Center and National Medical Center, Karachi, from 1^st March 2017 to till to date . All adult patients of either gender diagnosed with SRUS on basis of clinical history and endoscopic features were included in the study. The data obtained was analyzed on the statistical software SPSS version 26.Descriptive statistics were obtained by frequencies and percentages.

Results

There were total 85 patients in our study out of which 49(58%) were female and 36(42%) were male. Mean age was 35 ±17 years. Most common presentation was per rectal bleed 68(80%) ,Constipation 58 (68.57%) and followed by abdominal pain 32(37.9%).The most common predisposing risk factor was 85 (100%) self-digitation, 51(60%) prolong stay in toilet and rectal prolapse 5 (7.1%). Endoscopically most common finding was of single ulcer 80(95.7%), followed by proctitis 59(70%) and multiple ulcers 12(14.3%) and Histology revealed mucosal ulceration 75(88%) extension of muscular fibers 65 (77%), fibromuscular obliteration of lamina propria 59(70%) and crypt distortion 54 (64.3%). Associated psychological condition among patients were obsessive compulsive disorder 51 (60%) and anxiety disorder 46(52%). Most of the patients were treated through lifestyle modification and biofeedback. Only 4 patients were referred to surgical intervention.

Conclusion

SRUS is a rare disorder with variable clinical presentation. In this study patients commonly presented with bleeding p/r followed by abdominal pain. However, common predisposing factor was self -digitation, in this regard awareness is needed in our region.

References

1. Felt-Bersma RJF. Solitary rectal ulcer syndrome. Curr Opin Gastroenterol. 2021;37(1):59-65.
2. Sadeghi A, Biglari M, Forootan M, Adibi P. Solitary rectal ulcer syndrome: a narrative review. Middle East J Dig Dis. 2019;11(3):129-34.
3. Thirumal P, Sumathi B, Nirmala D. A Clinical entity often missed-solitary rectal ulcer syndrome in children. Front Pediatr. 2020;8:396.
4. Forootan M, Darvishi M. Solitary rectal ulcer syndrome: a systematic review. Medicine (Baltimore). 2018;97(18):e0565.
5. Abusharifah O, Bokhary RY, Mosli MH, Saadah OI. Solitary rectal ulcer syndrome in children and adolescents: a descriptive clinicopathologic study. Int J Clin Exp Pathol. 2021;14(4):399-407.
6. Abreu M, Azevedo Alves R, Pinto J, Campos M, Aroso S. Solitary rectal ulcer syndrome: a paediatric case report. GE Port J Gastroenterol. 2017;24(3):142-6
7. Lambin T, Lafeuille P, Rivory J, Rostain F, Fabritius M, Cotte E, et al. Adenocarcinoma arising from a long-standing solitary rectal ulcer syndrome.

Introduction

Solitary rectal ulcer syndrome (SRUS), often mistakenly classified as a rectal motility disorder, arises from defecatory irregularities and presents with diverse clinical manifestations. This prospective study conducted at a leading medical center aims to elucidate the spectrum of clinical presentations, potential risk factors, colonoscopic findings, histopathological characteristics, and therapeutic approaches in individuals affected by SRUS.

Aims & Methods

The prospective analysis included all patients diagnosed with SRUS at the Advanced Gastroenterology Institute (AGI) - The GASTROCITI, Ludhiana, over 48 months from March 2020 to February 2024. Cases were identified using the comprehensive database of the Endoscopy Department. Data retrieval from medical records provided insights into clinical symptoms, endoscopic observations, and histopathological features.

