Clinical Case Summary

Schistosomiasis, is a major public health concern in endemic regions. While its primary manifestation is in the form of urogenital and intestinal infections, the ability of Schistosoma to mimic colorectal polyps poses a diagnostic challenge for gastroenterologists.
This is a case of a 48-year-old female patient from Lanao City with initial ultrasound and elastography findings suggesting liver parenchymal disease, mild splenomegaly and moderate liver fibrosis. Follow up ultrasound 3 years later showed a “lace-like” liver echo pattern and increasing splenomegaly. Proctosigmoidosocpy was done to document presence of schistosoma egss which appeared to be embedded on the muscularis layer. The patient was referred to the Department of Health for praziquantel treatment. Two years later, screening colonoscopy showed a sessile descending colon polyp measuring 0.5cm with regular tubular vessel surface pattern (JNET2A) removed via cold snare polypectomy. Histology of the polyp revealed still the presence of schistosoma eggs, just as the previous rectal mucosa biopsy. She completed a total of four cycles of Praziquantel treatment in the entire course of her illness.
This case reviews the clinical presentation, diagnostic modalities, and management strategies of Schistosoma presenting as colonic polyps, providing insights into the importance of considering parasitic infections in the differential diagnosis of colonic lesions.

References

1. Kay, G. L., Millard, P. S., Kay, C. J., & Kerrigan, D. D. (1995). Schistosoma japonicum presenting as colonic polyps: a case report and review of the literature. Journal of Clinical Pathology, 48(3), 276–278. https://doi.org/10.1136/jcp.48.3.276
2. Al-Khafaji, B. M., Yaghan, R. J., & Suh, O. J. (2006). Schistosomiasis presenting as colonic polyposis. Gastrointestinal Endoscopy, 64(3), 464–465. https://doi.org/10.1016/j.gie.2006.03.937
3. Adamthwaite, D. N., Patel, K. R., Mee, A. S., & Owen, R. G. (2004). Schistosomiasis: A rare cause of multiple colonic polyps. Histopathology, 45(6), 650–652. https://doi.org/10.1111/j.1365-2559.2004.02013.x
4. Al Hammadi, H., & Madani, M. A. (2014). Schistosoma mansoni: A rare cause of colonic polyposis. Saudi Journal of Gastroenterology, 20(2), 123–125. https://doi.org/10.4103/1319-3767.129469

Disclosure

none

Clinical Case Summary

Syphilis is a sexually transmitted disease caused by the non-hepatotropic spirochete Treponema pallidum. Syphilitic hepatitis is rare complication from dissemination of these spirochetes to the liver either in the primary or secondary stages of infection. The mainstay of treatment for primary and secondary syphilis is a single injection of long-acting Benzathine penicillin G. However, patients who suffer from severe hypersensitivity reactions such as anaphylaxis with penicillin require alternative antibiotic therapies such as doxycycline. We present a case of a 43-year-old woman who presented to the emergency department with abdominal pain, nausea, and continued constipation after multiple treatment attempts. Her physical exam was remarkable for a diffuse, macular and pruritic rash that was noticed over the chest, arms, and legs; progressively worsening abdominal pain reported in the right upper and left lower quadrants; and bilateral tender inguinal lymph nodes, approximately 3 cm in size. The patient’s laboratory tests were significant for, elevated transaminases, alkaline phosphatase, gamma-glutamyl transpeptidase, hyperbilirubinemia, and positive quantitative RPR for syphilis. Ultrasound and CT of the abdomen and pelvis were both negative for any acute hepatic or cholecystitis findings. The patient was started on doxycycline due to a history of hypersensitivity allergic reactions from penicillin and experienced significant recovery of symptoms and aminotransferases on subsequent laboratory follow ups. Our case highlights a novel and unorthodox treatment strategy employed in the management of syphilitic hepatitis.

Clinical Case Summary

Lesions involving the appendiceal orifice pose an endoscopic therapeutic challenge. The characteristics of the cecal wall and the complexity of exposing the appendiceal lumen make for demanding and often incomplete resections. While various techniques have been proposed, each has its limitations, including lesion size, technical difficulty, and increased risk of complications. We aim to introduce a new alternative: complete resection using a diathermic snare assisted by traction with rubber band and clip.

