Introduction

The standard treatment for pT1 colorectal cancer classified as high risk (poor differentiation, deep submucosal invasion, intense tumor budding, resection margins that are positive or lymphovascular invasion) is surgery [1]. However, some studies have revealed that patients who undergo surgery and endoscopic treatment have similar disease progression outcomes, and it is also controversial which histological factors influence disease progression [2,3].

Aims & Methods

The aim of this study was to analyze the characteristics and evolution of patients undergoing surgery or endoscopic treatment after the resection of pT1 colorectal adenocarcinoma with histological findings considered high risk for lymph node metastasis.
We conducted an observational study of historical cohorts. We included patients with pT1 Adenocarcinoma and histological criteria of poor prognosis with at least six months of follow-up, and who were diagnosed between 2018 and 2024. The therapeutic approach was determined by a multidisciplinary committee.

Results

We included 54 patients (74.1% male) with a mean age of 65.3 years and mean follow-up time of 3.07 years; no significant differences in both groups. The indications for colonoscopy were screening (42.6%), alarm symptoms (38.9%), radiological findings (3.7%), prior polypectomy (9.3%), history of colorectal cancer (1.9%), and family history (3.7%). The rate of patients with endoscopic complications was 2.9% intraprocedural bleeding and 2.9% delayed bleeding.
The mean lesion size was 23.48 mm, and the most common location was the rectum.
Regarding the therapeutic approach, 63.0% of patients underwent surgery and 29.6% underwent endoscopic surveillance. Among the surgical patients, complications included suture dehiscence (6%), and hemorrhage (2%). In the surgical specimen analysis, residual lesion was found in 6 patients, and metastatic lymph nodes in 2. 5.55% required adjuvant therapy due to lymph node involvement, and 1.85% were stage IV at diagnosis, excluded from the comparative analysis.
Comparing both study groups, the surgical group had a significantly higher rate of submucosal invasion, with no differences in the remaining characteristics studied. During the study period, progression with lymph node involvement was observed in one patient who underwent surgery and two patients who underwent endoscopy treatment (average time 11 and 24.5 months, respectively). No patient has developed distant metastases to date.

	Surgery treatment (n =34)	Endoscopic therapy (n = 16)	p-value
Piecemeal resection (n, %)	16 (47.05%)	8 (50%)	p > 0.05
Poor differentiation (n, %)	1 (2.9%)	0	p > 0.05
Deep submucosal invasion (n, %)	33 (97%)	11 (68.75%)	P = 0.016
Margins affected or not precise (n, %)	14 (41.17%)	6 (37.5%)	p > 0.05
Lymphovascular invasion (n, %)	6 (18.18%)	0	P = 0.06
Perineural invasion (n, %)	2 (6.66%)	0	p > 0.05
Intense tumor budding (n, %)	0	0
Total number of poor prognostic factors (media, SD)	2,59 (1,076)	1,93 (1,03)	P = 0.043
Disease progression (n, %)	1 (2,9%)	2 (1,25%)	p > 0.05

Conclusion

In our study, patients who underwent endoscopic treatment did not present significant differences with respect to those who received surgery in terms of long-term tumor progression, despite having a higher rate of submucosal invasion. Further studies with larger sample sizes are needed to determine which factors and to what extent influence lymphatic and distant dissemination of pT1 adenocarcinoma.

References

1. Hassan C, Wysocki PT, Fuccio L, Seufferlein T, Dinis-Ribeiro M, Brandão C, et al. Endoscopic surveillance after surgical or endoscopic resection for colorectal cancer: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Digestive Oncology (ESDO) Guideline. Endoscopy 2019;51:266–77. https://doi.org/10.1055/a-0831-2522.
2. Ozeki T, Shimura T, Ozeki T, Ebi M, Iwasaki H, Kato H, et al. The risk analyses of lymph node metastasis and recurrence for submucosal invasive colorectal cancer: Novel criteria to skip completion surgery. Cancers (Basel) 2022;14:822. https://doi.org/10.3390/cancers14030822.
3. Zwager LW, Bastiaansen BAJ, Montazeri NSM, Hompes R, Barresi V, Ichimasa K, et al. Deep submucosal invasion is not an independent risk factor for lymph node metastasis in T1 colorectal cancer: A meta-analysis. Gastroenterology 2022;163:174–89. https://doi.org/10.1053/j.gastro.2022.04.010.

