Clinical Case Summary

27-year-old male with penetrating Crohn's disease (CD; A1, L2, pB3), diagnosed at the age of 9, with multiple hospitalizations. The patient was treated with infliximab + azathioprine for three years. Colonoscopy at 16 years showed pancolitis and was complicated with perforation, being submitted to total colectomy with rectal preservation and ileostomy. Therapy was switched to adalimumab+methotrexate, with partial clinical response. After seven years, due to severe complex fistulizing perianal disease, adalimumab was switched to ustekinumab. After 2 years of Ustekinumab monotherapy, he presented disabling symptoms and developed an enterocutaneous fistula peri-ileostomy. Combination therapy with ustekinumab+vedolizumab was started. The patient still maintained discharge from the enterocutaneous and perianal fistulas. After 1 year, a painful circumferential penile ulcer with swelling and seropurulent discharge was noted. Other causes, namely infections were excluded. Biopsies were performed and revealed non-caseous granulomatous inflammation with lymphocytic and eosinophilic infiltrates, compatible with CD. Topical therapy with tacrolimus ointment was applied, with no response. Ustekinumab+vedolizumab was switched to upadacitinib. There was a substantial improvement of the penile lesion, the enterocutaneous fistula discharge reduced, and perianal symptoms resolved on maintenance therapy with Upadacitinib.
Genital metastatic CD is uncommon and mainly occurs in the setting of colonic involvement and perianal disease. Treatment options for MCD remain underwhelming due to the limited available evidence and varying responses of reported therapeutic methods. Optimization of biologic therapy is mandatory.

References

For this case we'll include:
- Pictures ​of the penile ulcers before and during maintenance therapy with upadacitinib
- Endoscopic evaluation during follow-up
- Histological specimen of colectomy and from multiple endoscopic evaluations performed
- Radiological evidence of perianal and peri-ileostomy enterocutaneous fistula

Introduction

Fecal microbiota transplantation (FMT) is an established treatment for Clostridium difficile infection (CDI) and is increasingly explored for other conditions such as inflammatory bowel disease (IBD), autism spectrum disorder (ASD), and metabolic syndromes. Various FMT delivery methods exist, including colonoscopy, enema, nasogastric tube, and oral capsules, with colonoscopy often preferred for its high success rates. This study aimed to assess the safety profile of FMT administered via colonoscopy in pediatric patients.

Aims & Methods

Fecal microbiota transplantation (FMT) has been established as an effective treatment for Clostridium difficile infection (CDI) and is being increasingly explored for other conditions, including inflammatory bowel disease (IBD), autism spectrum disorder (ASD), and metabolic disorders. Various administration routes exist, with colonoscopy often preferred for its efficacy. This study aims to assess the safety profile of FMT via colonoscopy in pediatric patients since data in pediatric population is scarce.
We conducted a retrospective, single-center study at Vilnius University Hospital Santaros Klinikos, reviewing all pediatric FMT procedures performed between 2017 and 2024. Patient data, including demographic information, clinical indications, and post-procedure outcomes, were collected from medical records. All procedures adhered to institutional safety protocols.

Results

A total of 108 FMT procedures were performed on 73 pediatric patients (52 male, 21 female), with a median age of 8.8 years (range: 2.7–17.8 years). The primary indications for FMT included ASD - as part of an ongoing biomedical research (n=84, 77.8%), CDI (n=11, 10.2%), IBD (n=7, 6.5%), and other conditions (n=6, 5.6%). Among CDI cases, 81.8% were associated with underlying IBD. No complications related to anesthesia or the colonoscopy procedure were observed, and no serious adverse events occurred. Mild, self-limiting adverse events, such as transient diarrhea and abdominal discomfort, were reported in 10 cases (9.3%). One patient (0.9%) experienced fever and pharyngitis three days post-procedure, though this was deemed unrelated to FMT.

Conclusion

Our findings suggest that FMT via colonoscopy is a well-tolerated and safe procedure in pediatric patients, with no significant complications and only occasional mild, transient adverse effects. These results support the continued use of FMT as a safe therapeutic option in pediatric care.

Introduction

PEG is a procedure designed to provide prolonged nutritional access for patients who present an intact and/or functional gastrointestinal, but with difficulty or inability to swallow. In pediatric oncology services, PEG is most frequently indicated for children with central nervous system (CNS) tumors and head and neck cancers. While it is well established in clinical practice as an effective and safe method for obtaining enteral access, few studies specifically address the performance of PEG in children with cancer.

Aims & Methods

The main objective of this study is to describe demographic aspects, underlying pathologies, complications, and outcomes of patients who underwent PEG due to cancer. The present study consists in a retrospective cohort of PEG procedures performed in children with any neoplastic diseases that justified a PEG insertion, during the period of October 2000 and January 2018 at the Digestive Endoscopy Unit of the Cancer Hospital I of the Brazilian National Cancer Institute (INCA). Data collection included demographic and pathology baseline information, as well as details regarding post-PEG follow-up and complications. Data extraction was conducted with Excel with further descriptive analyses.