We present the case of a 62-year-old woman with a lesion in the cecum involving the appendiceal orifice. Previous histological examination revealed a tubular adenoma with low-grade dysplasia (LGD). Complete colonoscopy revealed a lesion with a Paris 0-IIa morphology, LST non-granular, measuring 18mm in diameter, located at the cecum and involving the appendiceal orifice. During examination with high-definition white light imaging and virtual chromoendoscopy using BLI, the lesion exhibited a Kudo IV crypt and JNET2A. Mucosectomy was performed piecemeal using the "underwater" technique. Residual lesion partially involved the appendiceal orifice, with the intra-appendicular lesion limits being indiscernible. Therefore, a novel approach involving traction and exteriorization of the appendicular mucosa was applied using a rubber band and TTS clip to achieve adequate exposure of the entire residual lesion. Subsequently, the lesion was completely resected using a diathermic snare. There were no complications. Histological examination confirmed the presence of a tubular adenoma with LGD.

Endoscopic resection of lesions involving the appendiceal orifice can be challenging. Traction methods have previously been described solely in the context of submucosal endoscopic dissection. We present an effective and safe alternative for adequately exposing the appendiceal lumen using a traction method, allowing for complete resection through endoscopic mucosal resection.

References

Justiniano CF, Ozgur I, Liska D, Valente MA, Steele SR, Gorgun E. The role of advanced endoscopy in appendiceal polyp management and outcomes. Surg Endosc. 2024 Apr;38(4):2267-2272. doi: 10.1007/s00464-024-10726-w.
Obri M, Ichkhanian Y, Brown P, Almajed MR, Nimri F, Taha A, Agha Y, Jesse M, Singla S, Piraka C, Zuchelli TE. Full-thickness resection device for management of lesions involving the appendiceal orifice: Systematic review and meta-analysis. Endosc Int Open. 2023 Oct 6;11(9):E899-E907. doi: 10.1055/a-2131-4891

Clinical Case Summary

A 55-year-old woman was referred to the Gastroenterology outpatient clinic due to a positive fecal occult blood test, in colorectal cancer screening context.
Patient’s history included asthma and hysterectomy. She was nulliparous, had no history of infertility, started menopause 6 years earlier and had never reported dyschezia, macroscopic hematochezia, dysmenorrhea nor changes in bowel habits. Physical examination was unremarkable.
Colonoscopy that followed revealed a vinous, sessile, polypoid, ulcerated and friable lesion measuring 30-40mm, at the anterior rectal wall (12 cm of anal margin). Histopathologic examination showed endometriosis foci invading rectal mucosa, without dysplasia or malignancy resembling signs. The lesion was also characterized by endoscopic ultrasound (EUS) which describes a 40x38x27mm, hemicircumferential, hypoechoic lesion, originating from the rectovaginal septum and invading muscularis propria and all rectal layers at certain locations, partially occluding rectal lumen.
Since the patient was asymptomatic and postmenopausal, risk of complications was considered low, and she was discharged.
When endometrial-like tissue invades beyond 5mm of depth into visceral peritoneum, it’s considered a deep infiltration of the endometriosis¹.
Colorectal involvement occurs in 5-12,3% of cases² and while most lesions invade the serosa and muscularis propria, only 5-6% invade the mucosa³ which is why rectal mucosal biopsies are rarely diagnostic. In rectum, implants are usually associated with dyschezia, cyclic hematoquezia and tenesmus.
What makes this case paradigmatic is the asymptomatic presentation with a large and ulcerative polypoid rectal lesion in a postmenopausal woman, which rose malignancy suspicion. The lack of correlation between symptom severity and endometrial implants’ size, has been previously described.⁴
Despite the low risk of progression during menopause, colonoscopy is helpful to rule out malignancy at presentation.

References

1. Vercellini P, Sergenti G, Buggio L, et al. Advances in the medical management of bowel endometriosis. Best Pract Res Clin Obstet Gynaecol 2021;71:78-99. doi: 10.1016/j.bpobgyn.2020.06.004 [published Online First: 2020/07/19]
2. Wills HJ, Reid GD, Cooper MJ, et al. Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: a review. Aust N Z J Obstet Gynaecol 2008;48(3):292-5. doi: 10.1111/j.1479-828X.2008.00871.x [published Online First: 2008/06/06]
3. Meuleman C, Tomassetti C, D'Hoore A, et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011;17(3):311-26. doi: 10.1093/humupd/dmq057 [published Online First: 2011/01/15]
4. Working group of Esge E, Wes. Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis daggerdouble dagger paragraph sign. Facts Views Vis Obgyn 2020;11(4):269-97. [published Online First: 2020/04/24]

Introduction

Colonoscopic surveillance reduces colorectal cancer (CRC) incidence and mortality in Lynch syndrome (LS) carriers. Still, its invasiveness and high costs highlight the need for a non-invasive approach to predict the presence of neoplastic lesions.