Clinical Case Summary

Introduction: PSC is closely associated with IBD and affects up to 3.6% of Crohn's disease patients, while AIH is also more prevalent in IBD patients, in up to 16% of patients.
Case report: We report a female patient who, at the age of 14, presented with right hypochondrial pain and abnormal liver biochemistry (SGOT: 44 U/l, SGPT: 145 U/l, γ-GT: 300 U/l, ALP: 421 U/l, TBL: 1 mg/dL). The patient underwent MRCP (Figure A) which revealed local strictures with prostenotic dilatation in both intrahepatic and extrahepatic bile ducts, suggestive of PSC. One year later the patient presented with severe abdominal pain and bloody diarrhea. Ileocolonoscopy showed terminal ileitis (Figure B) and segmental colitis. Histological evaluation (Figure C) showed disruption of the architecture, focal erosions of the epithelium, mild mucopenia, inflammatory infiltrate in the dermis, sites of cryptitis and focal formation of crypt abscesses with extension of inflammation to the muscularis mucosae, suggestive of Crohn’s Disease. Two years later, in a regular laboratory test, the patient had abnormal liver function tests (SGOT: 211 U/l, SGPT: 603 U/l, γ-GT: 54 U/l, ALP: 105 U/l, TBL: 0.9 mg/dl). Further evaluation with immunoassay revealed ANA (+) 1/80, AMA (-), SMA (+) 1/160, + F-actin, anti-LKM (-), anti-LC (-), anti-LM (-), p ANCA (+) 1/80, so the patient underwent percutaneous liver biopsy with findings of portal spaces with presence of waxy-containing macrophages, thin fibrous septa, parenchyma with centrolobular necrosis with aggregates of inflammatory cells and waxy macrophages, suggestive of Autoimmune Hepatitis. Today, the patient is in clinical remission under treatment with Ursodeoxycholic acid, Ustekinumab and Mycophenolate Mofetil.
Conclusion: The association of IBD with PSC, AIH and variant forms is now known, however the complexity of the diseases presents a challenge for the clinician and the provision of individualized care.

References

1. Ballotin VR, Bigarella LG, Riva F, Onzi G, Balbinot RA, Balbinot SS, Soldera J. Primary sclerosing cholangitis and autoimmune hepatitis overlap syndrome associated with inflammatory bowel disease: A case report and systematic review. World J Clin Cases. 2020 Sep 26;8(18):4075-4093.
2. Saich R, Chapman R. Primary sclerosing cholangitis, autoimmune hepatitis and overlap syndromes in inflammatory bowel disease. World J Gastroenterol. 2008 Jan 21;14(3):331-7.
3. Rocha HC, Vilela EG. Clinical aspects and prognosis of patients with inflammatory bowel disease associated with autoimmune liver diseases. Gastroenterol Hepatol. 2022 Feb;45(2):83-90. English, Spanish.
4. Malik T, A, Gutierrez A, M, McGuire B, Zarzour J, G, Mukhtar F, Bloomer J: Autoimmune Hepatitis-Primary Sclerosing Cholangitis Overlap Syndrome Complicated by Crohn’s Disease. Digestion 2010;82:24-26.

Clinical Case Summary

Splenic granulomas are a rare extraintestinal manifestation of Crohn’s disease (CD). In previously reported cases, the diagnosis was confirmed by biopsy. However, due to the increased risk of complications associated with biopsy, confirmation by imaging is desirable.
52-year-old male patient presented with a previously diagnosed, currently untreated CD.
Symptoms:

• Abdominal pain in the right lower quadrant for several weeks, postprandial
• Bowel movements: 4-6 times/day for a few weeks, liquid consistency
• No fever or weight loss
• Palpation: tenderness in the lower right abdomen

Findings:

