Introduction

Large or complex colorectal polyps have a greater than average risk of malignancy, incomplete resection/recurrence or complications associated with treatment. Appropriate management is therefore crucial for preventing cancer and improving patient outcomes. UK guidelines exist for the management of large non-pedunculated colorectal polyps (LNPCPs)¹. This review aims to evaluate the case mix and outcomes from a multidisciplinary team (MDT) approach to managing such polyps.

Aims & Methods

This study is a retrospective analysis of cases referred to the Complex Polyp MDT at a single centre in the United Kingdom between January 2020 and December 2021 (two-year period). Data collected included patient characteristics, index investigation and polyp complexity as defined by the size, morphology, site, and access (SMSA) score.
Therapy details, including standard endoscopic techniques (EMR, polypectomy) and advanced options (ESD, eFTR, Endorotor), as well as trans-anal surgery, were documented. Complications and re-admission needs were recorded, along with recurrence rates at first surveillance. Any subsequent treatment for recurrence was also documented.
An electronic survey was conducted among MDT members to gather feedback on the MDT's impact on clinical practices, perceived benefits, and suggestions for improvement.

Results

Over a two-year period, 258 cases were reviewed at the complex polyp MDT, with annual cases rising from 91 to 167. After exclusions (diagnosed cancer prior to MDT, discussion regarding management of already treated polyps), 220 cases were reviewed. The median polyp SMSA score was 11, with 34% of polyps classified as level 3 and 38% as level 4. Conservative management was recommended in 35 cases, in patients with a median age of 81 (IQR 78-84), 73% of which suffered from severe systemic disease. 110 colonic polyps (62% overall) were treated with EMR. 67 rectal polyps (38%) were managed with a combination of therapies, including EMR (36, 54%), ESD (13, 19%), or trans-anal surgery (18, 27%). Only 4 complications were observed: post-polypectomy bleeding in 3 cases (from rectal EMR, colonic EMR, and trans-anal surgery) and a small perforation from a low rectal ESD. All complications were managed conservatively, and patients discharged the next day.
MDT discussion led to downgrading of 44% of cases initially deemed high-risk for malignancy; none were subsequently found to contain cancer. Three cases were upgraded to high-risk; none were found to contain cancer, but all contained high-grade dysplasia.
Of 26 patients who experienced recurrence after initial polypectomy, 17 (65%) underwent endoscopic therapy, while others either had surgical excision or were awaiting ongoing surveillance.
Of those who underwent endoscopic treatment, 16 cases (94%) were successfully treated using various techniques, such as eFTR and endoscopic mucosal debridement (Endorotor resection) via one or more further sessions. 3 of the 16 recurrent lesions contained HGD. The remaining case required right hemicolectomy for early-stage adenocarcinoma. Of note, the initial site check in that case had identified HGD.
Survey responses reflected an overall feeling of significantly improved management of complex polyps since the inception of the MDT. Improvements included increased understanding of therapeutic options and better polyp assessment amongst endoscopists.

Conclusion

Multidisciplinary team management of large or complex polyps is effective, and meets standards set by national guidance. The team approach fosters learning amongst members, leading to wide reaching improvements in practice.

References

1: Rutter MD, Chattree A, Barbour JA, Thomas-Gibson S, Bhandari P, Saunders BP, Veitch AM, Anderson J, Rembacken BJ, Loughrey MB, Pullan R. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut. 2015 Dec 1;64(12):1847-73.

Disclosure

No conflicts of interest.

Introduction

Colonic diverticulosis is a prevalent gastrointestinal condition that is often diagnosed incidentally. However, its association with chronic polyps and rectal hemorrhoids remains underexplored, particularly in the northern region of Saudi Arabia.

Aims & Methods

This study aimed to assess the relationship between colonic diverticulosis and colonic conditions while considering demographic and clinical factors. This retrospective observational study was conducted at a tertiary referral center over four years. Data from 4,014 patients who underwent colonoscopy were analyzed. Statistical tests, including chi-square and independent sample t-tests, were used to determine associations between diverticulosis, polyps, hemorrhoids, and bowel preparation adequacy.

Results

Diverticulosis was observed in 14.2% of the patients, with a higher prevalence among males (16.1%) than among females (12.1%) (p < 0.001). Patients with diverticulosis were significantly older (mean age 61.35 years) than those without diverticulosis (mean age 48.25 years) (p < 0.001). Hemorrhoids were more frequent in patients with diverticulosis (18.6%) than in those without diverticulosis (11.9%) (p < 0.001). A similar association was found between diverticulosis and polyps, with the polyp prevalence being higher in patients with diverticulosis (21.4%) than in those without (11.7%) (p < 0.001). Additionally, inadequate bowel preparation was more common among patients with diverticulosis (17.1%) than among those with adequate bowel preparation (13.6%) (p = 0.023).