Results

From approximately 7000 diagnostic sigmoidoscopies & colonoscopies, a meticulous identification of 48 patients with SRUS was achieved. The average age was 48.5 years (±18.5), with 75% (36) being males. Rectal bleeding was reported by 77% (37) of patients, 64.5% (31) experienced constipation, and 50% (24) described bowel movement difficulties, with an average symptom duration of 13.7 months. Associated factors included constipation (75%), digital rectal manipulation (43.75%), high-pressure water jet usage (25%), prior rectal surgeries (10.5 %), and rectal prolapse (10.5%). Endoscopic findings revealed solitary ulcers in 64.5% of cases, multiple ulcers in 27 %, and polypoidal appearance in 10.5%. Two patients presented with a proliferative mass-like anomaly (pseudotumor) and two had a circumferential rectal stricture. The finding of difficult-to-take endoscopic biopsies due to underlying submucosal fibrosis showed a robust positive predictive value (PPV) exceeding 90% for SRUS diagnosis. Histopathological analysis revealed surface ulceration (90%), lamina propria fibrosis (70%), architectural distortions (60%), and increased muscle hypertrophy with mucin production (50%). Conservative interventions were effective in all cases, without the need for surgical intervention.

Conclusion

SRUS, often misinterpreted as a rectal motility disorder, presents with diverse manifestations. Management strategies including high-dose laxatives, avoidance of digital evacuation and high-pressure water jet usage, adoption of a fiber-rich diet, and localized application of mesalamine/sucralfate and biofeedback therapy have shown efficacy. This study highlights the complex nature of SRUS and emphasizes the importance of a comprehensive approach to diagnosis and management.

References

Introduction

The incidence of early-onset colorectal cancer is increasing alarmingly worldwide, and countermeasures against this issue are urgently needed. Although previous studies suggested age-related molecular pathological changes, the association between the roles of Immunosocore using the ration of CD3+ and CD8+ T cells in anti-tumor immune responses and early-onset colorectal cancer and adenoma resected by endoscopy remains unclear. This study aimed to investigate the association of Immunosocore using the ratio of CD3+ and CD8+ T cells and clinicopathological characteristics mainly focused on early-onset tumors. We defined early-onset colorectal tumors as those that occurred at less than 50 years of age at diagnosis and later-onset as those that occurred at 50 years of age or older in this study.

Aims & Methods

The aim of this study was to investigate the association between Immunosocore and clinicopathological features of early-onset colorectal tumors. Utilizing a molecular pathological database of 169 colorectal cancer and adenoma cases, we analyzed 306 colorectal lesions including 214 early-onset tumors resected by endoscopic procedures including cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection from February 2017 to January 2020 at Nippon Medical School Hospital in Japan. After collecting formalin-fixed paraffin-embedded (FFPE) tissue blocks, CD3 and CD8 immunostaining was performed, and the number of CD3+ and CD8+ cells was quantified in each area of tumor, stromal, and normal. One to five fields of view (median 5 fields) were selected depending on the size of the lesion using a fluorescence microscope BZ-X800 (KEYENCE) at 200x magnification, and the average number of CD3+ and CD8+ cells was calculated by automatic counting. Counting stromal and normal cells was limited to those specimens for which the excised specimens were large enough to contain sufficient stromal and normal portions in addition to the tumor portion. Immunoscore was calculated by the ratio of CD8+/CD3+ positive T cells. Clinicopathologic characteristics were also evaluated retrospectively. Chi-square test was used to compare categorical variables, Spearman's test to examine correlation, Mann-Whitney U test to compare continuous variables, and Kruskal-Wallis test to compare the three groups.

Results

The tumor location was 126 (41%)/142 (47%)/37 (12%) in the proximal/ distal colon/rectum. The number of CD3+T cells decreased significantly with increasing tumor diameter (P<0.001). The number of CD3+T cells was predominantly lower in type Ip (protruding type) compared to type non-Ip (P<0.001). The distribution of Immunoscore measured in tumor area was significantly different among tumor locations (P<0.05).

Conclusion

Using endoscopically resected specimens, we suggest that the anti-tumor immune response may differ according to tumor size, gross type, and location. Further studies are warranted to stratify early-onset tumors requiring careful surveillance after endoscopic resection in terms of the anti-tumor immune response in T cells.