• C-reactive protein and leukocytes: not elevated
• Calprotectin: 184ug/g. Stool culture and intestinal cytomegaly virus PCR biopsy negative
• Tuberculosis interferon-g release assay: negative
• Colonoscopy and magnetic resonance enterography (MRE): ileitis of terminal Ileum (Fig. 1)
• MRE: multiple T2w-hyperintense splenic lesions, increased in number since last imaging 2024 (Fig. 2)
• B-mode ultrasound: splenomegaly, round nodules of mixed echogenicity (Fig. 3)
• Contrast-enhanced ultrasound (CEUS): 1,5ml contrasting agent (sulphur hexafluoride microbubbles): arterial isoenhancement and late phase hypoenhancement of nodules (Fig. 3), atypical for haemangiomas
• 18-Fluorodeoxyglucose positron emission tomography with computed tomography: no uptake in the spleen (Fig. 4)

After excluding malignancy, abscesses, sarcoidosis, and infectious causes, the splenic granulomatous lesions represented an extraintestinal manifestation of CD. The patient was started on prednisolone, 60mg/day, resulting in marked clinical improvement in 4 days; with reduced abdominal pain and decreased stool frequency. Patient declined recommended maintenance therapy with ustekinumab.
This CEUS pattern is novel to CD and resembles previously reported enhancement patterns of inflammatory lesions. This is a rare reported case of splenic granulomas as an extraintestinal manifestation of CD diagnosed non-invasively by CEUS.

References

Figure 1: Colonoscopy shows 2-4mm aphthous ulcers in the terminal Ileum
Figure 2: (A)T2-Haste and (B)T2-STIR MRE depicting multiple hyperintense splenic lesions
Figure 3: B-mode (left) and CEUS (right) of the splenic lesions. (A) Nodules appear mixed in echogenicity, nodules show isoenhancement during the arterial phase. (B) Nodules exhibit hypoenhancement in the late phase
Figure 4: 18F-Fluorodeoxyglucose (FDG) positron emission tomography with computed tomography shows no uptake of FDG in the spleen
1. Castellani L, Sartini A, Marocchi M, Balbi T, Belluzzi A. Splenic granulomas in a patient with severe Crohn's disease associated with multiple extraintestinal manifestations. Inflamm Bowel Dis. 2011 Jun;17(6):E35-7. doi: 10.1002/ibd.21665. Epub 2011 Feb 11. PMID: 21319276.
2. Schulz C, von Arnim U, Kuester D, Fischbach F, Malfertheiner P. Milzbefall - seltene extraintestinale Manifestation bei Morbus Crohn [Splenic granulomas - rare extraintestinal manifestation of Crohn's disease]. Z Gastroenterol. 2010 Dec;48(12):1367-70. German. doi: 10.1055/s-0029-1245562. Epub 2010 Dec 1. PMID: 21125512
3. Safai Zadeh E, Prosch H, Ba-Ssalamah A, Findeisen H, Alhyari A, Raab N, Görg C. Contrast-enhanced ultrasound of the liver: basics and interpretation of common focal lesions. Rofo. 2024 Aug;196(8):807-818. English, German. doi: 10.1055/a-2219-4726. Epub 2024 Jan 4. PMID: 38176437

Disclosure

Travel grant from Johnson & Johnson

Clinical Case Summary

Introduction: Eosinophilic enteritis (EoEo) is a rare condition characterized by eosinophilic infiltration of the intestinal wall without an identifiable secondary cause. Clinical presentation varies depending on the affected intestinal segment and layer. While mucosal involvement causes digestive symptoms, muscular involvement may lead to obstruction, and serosal involvement—least common—can present with eosinophilic ascites.
Case Report: A 15-year-old male presented with epigastric pain, vomiting, and oral intolerance. Laboratory tests revealed marked eosinophilia (>5,000/μL). Abdominal CT showed free fluid and ileocecal wall thickening. Diagnostic paracentesis revealed ascitic fluid with a high leukocyte count and eosinophil predominance. Endoscopic studies revealed ileitis, typhlitis, and duodenitis. Biopsies confirmed eosinophilic infiltration of the intestinal wall. Other causes of eosinophilia, including infections and malignancy, were ruled out. The patient was treated with intravenous corticosteroids, with good clinical response, and discharged on oral budesonide. A relapse occurred after tapering steroids, prompting initiation of azathioprine for maintenance. The patient remains clinically stable without further hospitalizations.
Discussion: EoEo with eosinophilic ascites is rare and should be considered in the differential diagnosis of unexplained ascites, particularly in patients with peripheral eosinophilia. Key diagnostic findings include eosinophil-predominant ascitic fluid and GI tract biopsies with eosinophilic infiltration. Early recognition and treatment are essential to prevent complications. It is crucial to rule out parasitic and infectious causes before initiating corticosteroid therapy to avoid worsening an undiagnosed infection.