Conclusion

This study highlights a significant association between colonic diverticulosis and the presence of polyps and hemorrhoids. Older age and male sex were identified as the key risk factors. These findings emphasize the importance of targeted screening and optimized bowel preparation in at-risk patients. Further research is required to explore the underlying pathophysiological mechanisms and to develop preventive strategies.
Keywords: Diverticulosis; Hemorrhoids; Chronic Polyps

References

1 Nallapeta NS, Farooq U, Patel K. Diverticulosis. StatPearls. Treasure Island (FL): StatPearls Publishing 2025.
2 Tursi A, Scarpignato C, Strate LL, et al. Colonic diverticular disease. Nat Rev Dis Primers. 2020;6:20. doi: 10.1038/s41572-020-0153-5

Introduction

In Germany, screening colonoscopy has been offered to all adults aged 55 or older since 2002. In parallel to screening colonoscopy, fecal occult blood testing is offered (Guaiac test until 2017, fecal immunochemical test afterwards) and, in addition, there is a high use of diagnostic colonoscopies. In view of this context, we aimed to quantify the effectiveness of screening colonoscopy in reducing colorectal cancer (CRC) incidence in Germany in men and women aged 55–69 years.

Aims & Methods

Using a German claims database (GePaRD, 20% population coverage) we included persons at average CRC risk aged 55–69 years and without a colonoscopy, polypectomy or fecal occult blood test before baseline. We emulated a target trial with two arms: Colonoscopy screening vs. no colonoscopy screening at baseline. We estimated adjusted cumulative CRC incidence over 11 years of follow-up stratified by sex (at the time of the conference, 14-year follow-up data will be available).

Results

Overall, we included 99,101 men (women: 99,288) in the screening arm and 583,861 men (women: 664,052) in the control arm. In men, the adjusted 11-year CRC risk was 1.89% in the screening group and 2.85% in the control group resulting in a relative risk of 0.66 (95% CI: 0.63–0.73). In women, the adjusted 11-year CRC risk was 1.31% in the screening group and 1.96% in the control group resulting in a relative risk of 0.67 (95% CI: 0.63–0.73).

Conclusion

Our study shows that screening colonoscopy in Germany is effective in preventing CRC both in men and women. In the interpretation of the strength of the effect (~33% incidence reduction), the high background prevalence of diagnostic colonoscopy should be considered. As previously shown, screening colonoscopy accounts for less than half of the overall 10-year prevalence of colonoscopy in persons aged 55-69 years in Germany.

Introduction

Opium tincture in oral solution has been used for antidiarrheal treatment for centuries, and it is often used to treat chronic idiopathic diarrhea as a secondary choice after loperamide and bulking agents. However, the underlying mechanisms of opium tincture on gastrointestinal function are not evident and have not been investigated in clinical trials. This study aimed to investigate the effects of opium tincture on gastrointestinal motility, intestinal volumes, and water content of different gut segments assessed by magnetic resonance imaging (MRI).

Aims & Methods

Twenty healthy volunteers were included in a randomized, placebo-controlled, cross-over study with 9-day treatment (30 drops per day of opium tincture corresponding to 15 mg of oral morphine or placebo). MRI was performed on day 1 (before treatment) and day 9 (during treatment) using a pan-alimentary scan protocol. Images were obtained during fasting and after a 285-kcal granola bar meal. MRI measurements included assessments of gastric volume, gastric emptying half-time, gastric motility, small bowel volume, small bowel water content, small bowel motility, colon volume, colon water content, and whole gut transit. Data was analyzed using repeated measure mixed models and adjusted using baseline data as a covariate and a Bonferroni post hoc correction.

Results

The median age of the included subjects was 24 years (range 20-72 years), and 10 subjects were female. Opium tincture delayed gastric half-emptying time as compared to placebo (mean [95% confidence intervals] values: 38.5 [35.3-41.6] min vs. 32.8 [29.9-35.8] min, p=0.004). Opium tincture increased gastric meal volumes 15 and 30 minutes after the meal as compared to placebo (ps<0.018). Gastric contraction amplitude and frequency were not affected by treatment. Small bowel endpoints were not different between treatments (all p>0.05). Ascending-, transverse-, and descending colon volumes were increased after opium tincture as compared to placebo (ascending: 226 [197-253] ml vs 168 [140-195] ml, p=0.003; transverse: 208 [180-236] ml vs. 158 [131-185] ml, p=0.017; descending: 155 [125-184] ml vs. 110 [83-138] ml, p=0.045). T1-relaxation time (a proxy for water content) of the descending colon chyme was decreased during opium tincture as compared to placebo, indicating dryer feces (517 [425-609] ms vs. 690 [595-786] ms, p=0.030). Whole gut transit time was delayed during opium tincture as compared to placebo (p=0.027).

Conclusion

Opium tincture as compared to placebo induces changes in gastric and colonic motility and volumes as measured using a pan-alimentary MRI framework in a population of healthy volunteers. Based on the current results, opium tincture seems to affect the gastrointestinal tract in ways that are relevant for treating diarrhea. An improved understanding of how opioids affect gut functions may lead to a better understanding of and optimized management of diarrhea.

Introduction

Cold snare polypectomy (CSP) has become popular as a safe and simple treatment for small colonic lesions. According to the Japanese guidelines, CSP is indicated for adenomas <10 mm with no suspicion of carcinoma [1]. Occasionally, colorectal carcinoma is diagnosed after resection, and there is no consensus on the treatment of such lesions [2-4].