Aims & Methods

This study aimed to identify faecal bacterial biomarkers to discern between carriers with colorectal lesions and those with normal colon.
Two independent Spanish cohorts (a training and a validation cohort) were recruited through two multicenter studies (Table 1). Participants provided a faecal sample before surveillance colonoscopy to quantify the abundance of F. prausnitzii (FPRA) and its phylogroups I and II (PHGI and PHGII), P. stomatis (PTST), B. fragilis (BCTF), B. thetaiotaomicron (BCTT), B46 (best BLAST match S. variabile), G. morbillorum (GMLL), B48 (best BLAST match R. faecis), and E. coli (ECO) through qPCR. Eubacteria (EUB) was quantified as the total bacterial load. Participants were classified based on colonoscopy findings as normal colonoscopy (NC), non-advanced adenoma (NAA), and advanced neoplasia (AN, including advanced adenoma and CRC). A bacterial signature for neoplasia prediction was defined and validated in the training and validation cohorts, respectively.

Table 1. Main characteristics of the study participants. NC, normal colonoscopy; NAA, non-advanced adenoma; AA, advanced adenoma; CRC, colorectal cancer.

Results

The bacterial abundances were analysed in the training cohort according to age, sex, body mass index (BMI), germline mutation, and colonoscopy findings. Significant moderate positive correlations were identified between the abundances of BCTF and age (r=0.325, p=0.040), and PHGII and BMI (r=0.399, p=0.010). A significant negative correlation was identified between GMLL abundance and BMI (r=-0.331, p=0.036). Patients harbouring MLH1 mutations exhibited a significantly higher abundance of FPRA compared to PMS2 carriers (p=0.048). Patients with neoplasia (NAA+AN) presented significantly lower abundances of BCTF (p=0.027) and B48 (p=0.038) than patients with NC. Patients with AN presented a significantly lower abundance of PTST compared to patients with NC or NAA (p=0.032).
Although all the bacterial markers achieved a sensitivity of 100% to predict the presence of neoplasia, none of them presented a specificity higher than 25% by itself. To maintain sensitivity and increase specificity a bacterial signature was defined including ECO, BCTF, GMLL, FPRA, PHGI, PHGII, and B46 combined with the inherited mutation. The signature showed 100% sensitivity (SS), 52.50% specificity (SP), 34.48% positive predictive value (PPV), and 100% negative predictive value (NPV). This signature was subsequently validated demonstrating 100% SS, 56.45% SP, 53.44% PPV, and 100% NPV.

Conclusion

A new faecal bacterial signature to predict the presence of colorectal neoplasia in LS carriers has been identified, showcasing its potential usefulness to improve and personalise LS surveillance, optimising endoscopic resources, and providing a less invasive and cost-effective approach.

Disclosure

S. Taboada-López, M. Malagón, S. Ramió-Pujol and M. Serra-Pagès are employees of GoodGut.

Introduction

As no direct comparison between IBD drugs to prevent endoscopic postoperative recurrence (POR) in Crohn’s disease (CD) are available, hierarchizing these therapeutic options remains challenging.

Aims & Methods

The objective of this network meta-analysis was to compare the effectiveness of treatments to prevent endoscopic POR of CD.
We performed a systematic review and network meta-analysis of comparative studies conducted in adults, evaluating a treatment to prevent endoscopic POR after ileocecal resection. The selection of studies was made according to PRISMA guidelines. The primary endpoint was endoscopic POR at 6 months defined as Rutgeerts score ≥ i2.
The network meta-analysis was carried out according to a random effects model. The results are presented as odds ratio (OR) with 95% confidence interval, adjusted for risk factors of POR. The risk of bias of the studies was assessed according to the Cochrane risk-of-bias tool for randomized trials and overall statistical heterogeneity between studies was assessed using τ.
The SUCRA ranking method (surface under the cumulative ranking) was used to rank the treatments.