Introduction

Patients with ulcerative colitis (UC) are at an increased risk of cytomegalovirus (CMV) infection. CMV infection in acute severe ulcerative colitis (ASUC) may worsen disease severity and clinical outcomes. Current guidelines recommend colonic biopsies for the exclusion of CMV in all patients with ASUC. One study found that CMV positivity in ASUC was associated with greater need for rescue therapy, longer hospital length of stay (LOS) and higher readmission rates but found no difference in rate of colectomy.¹ We aimed to investigate the impact of positive CMV result on clinical outcomes in patients presenting with ASUC.

Aims & Methods

A retrospective review included all ASUC presentations to a quaternary hospital over a 10-year period based on modified Truelove and Witts’ criteria. ASUC presentations were grouped based on CMV positivity as determined by colonic biopsy. Data on pre-admission medications was collected. Data was collected on rates of rescue therapy, referral to colorectal surgery, colectomy, total parenteral nutrition (TPN). Outcomes assessed included intensive care unit (ICU) admission, 30- and 90-day readmission rates, 30- and 90-day mortality rates and mean LOS.

Results

A total of 172 ASUC presentations were identified. Of these, 133 had available colonic biopsy CMV results. 11 patients (8%) had positive CMV. Positive CMV result was significantly associated with increased need for TPN (36% vs 11%, p=0.02), ICU admission (27% vs 5%, p=0.004) and referral to colorectal surgery (82% vs 43%, p=0.01). Patients with CMV had longer LOS (27.1±14.0 vs 11.0±7.4, p=0.003). There were no significant differences in rates of rescue therapy, inpatient colectomy, readmission or mortality rates. 9 of the patients (82%) were treated with ganciclovir or valganciclovir. Patients on maintenance advanced UC therapies, including biologics and small molecule inhibitors, had significantly higher rate of CMV (22% vs 5%, p=0.01). Biologic therapy alone was associated with higher rate of CMV (24% vs 7%, p=0.02), whereas small molecule inhibitor alone was not (p=0.6). Pre-admission use of 5-aminosalicylates, high dose steroids, thiopurines or combination therapies were not associated with CMV positivity.

Table 1: Comparison data of clinical outcomes in ASUC between patients with and without CMV positivity on colonic biopsy

	CMV on biopsy		p-value
	Positive	Negative
Rescue therapy (n)	7 (64%)	44 (36%)	p=0.07
TPN (n)	4 (36%)	14 (11%)	p=0.02*
Referral to colorectal surgery (n)	9 (82%)	52 (43%)	p=0.01*
Inpatient colectomy (n)	3 (27%)	14 (11%)	p=0.13
ICU admission (n)	3 (27%)	6 (5%)	p=0.004*
Readmission at 90 days (n)	4 (40%)	23 (19%)	p=0.11
Mortality at 90 days (n)	1 (9%)	2 (2%)	p=0.11
Length of stay (days)	27.1 ± 14.0	11.0 ± 7.4	p=0.003*

Conclusion

Patients with CMV positive colonic biopsies tend to require more inpatient interventions, including increased need for TPN, ICU admission, referral to colorectal surgery and longer hospital length of stay. Despite more complex admission course of ASUC patients with concurrent CMV infection, these patients were not observed to have worse outcomes than those without CMV diagnosis. Maintenance biologic and small molecule inhibitor use was associated with higher rates of CMV, reflecting the immunosuppressant effects of advanced UC therapies. CMV detection needs to be considered as a potential exacerbating factor in disease severity.

References

1. Huang D, Rennie M, Krasovec A, Nagubandi S, Liu S, Ge E, Khehra B, Au M, Sivagnanam S, Kwan V, Rogge C, Mitrev N, Kariyawasam V. Impact of cytomegalovirus on outcomes in acute severe ulcerative colitis: a retrospective observational study. Ther Adv Chronic Dis. 2024 Mar 28;15:20406223241233203. doi: 10.1177/20406223241233203. PMID: 38560721; PMCID: PMC10981253.

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.