Results

During the study period, a total of 97 children who underwent PEG were included in the study. The mean age was 10.1 years (range: 0.5 to 18.9 years), and fifty-six children (57.7%) were male. The underlying oncological pathologies included 69 cases (71.1%) of neurological tumors, 23 cases (23.7%) of head and neck tumors, 4 cases (4.1%) of hematological malignancies and 1 case of adrenal cortex carcinoma (1%). Fifty-eight patients (59.7%) experienced complications, including granulation tissue formation in 25 cases (25.7%), stoma infection in 6 (8.1%), local pain in 21 (21.6%), bleeding in 3 (3.1%), accidental tube dislodgement in 4 (4.1%), and gastrocolocutaneous fistula in 2 (2.0%). The mean duration of tube placement was 22.1 weeks (range: 0.4 to 483 weeks). At the end of the study, 62 patients had died from their oncological disease (63.9%), 15 patients continued using the tube (15.4%), and 20 patients had the tube removed after completing treatment (20.6%). No cases were lost to follow-up.

Conclusion

PEG is a safe and effective procedure for providing prolonged enteral nutritional access in children with neoplastic disease. Complications are generally classified as minor, and typically do not require invasive treatments.

References

1. Pedersen AM, Kok K, Petersen G, Nielsen OH, Michaelsen KF, Schmiegelow K. Percutaneous endoscopic gastrostomy in children with cancer. Acta Paediatr 1999; 88 (8): 849-52.
2. Skolin I, Hernell O, Larsson MV, Wahlgren C, Wahlin YB. Percutaneous endoscopic gastrostomy in children with malignant disease. J Pediatr Oncol Nurs 2002; 19 (5): 154-63.
3. Gassas A, Kennedy J, Green G, Connolly B, Cohen J, Dag-Ellams U, Kulkarni A, Bouffet E. Risk of ventriculoperitoneal shunt infections due to gastrostomy feeding tube insertion in pediatric patients with brain tumors. Pediatr Neurosurg 2006; 42 (2): 95-9.
4. Parbhoo DM, Tiedemann K, Catto-Smith AG. Clinical outcome after percutaneous endoscopic gastrostomy in children with malignancies. Pediatr Blood Cancer 2011; 56 (7): 1146-8.
5. Schmitt F, Caldari D, Corradini N, Gicquel P, Lutz P, Leclair MD, Podevin G. Tolerance and efficacy of preventive gastrostomy feeding in pediatric oncology. Pediatr Blood Cancer 2012; 59 (5): 874-80.
6. Kaur S, Ceballos C, Bao R, Pittman N, Benkov K. Percutaneous endoscopic gastrostomy tubes in pediatric bone marrow transplant patients. J Pediatr Gastroenterol Nutr 2013; 56 (3): 300-3.

Introduction

Colorectal endoscopic mucosal resection (EMR) is the treatment of choice for large colorectal lesions, but it has an important recurrence risk, requiring endoscopic surveillance. This study aims to identify factors associated with relapse and complications, by analysing the 5-year follow-up.

Aims & Methods

Prospective cohort study conducted in a single centre, including all patients submitted to colorectal pEMR between 2009 and 2021 with follow-up ≥3 months. We analysed lesion characteristics, calculated Sydney EMR recurrence tool (SERT) and SMSA (size, morphology, site, access) scores and compared complication and recurrence rates and respective risk factors.

Results

Included 568 mucosal resections, median age 69.5 years (IQR 62.3-76.0), male sex 58.1%. From the lesions included: 32.6% ≥40mm; 51.6% plane and 48.4% sessile; 35.9% in the right colon, 27.6% in the rectum, 23.2% in the transverse colon and 13.2% in the left colon. The median SMSA score was 4 (IQR 3-4) and median SERT score 1 (IQR 0-2), complication rate of 7.0% (bleeding, n=33; perforation, n=4; post-polypectomy syndrome, n=3) and overall recurrence rate of 20.3%: 15.1% in 3 months, 6.3% in 12 months, 2.5% in 36 months and 0% in 60 months.
The variables associated with recurrence were size ≥40mm (35.0% vs. 14.6%, p<0.001), anal location (35.1% vs. 19.7%, p<0.01), SERT score>0 (27.5% vs. 11.8%, p<0.001) and SMSA score=4 (30.6% vs. 11.5%, p<0.001), but not argon plasma therapy (22.8% vs. 18.7%, p=0.26). By logistic regression, size ≥40mm was associated with higher recurrence, but not statistically significant (OR 3.19, CI95% 0.69-1.63).
Use of anticoagulant/antiplatelet drugs was associated with higher risk of complications (12.7% vs. 4.7%, p<0.001), particularly bleeding (11.4% vs. 4.2%, p<0.01), with no difference for size ≥40mm (9.2% vs. 6.0%, p=0.17) or SMSA score=4 (7.6% vs. 6.5%, p=0.61).

Conclusion

The 5-year surveillance proved colorectal EMR’s efficacy. Recurrence is higher in lesions ≥40mm, with anal location, SERT score>0 and SMSA score=4, whereas bleeding is more frequent with the use of anticoagulant/antiplatelet drugs.