Results

Twenty studies were included in this network meta-analysis, including a total of 2414 patients. Overall heterogeneity was moderate (τ =0.34). After adjustment for POR risk factors, ustekinumab (OR = 0.23 [0.07-0.70]), vedolizumab (OR = 0.17 [0.05 -0.59]), infliximab (OR = (0.18 [0.36-0.88]) and adalimumab (OR = 0.17 [0.07-0.42]) were superior to placebo to prevent endoscopic POR, contrary to 5-ASA (OR = 0.79 [0.42 -1.48]) and thiopurines (RR = 0.52 [0.22-1.24]) (Table 1). Ustekinumab (OR = 0.29 [0.08-0.99]), vedolizumab (OR = 0.22 [0.06-0.85]), infliximab (OR = (0.23 [0.09-0.54]) and adalimumab (OR = 0.22 [0.08-0.59]) were more effective than 5-ASA in preventing endoscopic POR. Adalimumab (OR = 0.33 [0.15-0.74]) and infliximab (OR = 0.34 [0.13-0.87]) were also more effective than thiopurines.
We observed no difference in efficacy between the 4 biologics (infliximab, adalimumab, ustekinumab and vedolizumab). The SUCRA ranking identified adalimumab (SUCRA = 0.81), infliximab (SUCRA = 0.80), vedolizumab (SUCRA = 0.79) and ustekinumab (SUCRA = 0.72) as the most effective treatments. The probability that thiopurines (SUCRA = 0.41), 5-ASA (SUCRA = 0.24), placebo (SUCRA = 0.16) and antibiotics (SUCRA = 0.08) were significantly higher weak.

Conclusion

This network meta-analysis confirms the efficacy of anti-TNF agents, vedolizumab and ustekinumab in preventing endoscopic CD POR without any difference between them. When prophylactic therapy is indicated, biologics appear as the best therapeutic option to prevent of endoscopic POR. Due to lower effectiveness, the use of 5-ASA and thiopurines should be limited in this situation.

Disclosure

Anthony BUISSON: Consulting fees for Abbvie, Amgen, Arena, Biogen, Celltrion Healthcare, CTMA, Galapagos/Alfa Sigma, GutyCare/Resilience, Janssen, MSD, Nexbiome, Pfizer, Roche, Sandoz, Takeda, Tillotts. And Viatris. Lecture fees for Abbvie, Amgen, Biogen, Celltrion Healthcare, Galapagos/Alfa Sigma, Janssen, Mayoli-Spindler, MSD, Nordic Pharma, Norgine, Pfizer, Roche, Takeda, Tillotts and Vifor Pharma. Research grants from: Abbvie, Celltrion Healthcare, Galapagos/Alfa Sigma, Janssen, Lessaffre, Lilly, Pfizer, Takeda.

Introduction

Resection of large non-pedunculated colorectal polyps (LNPCP) located in the rectum varies by institution and region with some, particularly colorectal surgeons, favouring TEM and others endoscopic resection (ER). There is a paucity of data directly comparing these strategies and the procedure of choice remains under debate. Our unit is a tertiary referral centre for complex polyps and early colorectal cancer. All rectal LNPCP were treated by TEM until a change in practice from 2011 when the first-line therapeutic strategy for rectal LNPCP changed to ER.

Aims & Methods

We aimed to report the outcomes of TEM and ER of rectal LNPCP from a large tertiary cohort. Large (≥20mm) rectal adenomas resected by TEM or ER (2009 – 2023) were analysed. From 2009-2011 all rectal adenomas were treated by TEM, after which the primary resection strategy changed to ER. Outcomes were compared between techniques. Given the difference in resection strategy, a composite outcome of septic complications included clinically significant perforation for ER (early or delayed perforation requiring any form of unplanned medical or surgical treatment) and septic complications for TEM (peritonitis or pelvic/anorectal sepsis).

Results

704 rectal adenomas were resected by TEM (n=71), EMR (n=145) and ESD/Hybrid ESD (n=488) with a mean size of 45mm for TEM vs 55mm for ER (p<0.001). 100% of patients undergoing TEM required hospital admission vs 15% for ER (p<0.001), and 100% required general anaesthesia (GA) for TEM vs 26%% for ER (GA or propofol sedation, p<0.001). En bloc resection was achieved for 96% of ESD resections, 54% of TEMS, 28% of EMR and 14% of hybrid ESD (p<0.001). The incidence of complications were similar (9.9% for TEM versus 5.0% for ER, p=0.10). Recurrence occurred in 2.7% after ESD, 21.1% after EMR, 23.6% after Hybrid ESD and 36.4% after TEM (p<0.001). No patients undergoing ER or TEM required surgery as a result of a complication.

Conclusion

Despite significantly larger lesion sizes, ER in our institution provides far superior results for patients than TEM with relatively fewer patients requiring hospital admission and lower recurrence rates, especially with ESD. En bloc resection was more likely with ER as a result of the difficulty achieving en bloc resection for extremely large lesions with TEM, which can invariably be resected en bloc by ESD. These results have led to a policy of ER for all apparently benign rectal tumours regardless of size and, in recent years, ESD as the primary approach for all rectal lesions.