Introduction

With the expansion of treatment options available for inflammatory bowel disease (IBD), the emphasis on refractory functional disorders grows along with new treatment targets, aiming at quality-of-life improvement. Pelvic floor disorders such as fecal incontinence (FI) and obstructive defecation syndrome (ODS) are considered as disabling conditions and are a source of embarrassment and suffering for IBD patients. Reluctance to complain and feeling of incompetence leads to a delay in diagnosis and treatment.

Aims & Methods

Aim: To characterize the etiology and the physiological characteristics of pelvic floor disorders in a cohort of IBD patients as compared with non IBD patients.
Methods: Data was collected from the medical files of IBD patients who went through a workup due to defecation disorder during 2015-2024. All patients completed either an anorectal manometry, trans anal ultrasound (TRUS) or evacuation proctography. Data was compared to that of a control group, that included patients with defecation disorders without IBD, that went through a similar medical workup.

Results

67 IBD patients were included, 44 patients (66%) with Crohn’s disease (CD) and 23 with ulcerative colitis (34%). Perianal involvement was diagnosed in 25% of the CD group. The control group consisted of 140 patients. Gender and age did not differ significantly between the groups. The median number of deliveries in the IBD group was 2.5 (IQR=1) versus 2 births (IQR=1) in the control group (P=0.38). The prevalence of pelvic floor surgery was higher in the control group (36%, VS. 18%, p=0.01).
Pelvic floor dyssynergy was diagnosed in 75% of the patients in the control group compared with 59% of the patients in the IBD group (p=0.03). Rectal hyposensitivity was found in 44% of the patients in the control group compared with 46% of patients in the IBD group (p=0.06), and rectal hypersensitivity was diagnosed in 13% of the patients in the control group versus 33% of the IBD group, p=0.003. (Table 1)

Conclusion

Pelvic floor disorders in IBD patients may be associated with higher prevalence of rectal hypersensitivity compared with non-IBD patients. Dyssynergy is common in IBD patients and is associated with FI. Understanding the mechanisms of pelvic floor disorders in IBD patients is essential for choosing the best treatment modalities in this group of.

Disclosure

No conflict of interest

Introduction

In cirrhosis, several prognostic scores have been developed to predict overall and complication-free survival. The MELD (Model for End-Stage Liver Disease), MELD-Na and MELD3.0 scores have been proposed as a criteria for allocating organs.

Aims & Methods

The aim of our study was to assess the performance of these 3 scores for the prediction of overall and complication-free survival in decompensated Tunisian cirrhotic patients.
Methods: We conducted an observational, retrospective study involving all patients with decompensated cirrhosis managed in Gastroenterology department of Taher Maamouri hospital during the period from January 2010 to December 2021. Mortality was assessed using the Kaplan Meier model. The performance of the scores was assessed using the AUROC (Area under the Receiver Operating Characteristic curve).

Results

One hundred and fifty-two patients were included with an average age of 61 years. Viral liver cirrhosis was the most common (65.13%). The mean value of the MELD-Na and MELD3.0 scores was 17.74 and 19.4, respectively. The mean follow-up time was 17.1 months. The rate of complications and short-term mortality was 33.6% and 18.4% respectively.
The AUROC of the MELD3.0 score in predicting of the occurrence of further decompensation was the highest (0.775) compared to those of the MELD and MELD-Na score (0.743 and 0.756 respectively). The cut-off value of the MELD3.0 score in predicting further decompensation was 20 (sensitivity 60.7%, specificity 73.3%).
In the prediction of 3-month mortality, the AUROCs of the MELD, MELD-Na and MELD3.0 scores were 0.786; 0.841 and 0.850 respectively. The cut-off value of the MELD3.0 score was 24 (sensitivity 68%, specificity 88%). A statistically significant correlation was noted between the MELD3.0 score ≥24 and 3-month mortality (p=0.04).

Conclusion

The MELD3.0 score had the best predictive value for the occurrence of further decompensation and short-term mortality in decompensated cirrhotic patients. Those with a MELD 3.0 score ≥24 should be prioritized on waiting lists.

Introduction

Piecemeal endoscopic mucosal resection (EMR) vs endoscopic submucosal dissection (ESD) has been a long standing debate in the endoscopic community worldwide with multiple studies done to evaluate the preferred method to manage large colorectal neoplasms. Piecemeal EMR with thermal ablation of the margin has been strongly advocated and reported by certain groups to be a simple, inexpensive and effective technique and this has been preferred widely due to its perceived ease of performance and shorter learning curve.¹ However, close, repeated surveillance colonoscopy is recommended even when the lesion is thought to have been completely resected² as residual tumors can cause interval cancers.³ Some groups, mainly from east Asian countries, have recommended en bloc resection by ESD due to significantly lower risk of local recurrence and precise pathological diagnosis.⁴ But its usage is limited due to concerns about risk of serious adverse events. With improvement in training and devices, colorectal ESD is now being performed by various centers globally. This study aims to report the outcomes of an international, multicenter study on colorectal ESD.

Aims & Methods

Patients who underwent colorectal ESD for lesions greater than 20mm between January 2022 to April 2024 from centers in USA, Japan, and India respectively were included in this study. Recurrent lesions after endoscopic therapy, neoplasms identified in patients with ulcerative colitis, and non-epithelial lesions were included. Primary outcomes were en bloc and R0 resection rate, delayed adverse events (bleeding/perforation), and local recurrence rate. Secondary outcomes were procedure time, lesion size, and pathology. Univariate and multivariate analysis were done to identify the risk factors for primary outcomes.