Aims & Methods

This single-center retrospective study aimed to investigate the long-term prognosis of Japanese patients with pathologically diagnosed colorectal carcinoma after resection by CSP. Patients who underwent CSP for small colonic lesions at our hospital in 2013–2022 and were histopathologically diagnosed with colorectal carcinoma were included in this study. We examined the local residual or recurrence rate, scar detection rate, and recurrence-free survival rate in patients who underwent at least one colonoscopy after CSP.

Results

Out of 12,935 lesions (6,082 cases) that were resected using CSP during the study period, 81 lesions (0.63%; 81 cases) were histologically diagnosed as colorectal carcinoma (mean age, 69.7 years; male patients, 69% [56/81]). Histologically, all tumours were well-differentiated adenocarcinomas. Negative lateral and vertical margins of the resected specimens were 47% (38/81) and 72% (58/81), respectively. Of these 81 cases, 47 (58%) were followed up at least once by colonoscopy. The breakdown of cases that were not followed up endoscopically is as follows: concurrent advanced cancer (n=15), advanced age (n=7), dropout (n=7), and others (n=5). Endoscopic evidence of residual disease or recurrence was found in 1/47 patients (2%), and the remaining 46 patients had a median colonoscopic follow-up of 425 days (interquartile range, 192.5–1078.5 days) with no endoscopic evidence of local recurrence. In 51% (24/47) of cases, post-polypectomy scars could be identified. In one case where local residual carcinoma was confirmed, a retrospective review of the CSP revealed incomplete resection at the time of treatment. Abdominal CT performed immediately after CSP showed coincidental peritoneal dissemination, and the patient died 177 days after diagnosis. In 46 patients with no endoscopic evidence of local recurrence, the median observation period was 921 days (interquartile range, 475–1654.5 days), with six cases of death from causes other than colorectal cancer, and the others were alive without recurrence.

Conclusion

The frequency of residual disease or recurrence of colorectal carcinoma treated by CSP was low, and the long-term prognosis was favourable once the absence of residual lesions was confirmed endoscopically.

References

1. Uraoka T, Takizawa K, Tanaka S et al. Guidelines for Colorectal Cold Polypectomy (supplement to "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection"). Dig Endosc 2022; 34: 668-675.
2. Yoshii S, Hayashi Y, Nakamura T et al. Endoscopic features and clinical course of colorectal carcinoma resected by cold snare polypectomy. J Gastroenterol Hepatol 2023, in press
3. Inoki K, Takamaru H, Furuhashi H et al. Management of colorectal high-grade dysplasia or cancer resected by cold snare polypectomy: a multicenter exploratory study. J Gastroenterol 2023, in press
4. Yoshida N, Fukumoto K, Hasegawa D et al. Recurrence rate and lesions characteristics after cold snare polypectomy of high-grade dysplasia and T1 lesions: A multicenter analysis. J Gastroenterol Hepatol 2021; 36: 3337-3344.

Clinical Case Summary

We present a rare case of protein losing gastropathy.A 60-year-old female presented to our clinic with 10 years history of intermittent dyspepsia with no alarm features and peripheral oedema for 6 months.Physical examination was unremarkable except mild bilateral pitting oedema.Pertinent investigations suggested normal albumin,urine analysis,renal&liver profiles and a normal echocardiogram.Subsequent testing with esophagogastroduodenoscopy(EGD) for dyspepsia showed hypertrophied mucosal folds predominantly in gastric corpus while sparing the antrum.Full thickness biopsies were taken and sent for histopathology with differentials of Lymphoma,adenocarcinoma,sarcoidosis and Menetrier’s disease.Stool antigen for Helicobacter Pylori(H.Pylori)thereafter,was positive while Contrast enhanced CT abdomen was consistent with mildly thickened gastric walls.Histological examination demostrated foveolar hyperplasia,elongated gastric pits and cystically dilated gastric glands without any features of malignancy.Hence a diagnosis of Menetrier’s disease(underlying H.Pylori) was made.
Patient then had H.Pylori eradication therapy as well as a diet rich in medium-chain fatty acids and proteins.H.Pylori eradication was confirmed.6 months follow up revealed partial resolution of her symptoms but no change in endoscopic findings.Patient could not undergo further treatment with biologics(cetuximab)due to financial constraints and octreotide for its local unavailability.She is now on a yearly endoscopic surveillance for future high risk of gastric malignancies.

References

​​Fig1A.Haematoxylin & Eosin staining shows foveolar & mucous cell hyperplasia,elongated gastric pits and lymphocytic infiltration.
Fig1B.Haematoxylin & ​Eosin staining shows cystic dilation of gastric glands
1.Pepa P, Uehara T, Wonaga A, Redondo A, Avagnina A, Mazzocchi O, Antelo P, Waldbaum C, Sorda J. Menetrier's disease. A diagnostic and therapeutic challenge. Medicina (B Aires). 2021;81(3):470-473. English. PMID: 34137712.
2.Gore M, Bansal K, Jadhav N. Menetrier Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2023 Jun 25].

Disclosure

No conflicts