Results

309 patients (median size, 40(27.5-60)mm; location rectum 52.4%, left colon 26.2%, right colon 21.4%) were involved in this study. The en bloc resection rate was 96.1% and R0 resection rate was 90.3%. 3 patients experienced delayed bleeding which was managed endoscopically. 2 patients underwent surgery for delayed perforation. 6 patients had a local recurrence. 67(23%) patients had intramucosal carcinoma on pathology. Univariate analysis showed lesser procedure time (median(IQR) 145(80-236.25) vs 270(180-300) minutes, P= 0.005) and smaller lesion size (median(IQR) 40(26-56.25) vs 60(40-90) mm, P= 0.004) were significant factors for successful en bloc resection. However, lesser procedure time (median(IQR) 74(29.5-97.5) vs 150(82.5-240) minutes, P= 0.034) led to an increased delayed adverse event rate. Multivariate analysis using Cox regression showed en bloc resection (odds ratio 0.038; 95% confidence interval 0.003-0.421; P= 0.008) was an independent factor preventing local recurrence.

Conclusion

This international, multicenter study with data from three countries shows favorable outcomes for colorectal ESD for large lesions. The high en bloc and R0 resection rate, and low adverse event rate show increased global adaptation to this procedure. Reduced local recurrence is an added benefit. Data from a more centers globally will be valuable to establish ESD as the standard for large colorectal neoplasms.

References

1. Sidhu M, Shahidi N, Gupta S et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology. 2021 Jul 1;161(1):163-70.
2. Gupta S, Lieberman D, Anderson JC et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:463-485.e5.
3. Rutter MD, Beintaris I, Valori R et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018;155:909-925.e3.
4. Ohata K, Kobayashi N, Sakai E et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology. 2022 Nov 1;163(5):1423-34.

Clinical Case Summary

A 21-years old male developed a perianal abscess and he undertook an ileocolonoscopy which showed right colon substenosis with ulcerations and deformation of the ileo-cecal valve. Stenosis histological samples were compatible with IBD-U (granulation tissue, chronic inflammatory infiltration and some cryptes with lowered mucous secretion). The MRI-enterography, showed thickening of distal ileum, ileo-cecal valve and cecum. A diagnosis of Crohn’s disease was made and the patient started adalimumab. The patient experienced recurring subocclusive crisis, thus another ileocolonoscopy was performed showing a scarring stenosis of proximal right colon, which could not be overcome by paediatric instrument. The patient underwent ileo-colonic resection. The surgical sample showed ileo-cecal valve circumferential stenosis and an occluding diaphragm between cecum and ascendent colon. Histologically the valve and the colonic wall had thickening and raising of only submucous membrane; mucosa was characterized by linfoplasmacellular inflammation with eosinophils granulocytes, architecture distortion and Paneth metaplasia. These features were compatible with colopathy with formation of fibrosus intraluminal diaphragm, namely diaphragm disease. The use of NSAIDs was investigated, but the patient took them just occasionally. Therefore, there was not a clear correlation between the use of NSAIDs and the diaphragm formation. At the ileocolonscopy performed six months after surgery, the ileal-colonic anastomosis appeared wide, slightly hyperaemic and without lesions. No more subocclusive crisis occurred.
Diaphragm disease is a rare colopathy associated with a long-term use of NSAIDs with a range of presentations and symptoms as abdominal pain, anemia, diarrhea, weight loss and constipation. The treatment is based on discontinuation of NSAIDs and eventually surgery. This clinical case shows a rare and challenging differential diagnosis of IBD.

Clinical Case Summary

Colorectal lymphomas are a rare cause of colonic neoplasia (0.2-0.6% malignant neoplasms of large bowel). Approximately 10% are primary colorectal lymphomas, while the rest correspond to colonic extension of systemic lymphoproliferative diseases.
We present the case of a 66-year-old woman with a history of rectum and pancreas adenocarcinoma (both in remission). During a follow-up CT, a thickening of the cecal pole was identified, with no adenopathy or other relevant findings (Photo1). The patient had no abdominal pain or B symptoms (night sweats, weight loss or fever).
The diagnosis was completed with a PET-CT that showed pathological uptake in the cecum (Photo2), so a colonoscopy was performed, which revealed a large polypoid lesion (30 mm) at the ileocecal level, with nodular areas with small ulcerations and no clear loss of the glandular pattern (Photo 3), from which multiple biopsies were taken.
Biopsies showed lymphoid proliferation with a ‘starry sky’ pattern, mitosis and apoptosis, and positive immunohistochemistry for CD45, CD20, CD10, BCL6, BCL2 and C-MYC, together with a high proliferation index (Ki-67 > 95%), all compatible with high-grade B-lymphoproliferative syndrome with Burkitt morphology (Photo 4).
Burkitt's lymphoma is a rare B-cell lymphoma (15% of GI lymphomas), associated with chromosomal translocation (8:14, 8:22 and 2:8) and overexpression of c-myc oncogene.
There are three clinical variants: endemic (common in Africa and associated with EBV and malaria), HIV-associated and sporadic (20%).
It is common in children and its most frequent symptoms are abdominal pain and weight loss, so diagnosis is often delayed. Although the yield of endoscopic biopsies is low (<20%), it is a key tool in its diagnosis, along with targeted biopsy of abdominal adenopathies.
Despite its aggressiveness, treatment with targeted chemotherapy achieves rates of more than 90%, and early diagnosis is essential to avoid complications and ensure adequate medical treatment.

References

- Photo 1: Thickening of the cecal pole seen in CT-Scan.
- Photo 2: Pathological uptake in the caecal area as seen on PET-CT Scan.
- Photo 3: Polypoid lesion in ileocecal area at colonoscopy
- Photo 4: Pathological anatomy of endoscopic biopsies: starry sky imaging and immunohistochemistry of Bcl-2 and C-myc